Grief and Loss

Prepared by: Rizabelle P. Molina-Evangelista, MSN.

• Grief refers to the subjective emotions and
affect that are normal response to loss.

• Grieving, also known as bereavement, is the

process of experiencing grief.

• Anticipatory grief is facing an imminent loss.

• Mourning is the outward sign of grief.

Prepared by: Rizabelle P. Molina-Evangelista, MSN.

Experiences of grief and
loss are essential and
normal in the course
of life; letting go,
relinquishing, and
moving on happen
as we grow and
develop.

Grief and loss are

uncomfortable.

Prepared by: Rizabelle P. Molina-Evangelista, MSN.

Types of Losses

Losses may be planned, expected, or sudden.

Loss of a loved one is probably the most
devastating type of loss, but there are many
other types of losses:

– Physiologic (loss of limb, ability to breathe)

– Safety (domestic violence, posttraumatic stress

disorder, breach of confidentiality)

Prepared by: Rizabelle P. Molina-Evangelista, MSN.

Types of Losses (cont’d)
• Security/sense of belonging (relationship loss
[death, divorce])

• Self-esteem (ability to work, children leaving

home)

• Self-actualization (loss of personal goals,

such as not going to college, never becoming
an artist or dancer)

Prepared by: Rizabelle P. Molina-Evangelista, MSN.

The Grieving Process

Nurses must recognize the signs of grieving to

understand and support the client through the
grieving process.

The therapeutic relationship and therapeutic

communication skills are paramount when
assisting grieving clients. Using these skills,
nurses may promote the expression and release of
emotional as well as physical pain during grieving.

Prepared by: Rizabelle P. Molina-Evangelista, MSN.

Theories of the Grieving Process
Kubler-Ross’s stages of grieving:
– Denial (shock and disbelief)
– Anger (toward God, relatives, health care
providers)
– Bargaining (trying to get more time, prolonging
the inevitable loss)
– Depression (awareness of the loss becomes acute)
– Acceptance (person comes to terms with
impending death or loss)

Prepared by: Rizabelle P. Molina-Evangelista, MSN.

Theories of the Grieving Process (cont’d)

Bowlby’s phases of grieving:

– Numbness and denial of the loss

– Emotional yearning for lost loved one and
protesting permanence of loss
– Cognitive disorganization and emotional despair
– Reorganizing and reintegrating sense of self

Prepared by: Rizabelle P. Molina-Evangelista, MSN.

Theories of the Grieving Process (cont’d)

John Harvey’s phases of grieving:

– Shock, outcry, and denial

– Intrusion of thoughts, distractions, and
obsessive reviewing of loss
– Confiding in others to emote and cognitively
restructure

Prepared by: Rizabelle P. Molina-Evangelista, MSN.

Theories of the Grieving Process (cont’d)

Rodebaugh’s stages of grieving:

– Reeling
– Feelings
– Dealing
– Healing
There are many similarities among theorists about
grief. Not all clients follow predictable steps or make
steady progress.

Prepared by: Rizabelle P. Molina-Evangelista, MSN.

Tasks of the Grieving Process
• Undoing psychosocial bonds to loved one
and eventually creating new ties
• Adding new roles, skills, and behaviors
• Pursuing a healthy lifestyle
• Integrating the loss into life

Prepared by: Rizabelle P. Molina-Evangelista, MSN.

Dimensions of Grieving
• Cognitive responses to grief
– Questioning and trying to make sense of the loss
– Attempting to keep the lost one present
• Emotional responses to grief
• Spiritual responses to grief
• Behavioral responses to grief
• Physiologic responses to grief

Prepared by: Rizabelle P. Molina-Evangelista, MSN.

Cultural Considerations
All cultures grieve for lost loved ones, but the rituals
and habits surrounding death vary among cultures,
for instance, how shock and sadness are expressed,
how long mourning should last, and so forth. Many
cultural bereavement rituals have their roots in a
major religion.

Nurses should be sensitive to cultural differences and

ask how the mourners can be assisted.

Prepared by: Rizabelle P. Molina-Evangelista, MSN.

African Americans
• Typically view the body in church
before burial
• Hymns, poetry, eulogies common
• Mourning may be expressed by public
prayer, wearing black clothing, and
decreasing social activities for a few
weeks to several years

Prepared by: Rizabelle P. Molina-Evangelista, MSN.

Muslim Americans
• Muslims do not permit cremation
• Important to follow the five steps of
the burial procedure

Prepared by: Rizabelle P. Molina-Evangelista, MSN.

Haitian Americans
• May practice vodun or calling on spirits
to make peace

Prepared by: Rizabelle P. Molina-Evangelista, MSN.

Chinese Americans
• Strict norms for announcing death,
preparing the body, arranging the
funeral and burial, mourning
• Burning incense and reading scripture
assist the spirit of the deceased on his
or her journey

Prepared by: Rizabelle P. Molina-Evangelista, MSN.

Japanese Americans
• Japanese Americans who are Buddhists view
death as a life passage
• Bathing and purification rites are performed
• Friends and family visit, bringing gifts or
money
• Prayers are said
• Incense is burned

Prepared by: Rizabelle P. Molina-Evangelista, MSN.

Filipino Americans
• Often Catholic
• Wear armbands or black clothing
• Place wreaths on casket
• Drape a black banner on the deceased’s
home
• Ask for prayers and blessings for the soul of
the deceased

Prepared by: Rizabelle P. Molina-Evangelista, MSN.

Vietnamese Americans
• Predominately Buddhist
• Deceased is bathed and dressed in
black clothes
• Rice and money may be sent with the
deceased on the journey to the afterlife
• Viewing the body before burial occurs
at home
Prepared by: Rizabelle P. Molina-Evangelista, MSN.
Hispanic Americans
• Predominately Catholic
• Pray for the soul during a novena and
rosary
• Mourning may involve wearing black
and decreasing social activities
• A wake in the home may be held

Prepared by: Rizabelle P. Molina-Evangelista, MSN.

Native Americans
• Variety of practices depending on religious
beliefs and practices of different tribes
• Death may be seen as a state of
unconditional love
• Many believe the deceased is going on
another journey
• Celebrations may include a ghost meal
• Mourners may be encouraged to be happy
for the person
Prepared by: Rizabelle P. Molina-Evangelista, MSN.
Orthodox Jewish Americans
• Leaving a dying person alone is a
sign of disrespect
• Burial must occur within 24 hours
unless delayed by the Sabbath
• Body should be untouched until rites
can be performed by family, rabbi, or
Jewish undertaker

Prepared by: Rizabelle P. Molina-Evangelista, MSN.

Nurse’s Role
The nurse must encourage clients to
discover and use effective and meaningful
grieving behaviors:
• Praying
• Staying with the body
• Performing rituals
• Attending memorials and public services

Prepared by: Rizabelle P. Molina-Evangelista, MSN.

Disenfranchised Grief or Complicated Grieving
Disenfranchised grief is grief over a loss that is not or
cannot be openly acknowledged, mourned publicly,
or supported socially:

• A relationship has no legitimacy

• The loss itself is not recognized
• The griever is not recognized

Complicated grieving is a response that lies outside

the norm of grieving in terms of extended periods of
grieving: responses that seem out of proportion or
responses that are void of emotion

Prepared by: Rizabelle P. Molina-Evangelista, MSN.

Complicated Grieving
People who are vulnerable to complicated grieving
include those with:
• Low self-esteem
• Low trust in others
• A previous psychiatric disorder
• Previous suicide threats or attempts
• Absent or unhelpful family members
• An ambivalent, dependent, or insecure attachment
to the deceased person

Prepared by: Rizabelle P. Molina-Evangelista, MSN.

Application of the Nursing Process
Assessment
• Does the client have adequate perception regarding
the loss?
– What does the client think and feel about the loss?
– How is the loss going to affect the client’s life?
– What information does the nurse need to clarify or share
with the client?
• Does the client have
adequate support?
• Does the client have adequate
coping behaviors?
Prepared by: Rizabelle P. Molina-Evangelista, MSN.
Application of the Nursing Process (cont’d)

Data Analysis and Planning

Possible nursing diagnoses:
• Grieving
• Anticipatory Grieving
• Dysfunctional Grieving

Prepared by: Rizabelle P. Molina-Evangelista, MSN.

Application of the Nursing Process (cont’d)
Outcome Identification
Grieving
The client will:
• Identify the effects of his or her loss
• Seek adequate support
• Apply effective coping strategies while expressing and
assimilating all dimensions of human response to loss
in his or her life

Prepared by: Rizabelle P. Molina-Evangelista, MSN.

Application of the Nursing Process (cont’d)
Anticipatory Grieving
The client will:
• Identify the meaning of the expected loss in his or
her life
• Seek adequate support while expressing grief
• Develop a plan for coping with the loss as it
becomes a reality

Prepared by: Rizabelle P. Molina-Evangelista, MSN.

Application of the Nursing Process (cont’d)
Dysfunctional Grieving
The client will:
• Identify the meaning of his or her loss
• Recognize the negative effects of the loss on
his or her life
• Seek or accept professional assistance to
promote the grieving process

Prepared by: Rizabelle P. Molina-Evangelista, MSN.

Application of the Nursing Process (cont’d)
Intervention
• Regarding perception of the loss
– Explore perception and meaning of the loss

• Regarding adequate support

– Help the client reach out and accept what others want to
give

• Regarding adequate coping behaviors

– Shift from an unconscious defense mechanism to
conscious coping
– Compare and contrast past coping
– Encourage the client to care for self
Prepared by: Rizabelle P. Molina-Evangelista, MSN.
Application of the Nursing Process (cont’d)
Essential communication and interpersonal
skills to assist grieving:
• Use simple, nonjudgmental statements
• Refer to a loved one or object of loss by name (if
acceptable in the client’s culture)
• Appropriate use of touch indicates caring
• Respect the client’s unique process of grieving
• Respect the client’s personal beliefs
• Be honest, dependable, consistent, and worthy of the
client’s trust
• Offer a welcoming smile and eye contact
Prepared by: Rizabelle P. Molina-Evangelista, MSN.
Application of the Nursing Process (cont’d)
Evaluation
Evaluation of progress is based on the
goals established for the client.
Make an evaluation of the client’s
status based on the theoretical tasks
and phases of grieving.

Prepared by: Rizabelle P. Molina-Evangelista, MSN.

Self-Awareness Issues

• Examining one’s own experiences with

grief and loss
• Taking a self-awareness inventory and
reflecting on the results may be
helpful.

Prepared by: Rizabelle P. Molina-Evangelista, MSN.

Prepared by: Rizabelle P. Molina-Evangelista, MSN.