Grief and loss is something that all people will experience in their lifetime. The loss may be actual or perceived and is the absence of something that was valued. An actual loss is recognized and verified by others while others cannot verify a perceived loss. Both are real to the individual who has experienced the loss. Grief is the internal part of the loss; it is the emotional feelings related to the loss. Nurses may experience this personally, or they may be the support system for 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 a number of 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. It is the nurse’s role to provide compassionate care to the patient and loved ones, and this care will be different from person-to-person. It is also important for the nurse to maintain emotional resiliency, so they are able to provide the best care for those experiencing grief. [1]

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 five stages of grief, but more recently, David Kressler has discussed an additional two stages (* denotes the additional two stages). They are as follows:

1. 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.
2. 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 sense that everything feels numb. Shock and denial help a person cope with loss and make their own 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 is in regards to denying the experience of all the feelings. As an individual is able to accept that this loss is their reality, they will be able to move into the healing process and denial will begin to diminish.
3. 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; it allows for something to hold on to. Anger may be directed at the thing or person that was lost, 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 a challenge for some to feel the anger; sometimes it is easier to try and suppress the anger. Feeling the anger and addressing the anger is part of the grieving process. Being aware that this is a step in the process is important, not only for the person experiencing grief but also for any caretaker involved. Do not take any outbursts personally as they are most likely a sign of a person in grief.
4. Bargaining – This is the step in the grieving process where one may think “If this __, then this__.” For example: “I will do anything if you take the hurt away” or “I will never sin again if my loved one will be 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 the fact that an individual wants life to go back 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 really exhibits the point that an individual can move through the different stages throughout their own healing process in a number of ways. There is no set linear path in grief. As a healthcare worker, it is important to be able to assess this stage of grief and listen. Provide empathy and compassion and educate them that this is a normal thought process if they question it. Provide resources if appropriate.
5. Depression – After the thoughts of the past in bargaining, thoughts of the present flood in. They realize that the situation is real. 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 great loss. An individual may withdraw from their daily life activities, and they may 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 normal 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.
6. 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 new way of life. It is possible to flow in and out of other stages during the testing phase as well. 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.
7. 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. Acceptance, as a stage, is about accepting that this is their new reality, and it is permanent. Life cannot go on as it once did, but through acceptance, life can and will go on. Roles will reorganize. 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]

As a nurse, one has the honor of taking care of the most vulnerable populations. This includes patients and loved ones who experience loss. It is important to assess characteristic signs of grief and loss and address them appropriately. It is important for the nurse to start this process by building rapport with the patient and any present loved ones. 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 will help demonstrate empathy and build rapport by utilizing the NURSE pneumonic as this example below shows:

When a family member mentions: “This is overwhelming.”

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’m really impressed with how well you are handling everything.” – Express your respect for them in this situation.
• Support: “I’ll be 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 important for the nurse to assist the patient and loved ones in their coping with their grief to include anticipatory grief. Educate them on what is expected to include the stages of grief and what are some normal feelings as well as what are some resources to help adjust to this loss they are experiencing. Evaluate how they are handling 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 take care of their own health. Remind them or help them have access to food and hydration. Encourage adequate sleep and hygiene. 

It is important to be able 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, and community peer support groups as well as social work referrals. [3]

Anticipatory grief may be experienced before an actual loss. This type of grieving gives the patient and their loved ones an opportunity 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 a long 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 a normal 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 will likely worsen instead of gradually fade. 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
• Intense 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 normal 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]

The goals of care are for the patient and their loved ones are to be free of complicated grieving and to have access to adequate resources to allow for the natural grieving process. It is important for them 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 own strengths and weaknesses. It is important that they 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

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 by 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 know how you feel, but I am here to help in any way I can.” Then follow through by providing any help that you can, be that an appropriate referral or simply a hot drink or listening ear. [10]