1. Dr. Belal Hijji, RN, PhD April 28 & 29, 2012
Loss and Grief
Dr. Belal Hijji, RN, PhD
April 28 & 29, 2012

2. Learning Outcomes
After this clinical session, students will be able to:
Define loss and identify its types and categories.
Define grief, discuss its types and some of its theories.
Discuss factors that affect loss and grief.
Describe nursing interventions of a grieving person.

3. Loss
A person experiences loss in the absence of an object, person, body part or function, emotion, or idea that was formerly present.
There are many types of loss, including:
Actual: which is a loss of person or object that can no longer be felt, heard, known, or experienced by an individual.
Perceived: a loss that is tangible and uniquely defined by a grieving client. It may be less obvious to others, such as loss of confidence, prestige, or control.
Maturational: which includes any change in the developmental process that is a normal life expectation. An example is a mother’s feeling of loss as child goes to school for the first time.
Situational: this includes any sudden, unexpected, external unpredictable event such as car accident.

4. There are also four major categories of loss. These are:
Loss of an external object: When an object that a person highly values is damaged, changed, or disappears, loss occurs. The valued object may be a person, pet, or one’s home. The loss of a pet, especially for those who live alone, can be a devastating loss.
Loss of familiar environment: This occurs when a person moves to another home or a different community, changes schools, or starts a new job. Also, a client who is hospitalized or institutionalized experiences loss when faced with new surroundings. This type of loss evokes anxiety caused by fear of the unknown.
Loss of aspect of self: Loss of an aspect of self can be physiological (loss of physical function as a result of illness or injury, disappearance of body part) or psychological (loss of ambition, or enjoyment of life).

5. Loss of significant other: The loss of a loved one is a significant loss. Such a loss can result from separation, divorce, running away, moving to a different area, or death. Responses to loss are highly individualized as each person perceives the meaning of loss differently. For example, the death of a spouse is different for men and women. Men who are widowed react as if they have lost a part of themselves, whereas women react as if they have been abandoned.
Figure 1: Losing a spouse who has been a part of their lives for many years is common for older adults. How can nurses support elders during the grieving process?

6. Grief
Grief [great sadness] is a series of intense physical and psychological responses that occur following a loss. It is a normal, natural, necessary, and adaptive response to a loss.
Loss leads to the adaptive process of mourning [showing of deep sadness], the period of time during which the grief is expressed and resolution and integration of the loss occur. Bereavement [الفاجعة] is the period of grief following the death of a loved one.
There is a number of theories that explain the grieving process. However, none of them provides comprehensive explanation. For our purpose, two theories will be described next.

7. Lindmann’s Theory: Reactions to Normal Grief
Somatic distress
Episodic waves of discomfort in duration of 10–60 minutes; multiple somatic complaints, fatigue, and extreme physical or emotional pain.
Preoccupation with the image of the deceased
The bereaved experience a sense of unreality, emotional detachment from others, and an overwhelming preoccupation with visualizing the deceased.
Guilt
The bereaved consider the death to be a result of their own negligence or lack of attentiveness; they look for evidence of how they could have contributed to the death.
Hostile reactions
Relationships with others become impaired owing to the bereaved’s desire to be left alone, irritability, and anger.
Loss of patterns of conduct
The bereaved exhibit an inability to sit still, generalized restlessness and continually search for something to do.

8. Engle’s Theory of Grief: Three Stages of Mourning
Stage I: Shock and disbelief
Disorientation
Feeling of helplessness
Denial gives protection until person is able to face reality
Stage I can last from minutes to days.
Stage II: Developing awareness
Emotional pain occurs with increased reality of loss
Recognition that one is powerless to change the situation
Feelings of helplessness
Anger and hostility may be directed at others
Guilt
Sadness
Isolation
Stage II may last from 6 to 12 months.

9. Engle’s Theory (Continued…)
Stage III: Restitution [the return of something to the condition it was in before it was changed] and resolution
Emergence of bodily symptoms
May idealize the deceased
Mourner starts to come to terms with the loss
Establishment of new social patterns and relationships
Stage III marks the beginning of the healing process and may
take up to several years.

10. Types of Grief
Uncomplicated grief: Many individuals use the term normal grief. The term uncomplicated grief describes a grief reaction that normally follows a significant loss. Uncomplicated grief runs a fairly predictable course that ends with the relinquishing [اعتزال] of the lost object and resumption of the previous life. Of course, the bereaved person’s life is changed forever, but the person is able to regain the ability to function. “Expression of loss is often experienced by common responses such as insomnia, anorexia, weight loss, and inability to concentrate.

11. Types of Grief (Continued…)
Dysfunctional grief: Persons experiencing dysfunctional grief do not progress through the stages of overwhelming emotions associated with grief, or they may fail to demonstrate any behaviors commonly associated with grief. The person experiencing pathologic grief continues to have strong emotional reactions, does not return to a normal sleep pattern or work routine, usually remains isolated, and has altered eating habits. The bereaved may have the need to endlessly tell and retell the story of loss but without subsequent healing. The pathologically grieving person is unable to reestablish a routine. A person experiencing chronic grief continues to focus on the deceased and may overvalue objects that belonged to him/ her.

12. Types of Grief (Continued…)
Anticipatory grief: Anticipatory grief is the occurrence of grief work before an expected loss. Anticipatory grief may be experienced by the terminally ill person as well as family. This phenomenon promotes adaptive grieving by freeing up the mourner’s emotional energy. Although anticipatory grieving may be helpful in adjusting to the loss, it may also result in some disadvantages. For example, for the dying client, anticipatory grieving may lead to family members’ distancing themselves and not being supportive to him. If this happens, they may seem cold and distant, thus, not meeting society’s expectations of mourning behavior. This response can prevent the mourners from receiving their own much needed support from others.

13. Factors Affecting Loss and Grief
Human development: persons of different ages and stages of development will display different and unique symptoms of grief.
A toddler feels anxious over loss of a toy or separation from parents.
School age children experience grief over the loss of body part.
Middle age adult is sensitive to own physical changes.
Older adults often experiences anticipatory grief over aging
Socioeconomic status: This influences a person’s ability to obtain option and use support mechanisms when coping with loss.
An example is a poor person who may not be able to replace a home lost in fire or purchase necessary medication.

14. Personal relationship: The quality and meaning of the relationship severed by loss of beloved one is critical in understanding a person’s grief experience.
Loss of parents: loss of the past.
Loss of spouse: loss of the present.
Loss of son: loss of the future.
Culture and ethnicity: Interpretation of a loss and the expression of grief arise from cultural and/ or ethnic backgrounds.
In the West, the grieving process usually personal and private; individuals show restrained emotions.
In the East, respect for the dead is shown by loud wailing [crying] and physical demonstration of grief.

15. Nursing Interventions of a Grieving Person
Therapeutic nursing care is based on an understanding of the significance of the loss to the client. To understand the client’s perspective, the nurse must spend time listening and must demonstrate acceptance. The nurse’s nonjudgmental, accepting attitude is essential while the bereaved expresses anger.
The nurse communicates an understanding of the client’s anger—and avoids using defensive behaviors. Grieving people need reassurance, counseling, and support (Figure 2). One mechanism of providing support on a long-term basis is social support groups. Thus, the nurse needs to be aware of the availability of such groups within the community to make appropriate referrals.

16. Figure 2: Note the nurse’s nonverbal expression of support for this couple’s grief over the loss of their child.