Grief and grieving

Grief and grieving for nursing students

1. Presenter Mrs.V.Jesinda Vedanayagi , H.O.D of psychiatric Nursing, S.H.N.C,Madurai .

2. Grief,a series of intense physical,spiritual and psychological responses that occur following a loss,is a normal,natural,necessary and adaptive responses to a loss.

3. Types of grief 1.Uncomplicated grief(normal grief) The grief reaction is similar to other physical conditions and draws a parallel between a disease process and grief process. -A common etiologic factor -A predictable symptomatology and course -Functional impairement for a period of time -Distress and inability to function normally

4. 2.Dysfunctional grief Is a demonstration of a persistent pattern of intense grief that does not result in reconciliation of feelings. The bereaved may have the need to endlessly tell and retell the story of loss but without subsequent healing. 3.Anticipatory grief Is the occurence of grief work before an expected loss actually occurs .

5. 4)Disenfranchised grief Grief that is not openly acknowledged,socially sanctioned or publicly shared.Individual either is reluctant to recognize the sense of loss and develops guilt feelings or feels pressured by society to get on with life. 5)Complicated grief Is distinguished from uncomplicated grief by ‘’length of time &intensity of emotions’’.The person’s response are maladaptive,usually prolonged or overwhelming.

6. 6)Chronic grief Begins as normal grief but continues longterm , with little resolution of feelings and inability to rejoin in normal life. 7)Masked grief It occurs when the person is grieving but expressing the grief through other types of behaviour. 8)Delayed grief Is grief that is put off until a later time.

7. Denial Usually occurs when the person is first told of the illness. Individual’s may say, “The tests are wrong.” “This can’t be happening to me.” “I don’t believe it.” Others don’t talk about it. Health care workers should listen without confirming or denying it.

8. Anger This stage occurs when the patient can no longer deny death. The patient may blame themselves, their loved ones, or health care workers for their illness. Health care workers must understand this is not a personal attack.

9. Bargaining Usually occurs when patient accepts death but wants more time to live. Patients turn to religion and spiritual beliefs during this period. They want to see their child gradate, get married, or hold a grandchild. Making promises to God to try and obtain more time sometimes occurs.

10. Depression This stage occurs when the patient realizes that death will come soon and they won’t be with their families any longer. They realize that some goals they set will not be met. Health care workers need to let the patient know that depression is “OK”.

11. Acceptance This is normally the final stage. The patient understands that they are going to die. May complete unfinished business and try to help those around them deal with death. Patients will slowly get farther away from the world and other people. They need emotional support during this stage.

12. Common grief reaction Physical: Loss of appetite Weight loss or gain Fatigue Decreased libido Decreased immune system response Decreased energy Head ache/stomach pain

13. Behavioural: Forgetfulness Withdrawn Insomnia or too much of sleep Dreaming of deceased Verbalizing the loss Crying Loss of productivity at work

14. Emotional: Anger Anxiety Sadness Guilt Shock Numbness Loneliness Fear Powerlessness Helplessness

15. Cognitive: Decreased concentration Impaired judgement Obsessive thought of lost object Preoccupation Confusion Questioning spiritual beliefs Searching for understanding Searching for purpose and meaning

16. THEORIES OF THE GRIEVING PROCESSS LINEMANN THEORY 1)Somatic distress The bereaved experience episodic waves of discomfort in duration of 10 to 60 minutes,multiple somatic complaints,fatigue and extreme physical and emotional pain. 2)Preoccupation with the image of the deceased The bereaved experience a sense of unreality, emotional detachement from others and an overwhelming preoccupation with visualizing the deceased.

17. 3)Guilt The bereaved consider the death to be a result of their own negligence or lack of attentiveness,they look for the evidence of how they could contributed to the death. 4)Hostile reaction The bereaved relationship with others become impaired. Desire to be left alone and have feeling of irritability and anger. 5)Loss of pattern of conduct Exhibit generalized restlessness and they continually search for something to do.

18. ENGLE THEORY Stage1:Shock and disbelief(last for mts to days) -Disorientation -Feeling of helplessness -Denial Stage2:Developing awareness(last from 6 months to 12 months) -Guilt -Sadness -Isolation -Loneliness -Feeling of helplessness -Anger &hostility towards others -Increasing emotional pain

19. Stage 3:Restitution and resolution(may take up to several years) -Emergence of bodily symptoms -Possible realization -Beginnings of coming to terms with the loss -Establishment of new social patterns and relationship

20. Theresa Rando theories of grief(2000) 3 Phases of grieving 1.Avoidance-Shock ,disbelief, denial,anger &bargaining. 2.Confrontation-Person actually faces loss,is a very emotional and upsetting time. 3.Accommodation-Person begins to livewithout the loss,feel better and resume some routine activities.

21. Rando six R’s of grieving R –Recognizing the loss(awareness) R- Reacting to the separation(feel the emotions) R- Recollecting memories of the deceased( remembering,reliving ) R- Relinquishing the old attachement (new ways of living without the deceased) R- Readjusting to the new environment(new coping skills) R- Reinvesting self(energy once turned inward on grief begins to be focused outward again)

22. John Bowlby’s attachement theory(1982) 1.Shock and numbness Disorientation Feeling of helpless 2.Yearning and searching Wanting to be reconnected with the deceased 3.Disorganization and despair Feeling the pain &emotions of grief 4.Reorganization Adjusting to life without the deceased,developing new coping skills

23. DUAL PROCESS MODEL I t describes the every day life experience of grief as moving back and forth between loss- oriented and restoration- oriented process. Loss-oriented behaviour-includes grief work,dwelling on the loss, breaking connections to the deceased, and resisting activities to get past the grief. Restoration- oriented activities- *Attending to the life changes *Finding new roles or relationships

24. *Coping with finance *Participating in distractions These provide balance to the loss oriented state. The extent to which an individual engage in loss or restoration oriented process depends on the factors such as personality, coping styles or cultural practices.

25. FACTORS AFFECTING LOSS & GRIEF 1.Developmental stage *Childhood *Adolescence *Adulthood 2.Religious and cultural beliefs 3.Relationship with the lost person pr object 4.Timeliness of death 5.Cause of death *Unexpected death *Traumatic or Suicide

26. 6.Amount of support for the bereaved 7.Conflicts existing at the time of death 8.Circumstances of the loss 9.Previous loss

27. Nursing care of the grieving client 1.Assessment -Determination of the personal meaning of the loss -Deciding the person’s progress in terms of the grieving process. 2.Nursing diagnosis -Identify the appropriate related factors 3.Planning Goals: -Verbalize feeling of grief -Share grief with significant others -Accept the loss -Renew activities and relationship

28. 4.Implementation -Must spend time in listening -Demonstrate acceptance -Non-judgemental and accepting attitude -Avoid personalizing and using defensive behaviour. -Provide reassurance,counseling and support(support group) 5.Evaluation