Definition
Losing is a state of the individual part with something that previously existed, and then becomes nothing, good things happen in part or whole. Loss of an experience ever experienced by each individual over the course of life, from birth individuals have experienced a loss and tend to experience it again, although in a different form.
S. Sundeen (1995:426) states:
Loss of attachment: The loss may be real or imagined and may include the loss of love, a person, physical Functioning, status or self esteem. Many losses take on importance because of their symbolic meaning. May involve the loss of old friends, warm memories, and neighborhood association. The ability to sustain, integrate and recover from loss, however is a sign of personal maturity and growth.
Loss of attachment (proximity of a person against another person is considered important), a loss which includes real events or just a fantasy (which caused a person's perception of events), such as love, loss of meaning, physical function, self-esteem. Many situations are considered highly influential lose because it has a higher meaning. May also include loss of old friends, wonderful memories, good neighbors. Person's ability to survive, remain stable, and be positive about losing, is a sign of maturity and growth.
Experiences of loss are normal and essential in human life. Letting go, relinquishing, and moving on happen continually as a person travels through the stages of growth and development. People frequently say “goodbye” to places, people, dreams, and familiar objects. Example of necessary losses that accompany growth include abandoning a favorite blanket or toy, leaving a first-grade teacher, and giving up the adolescent hope of becoming a famous rock star. Loss allows a person to change, develop, and fulfill his or her innate human potential. Loss may be planned, expected, or sudden. Although it can be difficult, loss sometimes is beneficial. Other times, it is devastating and debilitating.
Types of losses
A helpful way to examine different types of losses is to use Abraham Maslow’s hierarchy of needs motivates human actions. These needs begin with physiologic needs (food, air, water, sleep), then safety needs (a safe place to live and work), then security and belonging needs (satisfying relationships). After those needs comes the need for self-esteem, which leads to feelings of adequacy and confidence. The last and final need is self-actualization, the ability to realize one’s full innate potential. When these human needs are taken away or not met for some reason, the person experiences loss. Examples of losses related to specific human needs in Maslow’s hierarchy are as follows:
Process loss
Experiences of loss are normal and essential in human life. Letting go, relinquishing, and moving on happen continually as a person travels through the stages of growth and development. People frequently say “goodbye” to places, people, dreams, and familiar objects. Example of necessary losses that accompany growth include abandoning a favorite blanket or toy, leaving a first-grade teacher, and giving up the adolescent hope of becoming a famous rock star. Loss allows a person to change, develop, and fulfill his or her innate human potential. Loss may be planned, expected, or sudden. Although it can be difficult, loss sometimes is beneficial. Other times, it is devastating and debilitating.
Types of losses
A helpful way to examine different types of losses is to use Abraham Maslow’s hierarchy of needs motivates human actions. These needs begin with physiologic needs (food, air, water, sleep), then safety needs (a safe place to live and work), then security and belonging needs (satisfying relationships). After those needs comes the need for self-esteem, which leads to feelings of adequacy and confidence. The last and final need is self-actualization, the ability to realize one’s full innate potential. When these human needs are taken away or not met for some reason, the person experiences loss. Examples of losses related to specific human needs in Maslow’s hierarchy are as follows:
- Physiologic loss. Examples include amputation and loss of adequate air exchange or pancreatic functioning.
- Safety loss. Loss of a safe environment such as following domestic or public violence. A person may perceive a breach of confidentiality in the professional relationship as a loss of psychological safety secondary to broken trust between client and provider.
- Loss of security and a sense of belonging. The loss of a loved one affects the need to love and be loved. Loss accompanies changes in relationships such as birth, marriage, divorce, illness, and death: as the meaning of a relationship changes, a person may lose roles within a family or group.
- Loss of self-esteem. Any change in how a person is valued at work or in relationship can threaten his or her need for self-esteem. A change in self-perception can challenge sense of self-worth, which the person may experience as a loss. A loss of role function and the self-perception and worth tied to that role may accompany the death of a loved one.
- Loss related to self-actualization. An external or internal crisis that blocks or inhibits strivings toward fulfillment may threaten personal goals and individual potential (Parkes, 1998). A change in goals or direction will precipitate an inevitable period of grief as the person gives up a creative though to make room for new ideas and directions. Examples include having to give up plans to attend graduate school or losing the hope of marriage and family.
- Internal or external stressor --- --- disturbances and loss of individuals giving a positive meaning --- to compensate the positive activities --- repair (adapt and feel comfortable).
- Internal or external stressor disruption and loss --- --- --- individuals give meaning to feel angry and helpless --- --- expressed aggression applies to the self --- the physical symptoms appear.
- Internal or external stressor disruption and loss --- --- --- individuals give meaning to feel angry and helpless --- --- true aggression outward expression of individual compensation --- --- constructive manner improvements (to adapt and feel comfortable).
- Internal or external stressor disruption and loss --- --- --- individuals give meaning to feel angry and helpless --- --- true aggression outward expression of individual compensation --- --- destructive behavior to feel guilty -- - helplessness.
In a religious perspective in the face of human loss will be required to wait, surrender, accept, and return to God because only He is the absolute owner of all that we love and people are not owners of what is claimed. As word of God:
"And so we will test you with something of fear, hunger, lack of wealth and lives and fruits, and give glad tidings to those who wait, when they seized the disaster they say we belong to God and will return to God , they will get the blessing and mercy from their Lord ".
"And so we will test you with something of fear, hunger, lack of wealth and lives and fruits, and give glad tidings to those who wait, when they seized the disaster they say we belong to God and will return to God , they will get the blessing and mercy from their Lord ".
Loss phases
1. denial Phase
The first reaction of individuals who experience loss is shock, do not believe or deny the fact that the loss occurred, to say or deny the fact that the loss took place, saying "No, I do not believe that it happened '," it is not possible ". For individuals or families who have a terminal illness, will continue to seek additional information. Physical reactions that occur in the denial phase is tired, weak, pale, nausea, diarrhea, breathing difficulties, rapid heart rate, crying, nervous, not knowing what to do. Above reaction rapidly over within a few minutes to a few years.
2. anger Phase
Phase incidence begins with awareness of the reality of loss. Individuals showed an increased feeling yan often projected onto the people who have dilingkungannya, certain people or directed at herself, she seldom showed no aggressive behavior, talk rude, refused treatment, and accused the doctors and nurses who are not incompetent. Physical response that often occurs in this phase, among others, face red, rapid pulse, anxiety, difficulty sleeping, hands clenched.
3. Bargaining phase
If the individual has been able to express her anger intensively, then he will go to the bargaining phase with begging God's mercy. This response is often expressed with the words "if only this could be postponed so I would often pray". If this grieving process experienced by the family following statements are common, "if the pain is not my son".
4. depression Phase
Individuals in this phase often showed the attitude among others withdrew, did not want to talk, sometimes acting as a very good patient and according to, or in terms that express the despair, feelings of worthlessness. Physical symptoms that are often shown is refusing to eat, sleep, fatigue, decreased libido boost.
5. acceptance Phase
This phase is associated with the reorganization of the loss. The mind is always focused on the missing object or person will begin to diminish or disappear, the individual has to accept the fact that experienced loss, the image of the object or person is missing from released and attention gradually shifted to the new object. This phase is usually expressed received with words like "I really love clothes but I lost my new clothes, too sweet" or "what I do to dapt me a speedy recovery". If the individual can start these phases and entered the phase of peace or acceptance phase, then he will be able to end the grieving process and cope with feelings of loss completely. But if individuals remain in one phase and not dim until the acceptance phase, if you have lost more difficult for him in the acceptance phase.
1. denial Phase
The first reaction of individuals who experience loss is shock, do not believe or deny the fact that the loss occurred, to say or deny the fact that the loss took place, saying "No, I do not believe that it happened '," it is not possible ". For individuals or families who have a terminal illness, will continue to seek additional information. Physical reactions that occur in the denial phase is tired, weak, pale, nausea, diarrhea, breathing difficulties, rapid heart rate, crying, nervous, not knowing what to do. Above reaction rapidly over within a few minutes to a few years.
2. anger Phase
Phase incidence begins with awareness of the reality of loss. Individuals showed an increased feeling yan often projected onto the people who have dilingkungannya, certain people or directed at herself, she seldom showed no aggressive behavior, talk rude, refused treatment, and accused the doctors and nurses who are not incompetent. Physical response that often occurs in this phase, among others, face red, rapid pulse, anxiety, difficulty sleeping, hands clenched.
3. Bargaining phase
If the individual has been able to express her anger intensively, then he will go to the bargaining phase with begging God's mercy. This response is often expressed with the words "if only this could be postponed so I would often pray". If this grieving process experienced by the family following statements are common, "if the pain is not my son".
4. depression Phase
Individuals in this phase often showed the attitude among others withdrew, did not want to talk, sometimes acting as a very good patient and according to, or in terms that express the despair, feelings of worthlessness. Physical symptoms that are often shown is refusing to eat, sleep, fatigue, decreased libido boost.
5. acceptance Phase
This phase is associated with the reorganization of the loss. The mind is always focused on the missing object or person will begin to diminish or disappear, the individual has to accept the fact that experienced loss, the image of the object or person is missing from released and attention gradually shifted to the new object. This phase is usually expressed received with words like "I really love clothes but I lost my new clothes, too sweet" or "what I do to dapt me a speedy recovery". If the individual can start these phases and entered the phase of peace or acceptance phase, then he will be able to end the grieving process and cope with feelings of loss completely. But if individuals remain in one phase and not dim until the acceptance phase, if you have lost more difficult for him in the acceptance phase.
APPLICATION OF THE NURSING PROCESS
Because the strong emotional attachment created in a significant relationship is not released easily, the loss of that relationship is a major crisis with momentous consequences. Aquilera and Messic (1982) developed a broad approach to assessment and intervention in their work on crisis intervention. The state of disequilibrium that a crisis produces causes great consternation, compelling the person to return to homeostasis, a state of equilibrium or balance. Factor that influence the grieving person’s return to homeostasis are adequate perception of the situation, adequate situational support, and adequate coping. These factors help the person to regain balance and return to precious functioning or even to use the crisis as an opportunity to grow. Because any loss may be perceived as a personal crisis, it seems appropriate for the nurse to link understanding of crisis theory with the nursing process.
For the nurse to support and facilitate the grief process for clients, he or she must observe and listen for cognitive, emotional, spiritual, behavioral, and physiologic cues. Although the nurse must be familiar with the phases, tasks, and dimensions of human response to loss, he or she must realize that each client’s experience is unique. Skillful communication is key to performing assessment and providing interventions.
To meet clients’ needs effectively, the nurse must examine his or her own personal attitudes, maintain an attentive presence and provide a psychologically safe environment for deeply intimate sharing. Awareness of one’s own beliefs and attitudes is essential so that the nurse can avoid imposing them on the client. Attentive presence is being with the client and focusing intently on communicating with and understanding him or her (Skott, 2001). The nurse can maintain attentive presence by using open body language such as standing or sitting with arms down, facing the client, and maintaining moderate eye contact especially as the client speaks. Creating a psychologically safe environment includes assuring the client of confidentiality, refraining from judging or giving specific advice, and allowing the client to share thoughts and feelings freely.
Assessment
Effective assessment involves observing all dimensions of human response: what the person is thinking (cognitive), how the person is feeling (emotional), what the person’s values and beliefs are (spiritual), how the person is acting (behavioral), and what is happening in the person’s body (physiological). Effective communication skills during assessment can lead the client toward understanding his or her experience. Thus assessment facilitates the client’s grief process.
While observing for client responses in the dimensions of grieving, the nurse explores three critical components in assessment:
- Adequate perception regarding the loss
- Adequate support while grieving for the loss
- Adequate coping behaviors during the process
Assessment begins with exploration of the client’s perception of the loss. What does the loss mean to the client? For the woman who has spontaneously lost her first unborn child and the woman who has elected to abort a pregnancy, this question could have similar or different answers. Nevertheless the question is valuable for beginning to facilitate the grief process.
Other questions that assess perception as well as encourage the client’s movement through the grief process include the following:
- 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?
Assessing the client’s “need to know” in plain and simple language invites the client to verbalize perceptions that may need clarification. This is especially true for the person who is anticipating a loss such as in a life-ending illness or the loss of a body part. The nurse uses open-ended questions and helps to clarify any misperceptions.
Consider the following. The doctor has just informed Ms. Morrison that the lump on her breast is cancerous and that she is scheduled for a mastectomy in 2 days. The nurse visits the client after rounds and finds her quietly watching television.
Consider the following. The doctor has just informed Ms. Morrison that the lump on her breast is cancerous and that she is scheduled for a mastectomy in 2 days. The nurse visits the client after rounds and finds her quietly watching television.
Nurse: “How are you?” (offering presence; giving a broad opening)
Client: “Oh, I’m fine. Really, I am.”
Nurse: “The doctor was just here. Tell me, what is your understanding of what he said?” (using open-ended questions for description of perception)
Client: “well, I think he said that I will have to have surgery on my breast.”
Nurse: “How do you feel about that news?” (using open-ended question for what it means to the client)
Client: “Oh, I’m fine. Really, I am.”
Nurse: “The doctor was just here. Tell me, what is your understanding of what he said?” (using open-ended questions for description of perception)
Client: “well, I think he said that I will have to have surgery on my breast.”
Nurse: “How do you feel about that news?” (using open-ended question for what it means to the client)
Exploring what the person believes about the grieving process is another important assessment. Does the client have preconceived ideas about when or how grieving should happen? The nurse can help the client realize that grieving is very personal and unique: each person grieves in his or her own way.
The nurse finds Ms. Morrison hitting her pillow and crying. This is her second postoperative day. She has eaten little food and has refused visitors since the surgery.
Nurse: “Ms. Morrison. I see that you are upset. Tell me, what is happening right now?” (sharing observation; encouraging description)
Client: “oh, I’m so disgusted with myself. I’m sorry you had to see me act this way. I should be snapping out of this and getting on with my life.”
Nurse: “you’ve had to deal with quite a shock these past few days. Sounds to me like you are expecting quite a bit of yourself. What do you think?” (using reflection; sharing perceptions; seeking validation)
Client: “I don’t know, maybe. How long is this going to go on? I’m a wreck emotionally.”
Nurse: “you are grieving, and there is no fixed timetable for what you are dealing with. Everyone has a unique time and way of doing this work.” (informing; validating experience)
The nurse finds Ms. Morrison hitting her pillow and crying. This is her second postoperative day. She has eaten little food and has refused visitors since the surgery.
Nurse: “Ms. Morrison. I see that you are upset. Tell me, what is happening right now?” (sharing observation; encouraging description)
Client: “oh, I’m so disgusted with myself. I’m sorry you had to see me act this way. I should be snapping out of this and getting on with my life.”
Nurse: “you’ve had to deal with quite a shock these past few days. Sounds to me like you are expecting quite a bit of yourself. What do you think?” (using reflection; sharing perceptions; seeking validation)
Client: “I don’t know, maybe. How long is this going to go on? I’m a wreck emotionally.”
Nurse: “you are grieving, and there is no fixed timetable for what you are dealing with. Everyone has a unique time and way of doing this work.” (informing; validating experience)
SUPPORT
Purposeful assessment of support systems provides the grieving client with an awareness of those who can meet his or her emotional and spiritual needs for security and love. The nurse can help the client to identify his or her support systems and reach out and accept what they can offer.
Nurse: “who in your life should or would really want to know what you’ve just heard from the doctor?” (seeking information about situational support)
Client: “oh, I’m really alone. I’m not married and don’t have any relatives in town.”
Nurse: “there’s no one who would care about this news?” (voicing doubt)
Client: “oh, maybe a friend I talk with on the phone now and then.”
Client: “oh, I’m really alone. I’m not married and don’t have any relatives in town.”
Nurse: “there’s no one who would care about this news?” (voicing doubt)
Client: “oh, maybe a friend I talk with on the phone now and then.”
COPING BEHAVIORS
The client’s behavior is likely to give the nurse the easiest and most concrete information about coping skills. The nurse must be careful to observe the client’s behavior throughout the grief process and never assume that a client is at a particular phase. The nurse must use effective communication skills to assess how the client’s behavior reflects coping as well as emotions and thoughts.
The nurse has heard in report that Ms. Morrison received the news of her upcoming mastectomy. She enters Ms. Morrison’s room and sees her crying with a full tray of food untouched.
Nurse: “you must be quite upset about the news you received from the doctor today.” (making an observation, assuming client was crying as an expected behavior of loss and grief)
Client: “I’m not having surgery. You have me mistaken for someone else.” (using denial to cope)
The nurse also must consider several other questions when assessing the client’s coping. How has the person dealt with loss previously? How is the person currently impaired? How does the current experience compare with previous experiences? What does the client perceive as a problem? Is it related to unrealistic ideas about what he or she should feel or do? (McBride, 2001).
The client’s behavior is likely to give the nurse the easiest and most concrete information about coping skills. The nurse must be careful to observe the client’s behavior throughout the grief process and never assume that a client is at a particular phase. The nurse must use effective communication skills to assess how the client’s behavior reflects coping as well as emotions and thoughts.
The nurse has heard in report that Ms. Morrison received the news of her upcoming mastectomy. She enters Ms. Morrison’s room and sees her crying with a full tray of food untouched.
Nurse: “you must be quite upset about the news you received from the doctor today.” (making an observation, assuming client was crying as an expected behavior of loss and grief)
Client: “I’m not having surgery. You have me mistaken for someone else.” (using denial to cope)
The nurse also must consider several other questions when assessing the client’s coping. How has the person dealt with loss previously? How is the person currently impaired? How does the current experience compare with previous experiences? What does the client perceive as a problem? Is it related to unrealistic ideas about what he or she should feel or do? (McBride, 2001).
Data Analysis and Planning
The nurse must base nursing diagnoses for the person experiencing loss on subjective and objective assessment data. Nursing diagnoses used for clients experiencing grief include the following:
- Grieving related to actual or perceived loss such as a physiologic loss (e.g., loss of a limb). Loss of security and sense of belonging (e.g., loss of a loved one) is defined as a normal process in the human experience of loss.
- Anticipatory grieving (NANDA), related to the intellectual and emaotional responses and behaviors by which individuals, families, and communities work through the process of modifying self-concept based on the perception of potential loss.
- Dysfunctional grieving (NANDA diagnosis for complicated grieving) related to the extended, unduccessful use of intellectual and emotional responses by which individuals, families, and communities attempt to work through the process of modifying self-concept based upon the perception of loss.
Examples of outcomes for the three nursing diagnoses are as follows:
- Grieving: the client will
- Identify the effects of his or her loss.
- Seek adequate support.
- Apply effective coping strategies while espressing an assimilating all demensions of human response to loss in his or her life.
- 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.
- 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.
The nurse’s guidance helps the client examine and make changes. Changes imply movement as the client progresses through the grief process. Sometimes the client takes one painful step at a time. Sometimes he or she may seem to go over the same ground repeatedly.
INTERVENTIONS REGARDING THE PERCEPTION OF LOSS
Cognitive responses are connected significantly with the intense emotional turmoil that accompanies grieving. For example in the vignette, Margaret’s disillusionment with those friends unavailable after her husband’s death added great pain to her loss. She had counted on them to be there as she dealt with James’ death. A cognitive shift occurred when she realized they would not be there, meaning she was alone and they no longer cared. She felt abandoned. She then had two immediate losses: James’ death and realizing that people she had counted on were unavailable.
Exploring the client’s perception and meaning of the loss is a first step that can help alleviate the pain of what some would call the initial emotional overload in grieving. Using the example of Margaret, the nurse could ask what being alone means to her and explore the possibility of others being supportive. Further exploration could focus on her perception that those who had abandoned her no longer cared. Perhaps Margaret would then discover that others could meet her need to b e cared for. She may begin to think that it was fear or discomfort about death that kept former friends away. In fact, it was in just this way that she could accept the caring of some friends and release the importance of those who would not or could not b e there for her. In this situation, exploring perceptions and the meaning of the loss helped the bereaved to make cognitive shifts that valuably influenced her emotional experience.
When loss occurs, especially if it is sudden and without warning, the cognitive defense mechanism of denial acts as a cushion to soften the effects. Typical verbal responses are, “I can’t believe this has happened. It can’t be true. There’s been a mistake.”
Adaptive denial, in which the client gradually adjusts to the reality of the loss, can help the client let go of previous (before the loss) perceptions while creating new ways of thinking about himself or herself, others, and the world. For example, Margaret had to face the reality that, although she believed that a priest (because he was a priest) would care about her being alone in the surgery waiting room, he actually was concerned only about getting a paper. Gradually she was able to relinquish this assumption.
Effective communication skills can be useful I helping the client in adaptive denial move toward acceptance. In the following example, the nurse has heard in report that Ms. Morrison received the news of her upcoming mastectomy. She enters Ms. Morrison’s room and sees her crying with a full tray of food untouched.
Exploring the client’s perception and meaning of the loss is a first step that can help alleviate the pain of what some would call the initial emotional overload in grieving. Using the example of Margaret, the nurse could ask what being alone means to her and explore the possibility of others being supportive. Further exploration could focus on her perception that those who had abandoned her no longer cared. Perhaps Margaret would then discover that others could meet her need to b e cared for. She may begin to think that it was fear or discomfort about death that kept former friends away. In fact, it was in just this way that she could accept the caring of some friends and release the importance of those who would not or could not b e there for her. In this situation, exploring perceptions and the meaning of the loss helped the bereaved to make cognitive shifts that valuably influenced her emotional experience.
When loss occurs, especially if it is sudden and without warning, the cognitive defense mechanism of denial acts as a cushion to soften the effects. Typical verbal responses are, “I can’t believe this has happened. It can’t be true. There’s been a mistake.”
Adaptive denial, in which the client gradually adjusts to the reality of the loss, can help the client let go of previous (before the loss) perceptions while creating new ways of thinking about himself or herself, others, and the world. For example, Margaret had to face the reality that, although she believed that a priest (because he was a priest) would care about her being alone in the surgery waiting room, he actually was concerned only about getting a paper. Gradually she was able to relinquish this assumption.
Effective communication skills can be useful I helping the client in adaptive denial move toward acceptance. In the following example, the nurse has heard in report that Ms. Morrison received the news of her upcoming mastectomy. She enters Ms. Morrison’s room and sees her crying with a full tray of food untouched.
Nurse: “you must be quite upset about the news you received from your doctor about your surgery.” (using reflection, assuming the client was crying as an expected response of grief. Focusing on the surgery is an indirect approach regarding the subject of cancer.)
Client “I’m not having surgery. You have me mistaken for someone else.” (using denial)
Nurse: “I saw you crying and wonder what is up setting you. I’m interested in how you are feeling” (focusing on behavior and sharing observation while indicating concern and accepting the client’s denial)
Client: “I’m just not hungry. I don’t have an appetite and I’m not clear what the doctor said” (focusing on physiologic response; nonresponsive to nurse’s encouragement to talk about feelings; acknowledging doctor’s visit but unsure of what he said—beginning to adjust cognitively to reality of condition)
Nurse: “I wonder if not wanting to eat may be related to what your are feeling. Are there times when you don’t have an appetite and you feel upset about something?” (suggesting a connection between physiologic response and feelings; promoting adaptive denial)
Client: “well, as a matter of fact, yes. But I can’t think what I would be upset about.” (acknowledging a connection between behavior and feeling; continuing to deny reality)
Nurse: ”you said you were unclear about what the doctor said. I wonder if things didn’t seem clear because it may have upset you to hear what he had to say. Then tonight you don’t have an appetite.” (using client’s experience to make connection between doctor’s news and client’s physiologic response and behavior)
Client: “what did he say, do you know?” (requesting information; demonstrating a readiness to hear it again while continuing to adjust to reality)
In this example, the nurse gently but persistently guides the client toward acknowledging the reality of her impending loss.
Client “I’m not having surgery. You have me mistaken for someone else.” (using denial)
Nurse: “I saw you crying and wonder what is up setting you. I’m interested in how you are feeling” (focusing on behavior and sharing observation while indicating concern and accepting the client’s denial)
Client: “I’m just not hungry. I don’t have an appetite and I’m not clear what the doctor said” (focusing on physiologic response; nonresponsive to nurse’s encouragement to talk about feelings; acknowledging doctor’s visit but unsure of what he said—beginning to adjust cognitively to reality of condition)
Nurse: “I wonder if not wanting to eat may be related to what your are feeling. Are there times when you don’t have an appetite and you feel upset about something?” (suggesting a connection between physiologic response and feelings; promoting adaptive denial)
Client: “well, as a matter of fact, yes. But I can’t think what I would be upset about.” (acknowledging a connection between behavior and feeling; continuing to deny reality)
Nurse: ”you said you were unclear about what the doctor said. I wonder if things didn’t seem clear because it may have upset you to hear what he had to say. Then tonight you don’t have an appetite.” (using client’s experience to make connection between doctor’s news and client’s physiologic response and behavior)
Client: “what did he say, do you know?” (requesting information; demonstrating a readiness to hear it again while continuing to adjust to reality)
In this example, the nurse gently but persistently guides the client toward acknowledging the reality of her impending loss.
INTERVENTIONS REGARDING SUPPORT
The nurse can help the client to reach out and accept what others want to give in support of his or her grieving process.
Nurse: “who in your life would really want to know what you’ve just heard from the doctor?” (seeking information about situational support for the client)
Client: “oh, I’m really alone. I’m not married”
Nurse: “there’s no one who would care about this news?” (voicing doubt)
Client: “oh, maybe a friend I talk with on the phone now and then.”
Nurse: “why don’t I get the phone book for you and you can call her right now?” (continuing to offer presence; suggesting an immediate source of support; developing a plan of action providing further support)
Client: “oh, I’m really alone. I’m not married”
Nurse: “there’s no one who would care about this news?” (voicing doubt)
Client: “oh, maybe a friend I talk with on the phone now and then.”
Nurse: “why don’t I get the phone book for you and you can call her right now?” (continuing to offer presence; suggesting an immediate source of support; developing a plan of action providing further support)
Many internet resources are available to nurses who want to help a client find information, support groups, and activities related to the grieving process. Bereavement and Hospice Support Netline is one source with numerous internet links to various organizations that provide support and education throughout the United States. If a client does not have internet access most public libraries can help to locate groups and activities that would serve his or her needs. Depending on the state where a person lives, specific groups exist for those who have lost a child, spouse, or other loved one to suicide, murder, motor vehicle accident, or cancer.
INTERVENTIONS REGARDING COPING BEHAVIORS
When attempting to focus Ms. Morrison on the reality of her surgery, the nurse was helping her shift from an unconscious mechanism of denial to conscious coping with reality. The nurse used communication skills to encourage Ms. Morrison to examine her experience and behavior as possible ways in which she might be coping with the news of loss. Margaret and James’s logical approach to life allowed them to cope by continuing to have fun together while attending ti medical regimens as they faced the realty of his impending death.
Intervention involves giving the client the opportunity to compare and contrast ways in which he or she has coped with significant loss in the past and helping him or her to review strengths and renew a sense of personal power. Remembering and practicing old behaviors in a new situation may lead to experimentation with new methods and self-discovery. Having an historical perspective helps the person’s grief work by allowing shifts in thinking about himself or herself, the loss, and perhaps the meaning of the loss. Margaret’s religious practices of prayer and spiritual reading helped her to discover new depths of meaning and spiritual reading helped her o discover new depths of meaning and purpose in her life.
Encouraging the client to care for himself or herself is another intervention that helps the client cope. The nurse can offer food without pressuring the client to eat. Being careful to eat, sleep well, exercise, and take time for comforting activities are was that the client can nourish himself or herself. Just as the tired hiker needs to stop, rest, and replenish himself or herself, so must the bereaved person take a break from the exhausting process of grieving. Going back to a routine of work or focusing on other members of the family may provide that respite. Volunteer activities—volunteering at a hospice or botanical garden, taking part in church activities, or speaking to bereavement education groups, for example—can affirm the client’s talents and abilities and can renew feelings of self-worth.
Communication and interpersonal skills are tools of the effective nurse, just like a stethoscope, scissors, and globes. The client trusts that the nurse will have what it take to assist him or her in grieving, in addition to previously mentioned skills, these tools include the following:
Intervention involves giving the client the opportunity to compare and contrast ways in which he or she has coped with significant loss in the past and helping him or her to review strengths and renew a sense of personal power. Remembering and practicing old behaviors in a new situation may lead to experimentation with new methods and self-discovery. Having an historical perspective helps the person’s grief work by allowing shifts in thinking about himself or herself, the loss, and perhaps the meaning of the loss. Margaret’s religious practices of prayer and spiritual reading helped her to discover new depths of meaning and spiritual reading helped her o discover new depths of meaning and purpose in her life.
Encouraging the client to care for himself or herself is another intervention that helps the client cope. The nurse can offer food without pressuring the client to eat. Being careful to eat, sleep well, exercise, and take time for comforting activities are was that the client can nourish himself or herself. Just as the tired hiker needs to stop, rest, and replenish himself or herself, so must the bereaved person take a break from the exhausting process of grieving. Going back to a routine of work or focusing on other members of the family may provide that respite. Volunteer activities—volunteering at a hospice or botanical garden, taking part in church activities, or speaking to bereavement education groups, for example—can affirm the client’s talents and abilities and can renew feelings of self-worth.
Communication and interpersonal skills are tools of the effective nurse, just like a stethoscope, scissors, and globes. The client trusts that the nurse will have what it take to assist him or her in grieving, in addition to previously mentioned skills, these tools include the following:
- Use simple, nonjudgmental statements to acknowledge loss: “I want you to know I’m thinking of you”
- Refer to a loved one or object of loss by name (if acceptable in the client’s culture)
- Words are not always necessary; a light touch on the elbow, shoulder, or hand or just being there 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
A welcoming smile and eye contact from the client during intimate conversations indicate the nurse’s trustworthiness.
Evaluation
Evaluation of progress depends on the goals established for the client. A review of the tasks and phases of grieving (discussed earlier in the chapter) can be useful in making a statement about the client’s status at any given moment. We could say that while Margaret, in the vignette, still misses James, she is in the reorganization phase of grieving. She has a sense of independence and confidence and has accomplished several tasks of grieving: creating new ties, developing a new sense of self, pursuing new activities, and integrating the loss into her life.
SELF-AWARENESS ISSUES
Clients who are grieving need more than someone who is equipped with skills and basic knowledge; they need the support of someone they can trust with their emotions and thoughts. For clients to see nurses as trustworthy, nurses must be willing to examine their personal attitudes about loss and the grieving process. Taking a self-awareness inventory means periodic reflection on questions such as:
- What are the losses in my life, and how do they affect me?
- Am I currently grieving for a significant loss? How does my loss affect my ability to be present to my client?
- Who is there for me as I grieve?
- How am I coping with my loss?
- Is the pain of may personal grief spilling over as I listen and watch for sues of the client’s grieving?
- Am I making assumptions about he client’s experience based on my own process?
- Can I keep appropriate nurse—client boundaries as I attend to the client’s needs?
- Do I have the strength to be present and to facilitate the client’s grief?
- What does my supervisor or a trusted colleague observe about my current ability to support a client in the grief process?
Ongoing self-examination is an effective method of keeping the therapeutic relationship goal-directed and acutely attentive to the client’s needs.
KEY POINTS
KEY POINTS
- Grief refers to the subjective emotions and affect that are normal responses to the experience of loss.
- Grieving is the process through which a person travels as he or she experiences grief.
REFERENCES
Albert, P. L. (2001). Grief and loss in the workplace. Progress in Transpantation, 11(3), 169. http://psychiatry.medscape.com/NATCO
Bowlby, J. (1980). Attachment and loss, Vol. 3. Loss, sadness, and depression. New York: Basic Books.
McBridge, J. (2001). Death in the family: Adapting a family systems framework to the grief process. American Journal of Family Therapy, 29(1), 59-73
Parkes, C. M. (1998). Coping with loss: Bereavement in adult life. British Medical Journal, 316(7134), 856-859.
Schultz, J. M., & Videbeck. S. L. (2002). Lippincott’s manual of psychiatric nursing care plans (6 th ed.). Philadelphia: Lippincott Williams & Wilkins.
Skott. C. (2001). Caring narratives and the strategy of presence: Narrative communication in nursing practice and research. Nursing Science Quarterly, 14(3), 249-255.
Yosep, iyus. 2007. Mental nursing. Bandung: PT Refika Aditama.
Bowlby, J. (1980). Attachment and loss, Vol. 3. Loss, sadness, and depression. New York: Basic Books.
McBridge, J. (2001). Death in the family: Adapting a family systems framework to the grief process. American Journal of Family Therapy, 29(1), 59-73
Parkes, C. M. (1998). Coping with loss: Bereavement in adult life. British Medical Journal, 316(7134), 856-859.
Schultz, J. M., & Videbeck. S. L. (2002). Lippincott’s manual of psychiatric nursing care plans (6 th ed.). Philadelphia: Lippincott Williams & Wilkins.
Skott. C. (2001). Caring narratives and the strategy of presence: Narrative communication in nursing practice and research. Nursing Science Quarterly, 14(3), 249-255.
Yosep, iyus. 2007. Mental nursing. Bandung: PT Refika Aditama.