A wise person once said, “Grief is not a disease or pathology to be cured. Grief is the tangible evidence that we’ve cared and loved someone.” The author of this lovely quote remains unknown, but the quote speaks to us.

Healthcare demands multitasking and running from one fire to another with barely enough time to catch a breath as the demands of time and tasks push us forward. Throughout the shifts, nurses care on many levels. When a patient dies, especially a patient who has touched our hearts, we grieve.

We lovingly provide post-mortem care, notify family, call the physician, and contact the mortuary of choice and/or hospital morgue. Once the patient has left the room, we rush to the next situation with very little, if any time, to reflect on the patient who has died. We grieve for the patient who has inspired us, challenged us and made us better practitioners. We grieve for their families and the loss they have suffered. Grief happens.

Kumar says, “From the perspective that grief happens, then, there is nothing wrong with us when we grieve. Grief is a part of life. We all inherently want to experience pleasure and avoid pain. Yet suffering is a part of all of our lives, and, although not desirable, it will happen no matter what we do. If we view grief as a problem, we think of one of the natural parts of life, and love, as a pathology or disorder.”

Make no mistake; even in the busy world of medicine, healthcare providers need to acknowledge their own personal grief. Providers must know themselves in order to help those around them.

Range of emotions

Even with years of experience, thoughts of grief are often foreign to us and may be unfamiliar and intense. It can surprise us that the grief process can take longer than most people expect. Not so long ago, we told families that their grief might last two months or so. Moving through the stages of grief is not always smooth and predictable. It is no surprise that grief work is some of the hardest work we will ever do and can affect us for years. Factors that affect the work of grief include, but are not limited to the following:

• The level of growth and development of the person who is grieving. (Usually by age 9, children can grasp the meaning the death.)
• Relationship of the deceased to the survivor
• Circumstances surrounding the death
• For providers, compassion fatigue is a factor
• Past history of losses
• Medical history of the survivor
• Prior patterns of grieving, unresolved grief
• Personality of survivor
• Social and cultural patterns
• Everyday stresses
• Disposition of the body

Terms to know

To better understand grief, it’s important to understand various terms. Grief is the overall reaction to the death and/or loss. Bereavement is the state of individuals who have experienced loss. Mourning encompasses all the processes of coping or learning to live with the loss and grief.

Disenfranchised grief is the grief people experience when they incur a loss that is not or cannot be openly acknowledged. Instrumental grief is a process of grieving that is private, thought and action-oriented. Instrumental grievers include those who are the “doing griever.” They face their grief with practicality, planning, organizing, and problem solving.

Intuitive grief involves the process of grieving with a full, rich range of emotions in response to loss. This person is the “feeling griever.” The intuitive griever is sensitive to self and others.

Anticipatory grief involves being aware that death is coming and knowing experiencing grief in advance of the event. Anticipatory grief allows a preparation for what is to come.

Myths about grief

Myths related to grief abound. Such myths can include:

Myth: Grief, mourning and bereavement are the same.

Truth: Grief is our reaction to the death experience. Reactions may be physical, emotional, behavioral, social, and spiritual. Bereavement is the situation of individuals who have experienced loss. Mourning is all the processes of coping or learning to live with the loss and grief.

Myth: There are predictable stages of grief.

Truth: Grief is not predictable. Each of us experience grief differently.

Myth: We should avoid the painful parts of grieving.

Truth: Avoiding grief means avoiding healing.

Myth: We should get over it as soon as possible.

Truth: We can reconcile grief and grow through it. It may take several years. There is no magic timetable.

Culture, faith, values, and death

Culture is fully embedded in each of us. Our culture shapes who we are and what we believe. Faith, culture and values drive us each day of our lives. Culture, faith and values touch us in death as well.

Obviously, our values and culture do not always reflect the values and culture of those we care for. Before talking to a family about death, dying and grief, it is extremely helpful to consider their culture and faith before proceeding.

For example Culture Vision says, “Latinos beliefs about death are heavily influenced by their religious practices — Catholicism, Evangelical or Pentecostal Protestantism or Santeria. Like many other people, Hispanics may be hesitant to plan for or talk about death. Some Latino families may believe that talking about a patient’s terminal illness or death may precipitate the person’s dying.”

Grief in the workplace

In his book, Understanding Grief: Helping Yourself Heal, Alan Wolfelt describes seven stages of grief that apply to all in the healthcare community but also to our patients and families. As providers, we can help ourselves by understanding these stages. We can help our families by validating that these emotions are normal and part of the grieving process.

1. Shock: Reacting to learning of the loss with numbed disbelief. You may deny the reality of the loss at some level, to avoid the pain. Shock, which provides emotional protection from being overwhelmed, may last for weeks.
2. Pain: As shock wears off, it is replaced with the suffering of “unbelievable pain.” Although the pain can be almost unbearable, it’s important to experience the pain fully, instead of hiding it, avoiding it, or escaping from it through drugs or alcohol.
3. Anger and bargaining: Frustration gives way to anger. You may lash out at others and inappropriately blame someone else for the death.
4. Depression, reflection and loneliness: This is a normal stage of grief, so do not be “talked out of it” by well-meaning outsiders. At this stage, encouragement from others might not be helpful.
5. Experiencing an upward turn: At this point, you begin to adjust to life without the deceased. Life becomes a little calmer and more organized. Physical symptoms may ease, and sadness begins to lift a bit.
6. Reconciliation: Now your mind starts working better and your thoughts are clearer. You start working on practical problems such as finances and reconstructing life without the deceased.
7. Acceptance: Acceptance doesn’t equal happiness, and you will never return to your previous life. Life has changed, but a way forward exists and can be found.

Interventions for providers

Before we can help our grieving families, it can be productive to examine our own grief patterns and interventions. In the article “Emotional Debriefing,” Huff wrote, “In health care, stress and sadness come with the job. Hospitals now recognize that letting clinicians and non-clinicians decompress–through talking groups, counseling or a few minutes of quiet time-is good for the soul and for the quality of patient care.”

Reviewing our support network and defining those in the network who have provided care and follow-up is a great start. The support network can include family, friends, and co-workers. Examining where we receive support is also critical and can include our social settings such as our religious or faith community, support groups, Employee Assistance Programs (EAP), staff debriefings following death of patients, hospital-based memorial services, and/or hospital pastoral care support.

In short, we must help ourselves before we can effectively help our families.

To help sort out our own dealings with death and fully grieve ourselves, it can be helpful to work through the following self-assessment exercise:

Experiences with death

Interventions for families

As healthcare providers, our support and care of families does not end with the death of the loved one. A personal call or note of care and concern can be very much appreciated. Tangibly let family members know they are cared for, supported, and being remembered. Encourage families to know that it is acceptable to talk about the person who died. It may be timely to offer a list of grief support groups.

Know that even though people may look good on the outside, they may be hiding pain underneath the surface. Avoid putting a time limit on grief. Allow family members to cry. Know that sitting in silence with a family is beneficial. The nurses’ mere presence conveys tremendous care. Help people create grief rituals such as making a memory wreath or starting a journal. Talk with family about availability of counselors.

Emphasize that it is not necessary to find something positive about the death. Try not to run away from the subject of the death. Don’t say to the grieving family, “You can always find or have another _______.” Avoid telling the family that you know how they feel… you don’t. You can empathize but not sympathize. Provide families with a list of helpful quotes such as the following:

“Death ends a life, not a relationship.” ~ Robert Anderson

“Isn’t this what grieving is all about—trying to make it part of our lives? Trying to enable ourselves to live with it rather than ‘overcome’ it?” ~ Stefan Baltzar

“Perhaps they are not the stars but rather openings in the heaven where the love of our lost ones pours through and shines down upon us to let us know they are happy.” ~ From an Eskimo Legend

Process of change

For all of us who grieve, we must start by acknowledging the reality of the death. We must embrace the pain of the death and not run away from it. To run away deepens the void and postpones effective grieving. We must do the work of remembering the person.

This work of mourning provides a link to the memories and pursuit of relationship with the deceased. Recognize that the death of a loved one changes our identity. Death moves us from husband, wife to widower or widow. Death has changed who we are and who we will be but it does not change our love and remembrance. Know that the meaning of the death can be elusive.

The Holocaust survivor Viktor Frankl MD, PhD, once said, “Man is not destroyed by suffering; he is destroyed by suffering without meaning.”

There is meaning in death. The “why” and “how” will eventfully be revealed but it may take time. Encourage families to have patience with this task of mourning. Mourners should consider allowing the ongoing support from others. People in the caring circle need to feel as though they contribute in some meaningful way. Allowing others to help can provide solid support and an outlet for their grief as well.

Finally, it will be critical to reconcile or make peace with the grief. Reconciliation does not involve “getting over it”. With reconciliation comes a renewed spirit of life and energy. Grief will be part of the life journey… pain will soften as will despair. The intense pain we feel as caregivers and families will be replaced by hope and purpose.

Knowing ourselves can help us know our patients and families. Together we can all move graciously and lovingly through the journey of grief.

Rebecca Ruppert, RN, MS, was working as a palliative care nurse with Salem Health in Salem, Oregon, when this article was written.

From our readers gives nurses the opportunity to share experiences that would be helpful to their nurse colleagues. Because of this format, the stories have been minimally edited. If you would like to submit an article for From our readers, click here.

References

Anderson KA, Gaugler JE. The grief experiences of certified nursing assistants: personal growth and complicated grief. Omega: Journal of Death & Dying. 2006;54(4):301-18.

Brosche TA. A grief team within a healthcare system. Dimensions Crit Care Nurs. 2007;26(1):21-8.

Culture Vision website: http://crculturevision.com/. Accessed May 5, 2011.

Huff C. Emotional debriefing. Hospitals & Health Networks. 2006;80(8):38-40, 42, 2.

Kumar S. Grieving Mindfully. Oakland, CA; New Harbinger Publications, 2005.

Meadors P, Lamson A. Compassion fatigue and secondary traumatization: provider self care on intensive care units for children. J Pediatric Health Care. 2008;22(1):24-34.

Wolfelt A. Understanding Grief: Helping Yourself Heal. Muncie, IN: Accelerated Development, 1992.