Introduction

Grief and loss are something that all people experience in their lifetime. The loss may be actual or perceived and is the absence of something valued. A substantial loss is recognized and verified by others, while others cannot prove a perceived loss. Both are real to the individual who has experienced the loss. Grief is the internal part of the loss and the emotional feelings related to it. Nurses may share this personally or support patients and their families going through grief and loss. There are normal stages of grief that people experience; however, every person's experience is individual. The feelings of loss are commonly associated with the death of a loved one, but they can be experienced for several reasons. People may experience grief and feelings of loss about a significant change, such as the loss of a job, loss of function, loss of a limb, loss of a pet, the feeling of loss of control, and loss of loved ones. The nurse's role is to provide compassionate care to the patient and loved ones, and this care differs from person to person. It is also essential for nurses to maintain emotional resiliency so they can provide the best care for those experiencing grief.[1]

Function

Grief, when permitted, helps process the pain of loss and allows for the pain to heal. 

Dr. Elisabeth Kübler-Ross first identified the five stages of grief in her 1969 book Death and Dying. Later, she co-authored On Grief and Grieving: Finding the Meaning of Grief through the Five Stages of Loss with David Kressler, an expert on death and grieving. Their explanations of the stages of grief are widely accepted and taught throughout the world. Initially, they explained 5 stages of grief; more recently, David Kressler has discussed 2 additional stages (as denoted by an * below). They are as follows:

Shock* 

A person may react to the learning of a loss with numbed disbelief. Shock may provide an emotional buffer and can protect an individual from being overwhelmed all at once.

Denial

This stage continues to help survive the loss. An individual may feel like the world around them is meaningless or overwhelming, and their life may make no sense. They may have a feeling or understanding that everything feels numb. Shock and denial help a person cope with loss and make their survival possible. Denial allows an individual to pace their feelings of grief. This is the beauty of denial; it is nature's way of dealing with only what can be handled. Denial does not just mean denying that a loss has happened; although this may occur, denial often restricts the experience of all the feelings. As an individual can accept that this loss is their reality, they can move into the healing process, and denial will begin to diminish.

Anger 

Anger is a necessary stage of the healing process. Before the anger stage, an individual who is experiencing grief may feel like they have been abandoned or may feel no connection to anything. Experiencing anger allows for a connection and something to hold on to. Anger may be directed at the lost thing or person, the doctors, friends, family, God, etc. Under the anger is the individual's pain. Anger provides structure, and that is better than the preceding numbness. It can be challenging for some to feel the anger; sometimes, it is easier to suppress it. Feeling the anger and addressing the anger is part of the grieving process. Awareness that this is a step in the process is essential for the person experiencing grief and any caretaker involved. Do not take any outbursts personally, as they are likely signs of a person's grief.

Bargaining 

Bargaining is the step in the grieving process where one may think, "If this __, then this__." For example: "I would do anything if you took the hurt away" or "I would never sin again if my loved one were spared." Bargaining may come in the form of "what if" statements. For example, "What if we found the cancer sooner?" or "What if this accident never happened?" These "what ifs" are a way to negotiate that an individual wants life to return to how it once was. Guilt will often accompany this frame of thinking. This stage may be experienced at any point in the grieving process and exhibits that individuals can move through the different stages throughout their healing process in several ways. There is no set linear path in grief. As a healthcare worker, assessing this grief stage and listening is essential. Provide empathy and compassion and educate them that this is a normal thought process if they question it. Provide resources if appropriate.

Depression 

After the thoughts of the past in bargaining, thoughts of the present flood in. They realize that the situation is actual. Empty feelings come forward, and one's grief moves in on a deeper level than before. This type of depression is not a sign of mental illness, although reaching out for help may be the right step. It is an appropriate response to a significant loss. An individual may withdraw from their daily life activities and feel a fog of intense sadness. To not experience any depression after the loss of a loved one would be unusual. The stage of depression is a necessary step in the healing process that is grieving. As a healthcare worker, it is imperative to be able to discern typical signs of depression due to grief and someone who is struggling with complicated grief and depression. Be able to assess for signs of suicidal ideations, and when in doubt, ask. Provide appropriate resources as needed.

Testing*

An individual may try to find realistic solutions for dealing with and living with this loss. This is the process of rebuilding their life in their new reality. The individual may require further resources during this stage as they are trying out what works for their unique way of life. It is also possible to flow in and out of other stages during the testing phase. Providing resources that may be appropriate during this phase can be very helpful for the individual to try out as they may feel ready for that experience.

Acceptance 

Acceptance does not have to mean one is "alright with what has happened." An individual may never be the same as before after a loss. They may never feel "OK" about the loss. As a stage, acceptance is about accepting that this is their new reality and that it is permanent. Life cannot continue as it once did but can and does continue through acceptance. Roles will be reorganized. New connections and relationships will be made. Individuals experiencing acceptance understand that they must listen to their needs and evolve. There may be days that are harder than others, but an individual who has given their grief the time it has needed to heal will begin to live again.[2]

Issues of Concern

As a nurse, one has the honor of caring for the most vulnerable populations. This includes patients and loved ones who experience loss. It is essential to assess characteristic signs of grief and loss and address them appropriately. The nurse must start this process by building rapport with the patient and any present loved ones. Please encourage them to speak openly and honestly about their emotional and physical feelings. Utilize active listening skills and provide a nonjudgmental environment.

The American Association of Critical Care Nurses supports a method for therapeutic communication during emotional conversation topics called the NURSE technique. Utilizing this technique when communicating with people experiencing grief helps demonstrate empathy and build rapport by using the NURSE pneumonic, as this example below shows:

When a family member mentions they are overwhelmed, the nurse may respond:

• Name: "You feel overwhelmed." Name what they just said.
• Understand: "There is so much going on; how can I help you?"
• Respect: "I am really impressed with how well you are handling everything." Express your respect for them in this situation.
• Support: "I am here with you all shift." Show them that you are there for them.
• Explore: "What is the hardest part?" Further the conversation with an open-ended question.

These techniques can be used individually or as a bundle. It is essential for the nurse to assist the patient and loved ones in coping with their grief, including anticipatory grief. Educate them on what is expected to be the stages of grief, what some normal feelings are, and what resources are available to help them adjust to this loss they are experiencing. Evaluate how they handle this experience and address any fears related to grief and loss.

Grief may affect individuals differently but can be exhibited through signs and symptoms such as altered immune responses, distress, anger, sleep disturbances, withdrawal, pain, panic, and suffering. It may be evident by one's lack of understanding of death and its severity and finality of the loss. Encourage loved ones at the bedside to remember to care for their health. Remind them or help them have access to food and hydration. Encourage adequate sleep and hygiene. 

It is essential to provide your patients and their loved ones with resources to adjust to their loss and help them through their grieving process. This may mean chaplain services, their own clergy or spiritual support, psychological referrals, individual therapy, group therapy, community peer support groups, and social work referrals.[3]

Anticipatory grief may be experienced before an actual loss. This type of grieving allows the patient and their loved ones to begin the grieving process together. This is often displayed when a patient learns of a terminal illness diagnosis or has a planned amputation surgical procedure. 

Complicated grief is when the feelings of loss are debilitating and do not improve after an extended amount of time passes. There is no set amount of time that one moves through the stages of grief; however, there is a general movement toward growth and healing in an average grief experience. A generally accepted amount of time is one year. In complicated grief, the painful emotions are so consuming that the individual has trouble recovering from the loss to resume their life. In the beginning months after a loss, normal grief and complicated grief appear very similar; however, complicated grief likely worsens instead of gradually fading. Individuals experiencing complicated grief generally need support and resources to help them reclaim a sense of acceptance and peace.[4]

Signs and Symptoms of Complicated Grief

• Intense sorrow, pain, and rumination over the loss
• Inability to focus on anything other than the loss itself
• Severe and persistent longing or pining for the deceased
• Difficulty accepting the death
• Numbness or detachment
• Bitterness about loss
• Feelings that life holds no meaning or purpose
• Lack of trust in others
• Inability to enjoy life or even remember any positive experiences of a loved one
• Have trouble carrying out everyday routines

Some types of relationships to the loss are at a higher risk of complicated grief, such as the loss of a child, the loss of a spouse, and the loss of a loved one, whom the bereaved may not be able to show their grief, such as in an affair or a divorced partner.[5]

Clinical Significance

The goals of care are for the patient and their loved ones to be free of complicated grieving and access adequate resources to allow for the natural grieving process. They need to verbalize and express their true feelings and seek the help and support of others. When they do so, they are more likely to be able to identify their strengths and weaknesses. They must utilize the necessary resources to help them process their grief and understand the meaning of their loss so that they may learn to live their new life.[6][7][8][9]

Nursing Diagnosis Related to Grief and Loss

• Anticipatory grieving
• Risk for complicated grieving
• Risk for anxiety
• Risk for knowledge deficit related to the grieving process

Other Issues

Sometimes, it is hard to know what to say to someone experiencing grief and loss. The most important thing is to be there and to listen. Allowing a loved one to share a memory or a feeling about the person they are grieving can be invaluable. It is okay not to know what to say. Acknowledge that saying, "I wish I had the right words; just know I care." Or, "I am" so sorry for your loss." It is important to understand that not everyone experiences feelings the same, so it is not appropriate to say, "I know how you feel." Instead, say, "I don’t how you feel. Still, I am here to help in any way I can." Then follow through by providing any help you can, be that an appropriate referral or simply a hot drink or listening ear. [10]