17.3 Applying the Nursing Process to Grief

Grieving a loss is a normal process that has implications for both client and family well-being. NANDA formally recognizes the dimensions of grief with the nursing diagnoses of Grieving and Complicated Grieving. Recall that grief can be experienced due to many types of loss, in addition to death. For example, when clients receive a diagnosis of breast cancer, they may demonstrate signs of various stages of grief, such as denial, anger, bargaining, depression, and acceptance. When undergoing mastectomy and chemotherapy, the client may grieve over the loss of prior body image.

Communities can also experience grief. For example, when a town experiences a significant tragedy, such as a devastating flood or a tornado, there can be widespread community grief as families grieve the loss of life, property, or a previous way of life. In these situations, nurses must be cognizant of the multiple factors that may impact an individual’s health and grieving process. Identifying these factors can help ensure that appropriate resources are mobilized to facilitate coping and progression through the grief process.

Assessment

Grief assessment includes the client, family members, and significant others. It begins when a client is diagnosed with an acute, chronic, or terminal illness and/or when the client is admitted to a hospital, nursing facility, or assisted living facility. It continues throughout the course of a terminal illness for the client, family members, and significant others and then continues through the bereavement period for the survivors. During the bereavement period, the nurse monitors for symptoms of complicated grief.^[1]

Grief can be manifested by physical, emotional, and cognitive symptoms. Physical symptoms can occur, such as feeling ill, headaches, tremors, muscle aches, exhaustion, insomnia, loss of appetite, or weight loss or gain. Cognitive symptoms may occur, such as lack of concentration, confusion, and hallucinations. Emotional symptoms, such as anxiety, guilt, anger, fear, sadness, helplessness, or feelings of relief may occur. These symptoms of grief and loss can be manifested in many different ways and can vary from day to day. Manifestations of grief are unique to the individual and may be influenced by one’s age, culture, resources, and previous experiences with loss. Additionally, as clients cope with grief and loss, it is important for the nurse to recognize that support is often needed by their family members.^[2]

Any behavior that may endanger the client or family should be reported to the health care provider, such as symptoms of depression, suicidal ideation, or symptoms lasting greater than six months.

Diagnoses

Consult a nursing care planning resource when selecting nursing diagnoses for clients and their family members experiencing grief. See Table 17.3 for the definition and selected defining characteristics of the NANDA-I diagnoses Maladaptive Grieving while also keeping in mind the previous discussion in this chapter regarding stages and tasks of normal grief.

Table 17.3 NANDA-I Maladaptive Grieving Nursing Diagnosis^[3]

Examples

See the following example of a PES statement related to Maladaptive Grieving:

• A client’s husband died two years ago, and she continues to be preoccupied with thoughts about her husband. Her grown children live several hours away, and she becomes isolated and unable to complete daily activities, such as cleaning the house and grocery shopping. A sample PES statement is: “Maladaptive Grieving related to excessive emotional disturbance as evidenced by decreased role performance and preoccupation with thoughts about her deceased husband.” The nurse would plan interventions to facilitate grief work while also arranging for assistance with ADLs in the client’s home.

Outcome Identification

Goal setting and outcome identification for clients and family members experiencing grief are customized to the specific situation and focus on grief resolution. Grief resolution is evidenced by the following indicators^[4]:

• Resolves feelings about the loss
• Verbalizes reality and acceptance of loss
• Maintains living environment
• Seeks social support

For the nursing diagnosis of Grieving and Complicated Grieving, a sample goal is, “The client will experience grief resolution.”

A sample SMART outcome is, “The client will discuss the meaning of the loss to their life in the next two weeks.”^[5]

Planning and Implementing Interventions

Nurses are in the ideal position to assist clients with identifying and expressing their feelings related to loss. The most important intervention that nurses can provide is active listening and offering a supportive presence. Actively listening to the bereaved helps them express their feelings and relate the emotions and feelings related to the loss. Interventions to facilitate grief resolution focus on coping enhancement, anticipatory grieving interventions, and grief work facilitation.

Coping Enhancement

Interventions to enhance coping can be implemented for clients and families experiencing any type of actual, anticipated, or perceived loss. Sample interventions include the following^[6]:

• Assist the client in identifying short- and long-term goals.
• Assist the client in examining available resources to meet the goals.
• Assist the client in breaking down complex steps into small, manageable steps.
• Encourage relationships with others who have common interests and goals.
• Assist the client to solve problems in a constructive manner.
• Appraise the effect of a client’s life situation on roles and relationships.
• Appraise and discuss alternative responses to the situation.
• Use a calm, reassuring approach.
• Provide an atmosphere of acceptance.
• Help the client identify information they are most interested in obtaining.
• Provide factual information regarding medical diagnosis, treatment, and prognosis.
• Provide the client with realistic choices about certain aspects of care.
• Encourage an attitude of realistic hope as a way of dealing with hopelessness.
• Seek to understand the client’s perspective of a stressful situation.
• Discourage decision-making when the client is under severe stress.
• Acknowledge the client’s cultural and spiritual background and encourage use of spiritual resources, if desired.
• Encourage verbalization of feelings, perceptions, and fears.
• Encourage family involvement, as appropriate.
• Assist the client to identify positive strategies to deal with limitations and manage needed lifestyle or role changes.
• Instruct the client on the use of relaxation techniques.

See Figure 17.17^[7] for an image of a nurse enhancing a client’s ability to cope with their illness through active listening and touch.

Anticipatory Grieving Interventions

Anticipatory grieving refers to a grief reaction that occurs in anticipation of an impending loss. Recall that anticipatory grieving can be related to impending death of oneself or a loved one, but it can also occur in anticipation of other losses, such as the loss of a body part due to scheduled surgery or the loss of one’s home due to a move to a long-term care facility. Interventions to facilitate resolution of anticipatory grieving include the following^[8]:

• Develop a trusting relationship with the client and family members by using presence and other therapeutic communication techniques.
• Keep the client and family members apprised of the client’s ongoing condition as much as possible.
• Keep the family informed of the client’s needs for physical care and support in symptom control, and inform them about health care options at the end of life, including palliative care, hospice care, and home care.
• Actively listen as the client grieves for their own death or loss. Normalize the client’s expressions of grief.
• Discuss the client’s preferred place of death and document their wishes.
• Ask family members about having adequate resources to care for themselves and the critically ill family member.
• Recognize caregiver role strain in family members providing long-term care at home.
• Listen to the family member’s story.
• Encourage family members to show their caring feelings and talk with the family members.
• Recognize and respect different feelings and wishes from the client and their family members.
• Refer the client and family members to counselors or chaplains for spiritual care as appropriate.

Grief Work Facilitation

Grief work facilitation assists clients and family members in resolution of a significant loss. Sample interventions include the following^[9]:

• Identify the loss.
• Assist the client to identify the initial reaction to the loss.
• Listen to expressions of grief.
• Encourage discussion of previous loss experiences.
• Encourage the verbalization of memories of the loss.
• Make empathetic statements about grief.
• Encourage identification of greatest fears concerning the loss.
• Educate about stages and tasks of the grieving process, as appropriate.
• Support progression through personal grieving stages.
• Assist in identifying personal coping strategies.
• Encourage implementation of cultural, religious, and social customs associated with the loss.
• Answer children’s questions about the loss and encourage discussion of feelings.
• Identify sources of community support.
• Reinforce progress made in the grieving process.
• Assist in identifying modifications needed in lifestyle.

Community Resources

Bereavement follow-up with families is a component of hospice programs and includes formal activities and events to promote closure and acceptance. Many hospices have nondenominational memorial services to honor clients. Family members and staff are invited to participate, which can be effective at helping individuals find closure. Other formal types of support can include organized support groups to facilitate discussion and coping. Individual, group counseling, or psychotherapy are other methods that can assist the bereaved in coping with their loss. See additional resources for family members in the following box.

Evaluation

It is always important to evaluate the effectiveness of interventions implemented. Nurses assess the effectiveness of interventions in helping individuals cope and work through the grief process based on the customized outcome criteria established for their situation.