In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of grief and loss in order to:

  • Assist the client in coping with suffering, grief, loss, dying, and bereavement
  • Support the client in anticipatory grieving
  • Inform the client of expected reactions to grief and loss (e.g., denial, fear)
  • Provide the client with resources to adjust to loss/bereavement (e.g., individual counseling, support groups)
  • Evaluate the client's coping and fears related to grief and loss

Grieving is a normal response to a loss; grieving, as defined by the National North American Nursing Diagnosis Association International, is "a normal, complex process that includes emotional, physical, spiritual, social and intellectual responses and behaviors by which individuals, families, and communities incorporate a loss into their daily lives"

All losses impact on the client. Losses can occur as the result of an intrapersonal loss of self and one's bodily image and extrapersonal losses like the loss of a pet, the death of a loved one including a child or a spouse, the loss of a personal friendship as the result of a spat, and the loss of one's life savings.

Losses can be categorized and classified as an actual loss, a perceived loss, a situational loss, a developmental or maturational loss and a necessary loss. These losses occur as the result of an actual event, an event that is perceived by the client but not based in reality, a loss of a loved one, the loss of one's youth, and a loss that is expected during the life span, respectively.

Grief and the types of grief can be categorized and classified as normal grief, dysfunctional complicated grief, anticipatory grief, disenfranchised grief, and grief that occurs as the result of a public tragedy. Examples of these types of grief include normal grief that is coped with in a healthy adaptive manner, grief that is complicated and prolonged beyond what is normally expected, grief that occurs prior to the actual loss, grief after a substance abuse overdose that kills a family member and one that is not shared with others because the loss is socially unacceptable, and grief following a natural or man-made disaster such as the World Center terrorism and a major flood, respectively.

Grief and the grieving process are characterized with suffering, despair, sleep impairments, pain, distress, anger, detachment, guilt, and even personal growth.

There are theories and conceptual frameworks that provide nurses, and other health care providers, with insight into grief, loss, the grieving process and ways that nurses can meet the needs of clients who are affected with normal grief and unresolved complicated grief.

These theories include those summarized below:

  • Warden's Four Tasks of Mourning: This theory has four tasks that people go through after the loss of a loved one. These four tasks are typically completed by the person after about a year of grieving. These tasks are accepting the loss, coping with the loss, altering, modifying and changing the environment to cope with and accommodate for the absence of the lost person, and, finally, resuming one's life while still having a healthy connection with the loved one.
  • Engel's Stages of Grieving: Engel's Stages of Grieving theory describes these steps in this proper sequential order:
    • Shock and disbelief
    • Developing awareness
    • Restitution
    • Resolving the loss
    • Idealization
    • Outcome

The client denies the loss and refuses to accept the fact that the loss has actually occurred during the shock and disbelief stage; during the developing awareness stage of this theory, the client discards the previous denial and begins to develop an awareness and acknowledgement of the loss; the grieving person works through the mourning process and they often perform spiritual and cultural rituals during this stage; the resolution stage is characterized with the affected person's seeking out of social support systems to resolve the grief after which the client may deify and idealize the lost one; the final stage of Engel's theory is the outcome phase during which time the affected client will adjust to and cope with the loss.

  • Sander's Phases of Bereavement: Sander's phases of bereavement in correct sequential order are:
    • Shock
    • Awareness of the loss
    • Conservation and withdrawal
    • Healing or the turning point
    • Renewal

These phases are quite similar to those of Engel with some variations. For example, during the conservation and withdrawal phase, the person will withdraw from others and attempt to restore their physical and emotional wellbeing; and during the healing stage, the person will move from emotional distress to the point where they are able to learn how to live without the loved one. During the renewal phase, the person is able to independently live without the loved one.

  • Kubler Ross's Stages of Grieving: This theory is perhaps the most popular of all theories and conceptual frameworks relating to grief and loss. This theory has five stages in this sequential order.
    • Denial
    • Anger
    • Bargaining
    • Depression
    • Acceptance

Kubler Ross's Stages of Grieving are similar to other theories in terms of denial, anger, depression and acceptance. The bargaining stage, however, is unique to Kubler Ross's Stages of Grieving. In this context, bargaining entails the client's negotiation with their maker or higher power to delay their inevitable death. For example, they may pray to their god to let them live long enough to be able to participate in a major event like the birth of a grandchild, the graduation of a child, or the wedding of their god daughter.

Assisting the Client in Coping with Suffering, Grief, Loss, Dying, and Bereavement

The defining characteristics of grief and loss can include altered immune responses, distress, anger, sleep disturbances, blame, withdrawal, pain, panic, suffering and alterations with neuroendocrine functioning, among other signs and symptoms.

Coping and coping mechanisms to grief can vary greatly among individuals. This coping can be impacted by a number of factors and forces such as one's cultural background, spiritual or religious background, the client's past experiences with losses, the person's level of growth and development which impacts on one's perception of death and loss such as a lack of understanding about the finality of death, one's level of social supports and interpersonal relationships, socioeconomic status, ethnicity, and the client's perception of the gravity and severity of the loss.

Nurses assist the client with the grieving process and with coping with the suffering, grief, loss, death and bereavement. As with all other nurse-client relationships, the nurse initiates the relationship by establishing trust with the client and then encouraging the person to ventilate their feelings within the trusting, supportive and nonjudgmental environment. The nurse also assists the client in terms of their coping with grief and loss by encouraging the client to learn about and employ effective coping strategies, by encouraging the family members and significant others to care for and support the affected the client, and, when needed, the nurse makes referrals for the client so that available community resources are utilized. Some of these referrals may include psychological, social, religious and spiritual support, individual counseling, group and family therapy, and peer support groups in the community to promote adaptive grieving and to prevent complicated grieving.

Complicated grieving is a failure of the client to go through the grieving process in a normal manner without prolonged signs and symptoms and the resumption of the normal activities of daily living and socialization within a reasonable amount of time. The client should be assessed for complicated grieving and, at times, standardized tests and tools such as the Pathological Grief Items Checklist, the Hamilton Rating Scale for Depression, the Hogan Grief Reaction Checklist, the Beck Depression Inventory, the Texas Inventory of Grief, and the Social Adjustment Scale are used to more comprehensively assess the client.

Supporting the Client in Anticipatory Grieving

As previously mentioned, grief can be categorized and classified as normal grief, dysfunctional complicated grief, anticipatory grief, disenfranchised grief, and grief that occurs as the result of a public tragedy. Anticipatory grief is grief that is experienced prior to an actual loss. Anticipatory grieving gives the client and the family members the opportunity to begin the grieving process before a client is actually lost.

Anticipatory grieving can occur as the result of a terminal illness, the anticipated loss of a bodily part as the result of a planned surgical procedure and other losses.

Informing the Client of Expected Reactions to Grief and Loss

Clients typically react in different ways to grief and loss. Nurses assess these reactions and they also educate and inform the client about these reactions and how they are the normal results of the grieving process when indeed they are. This acknowledgement and the support of the nurse can help the client to understand that they are not alone and that they are experiencing normal feelings, signs and symptoms of grief.

Providing the Client with Resources to Adjust to Loss/Bereavement

As previously mentioned, clients who are experiencing loss and bereavement can often be helped with resources such as individual therapy, group therapy and peer support groups in the community.

Evaluating the Client's Coping and Fears Related to Grief and Loss

Nurses evaluate the client's coping and their fears related to grief and loss. Some of the expected outcomes for these clients can include:

  • The client will be free of complicated grieving
  • The client will verbalize and express their true feelings
  • The client will seek the help and support of others
  • The client will identify their own strengths and weaknesses
  • The client will utilize effective coping mechanisms
  • The client will resume their normal life in one year of less
  • The client will discuss the meaning of their loss

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