concept analysis -grieving process

Nursing Forum Volume 40, No. 4, October-December, 2005 123

Blackwell Publishing IncMalden, USANUFNursing Forum0029-6473© by Nursecom, Inc. 2005404

ORIGINAL ARTICLE

The Grieving Process for NursesThe Grieving Process for Nurses

A Concept Analysis: The Grieving Process for Nurses

Tina Brunelli, RN, BSN

The concept of the grieving process has been

explored extensively in families losing a loved one

or in a patient grieving over a terminal diagnosis.

The patients and families live through this

experience one time. What about the nurse who

lives it several times a week by caring for these

patients and families? How does a nurse grieve?

Little publication and research have been done

surrounding the grieving process for nurses.

This is a concept analysis that clarifies the

grieving process for nurses. Clarifying this

process will enable further development of

nursing research and education, ultimately

benefiting nursing practice and retention.

Search terms:

grieving process, nurses

Tina Brunelli is an MSN/FNP student at the Winston-Salem State University, Winston-Salem, North Carolina.

A Concept Analysis: The Grieving Process

A nurse working in a bone marrow transplant unitadmits a 15-year-old female patient for her secondallotogenous transplant. The patient will receive herstem cells from her 12-year-old brother, just as shedid with her first transplant less than 2 years ago.This young, vibrant, seemingly healthy young womanbrought with her hopes of a cure. Unknown to me, thatyoung woman also brought with her a lesson in grievingthat I had not experienced in 19 years of employment.The patient died a horrible death, 65 days after hertransplant. She endured graft-versus-host disease involv-ing not only her gastrointestinal tract, but also her liver.She developed acute respiratory distress syndrome(ARDS) from an alveolar bleed as a result of the high-dose chemotherapy and her low platelet count. Sheeventually required mechanical ventilation and thentracheotomy after being on the ventilator for over3 weeks. Her parents stayed by her side day and nightfor months. I was the patient’s primary nurse every daythat I worked. I was off the day she died. Everyonewho knew her grieved for her. The grieving processis a concept that all nurses need to examine, becausegrief is a phenomenon that every human being willeventually experience.

How do nurses grieve the loss of their patients?Especially nurses who deal with patients who fre-quently have prolonged suffering with little comfortcare in the name of a cure? My personal beliefs arethat, too frequently, nurses are expected to “deal withit” or help the family or patient cope. However, whohelps the helper? Who assists the nurse who spendshours every working day dealing with the sufferingand trying to make it “better” when she or he knowsthat nothing she or he does would really help make itbetter? How does the nurse work through such a loss?Clearly, the grieving process needs to be understoodamong healthcare providers.

124 Nursing Forum Volume 40, No. 4, October-December, 2005

The Grieving Process for Nurses

How do nurses grieve the loss of their

patients?

Definitions

According to Walker and Avant (1999), conceptanalysis allows one to explore the attributes or charac-teristics of a concept. The purpose of a concept analysisis to distinguish between concepts. Concept analysis isa careful examination and description of a word.

Based on

Merriam-Webster’s Online Dictionary

(2004),

grieving

means to cause to suffer, or to feel grief orsorrow. Process is defined as a natural phenomenonmarked by gradual changes that lead toward a particu-lar result, a natural continuing activity or function, or aseries of actions or operations conducing to an end.

The grieving process is how you reconcile yourpersonal feelings of loss. It is the way one develops apeace with one’s self in relation to a loss, and thenmoves on with one’s life (Reese, 1996).

Furthermore, Kubler-Ross (1969) defines the grievingprocess as moving through the five stages of grieving:denial (denying the presence of loss or disease), anger(at the loss or about being ill toward people or God),bargaining (is there another way), depression, andacceptance.

Unlike Kubler-Ross, Stephenson (1985) describes thegrieving process in three phases: reaction (involvingshock, numbness and anger), disorganization and re-organization (stopping old actions then replacing themwith new actions or resuming actions that contributetoward closure of the process), and reorientation andrecovery (resolution of previous strong felt emotions).

However, Pessagno (2002) lists four tasks of griefthat are described as follows: accepting the reality ofthe loss, experiencing the pain of the loss, adjusting tothe environment from which the deceased is missing,

and withdrawing energy from the relationship withthe deceased and reinvesting in other relationships.

Clearly, all of the above definitions of the grievingprocess revolve around an individual feeling of lossor sorrow then working toward a healthy resolution ofthis loss or sorrow. This process is marked with stagesor steps that may vary from individual to individual,but the goal is a healthy resolution of the loss or sorrowso the person can proceed through life.

Literature Review

I searched medical and nursing databases for theconcept of the grieving process. Many articles and stud-ies have been written in relation to the nurse helpingthe patient with his or her grief or the nurse helping thefamily work through the process of losing a loved one.These articles included studies on what actions by thenurse or physician made the family more comfortablewith the patient’s death or impending death. Most ofthese articles spoke of how the nurse was speciallytrained to deal with and teach the grieving process to laypersons. I must have missed that semester in nursingschool. We as nurses learn how to care for patients in allaspects of life and death, but never have I been in a classthat presented how to teach a family or patient to grieve.

We as nurses learn how to care for patients

. . . but never have I been in a class that

presented how to teach a family or patient to

grieve.

On the other hand, there were very few studies andarticles found related to how the nurse deals with theloss of a patient. Papadatou, Bellali, Papazoglou, and


Petraki (2002) explored grief responses of Greek nurseswho provided care to children dying from cancer.The researchers found that nurses fluctuated betweenexperiencing and avoiding their grief. Reactions rangedfrom crying, sadness, anger, and recurring thoughts ofthe dying conditions (pain and suffering) and the actualdeath of the child. Support was found from other nurs-ing staff by recalling the positive attributes of the childand discussing positive contributions the nurse hadmade to make the child’s death more peaceful. Mostfrequently, the nurse avoided the grief and was notedas saying that a curtain was drawn down and the painwas forgotten, or the pain was placed in a drawer andclosed away. The process of working through loss wassignificantly compromised and led to various degreesof burnout.

Likewise, Lenart, Bauer, Charise, Brighton, Johnson,and Stringer (1998) found that nurses mainly repressedgrief and that their support systems were mainly fromother nurses. Some nurses reported grief responsessuch as fatigue, sleep disturbances, anxiety, sorrow,moodiness, and difficulty concentrating. All being docu-mented unresolved grief responses.

Contrarily, Puckett, Hinds, and Milligan (1996) pre-sented an article where an oncology nurse experiencingthe loss of a patient receives assistance from the beginningof the patient’s diagnosis. The support is continuedthrough to the death of the patient. This approach useda support group for nurses, which involved a multi-disciplinary team to assist nurses through the stages ofgrieving until acceptance was reached.

Just as important, Brosche (2003) established a GriefCare Plan for the nurse to assist the nurse through thegrieving process. The diagnoses used for this plan wereshock, denial, disorganization, volatile reactions, guilt,loss and loneliness, relief, and, finally, reestablishment.

Antecedents

Antecedents are the events that need to take placeprior to the occurrence of the concept (Walker & Avant,1999). In order to experience the grieving process, the

nurse must experience a loss or perceived loss. Thenurse must not repress his or her grief for the sake oflooking strong or in the name of looking professional.The nurse must work through the stages of the grievingprocess until a healthy resolution and acceptance ofthe loss is obtained.

Defining Characteristics/Attributes

Defining attributes are a list of characteristics of aconcept that appear over and over again when reviewingthe literature. They help you name the occurrence of theconcept as differentiated from a similar concept (Walker& Avant, 1999). The grieving process has the definingcharacteristic of being a loss that causes grief. The loss isthen processed to acceptance or resolution of this lossthrough stages such as denial, anger, disorganization,reorganization, and depression. The resolution oracceptance of the loss results in the individual beingable to establish or invest in other relationships andmove on in a healthy fashion throughout the restof his or her life. Resolution enables the nurse to befully present for his or her patient (Furman, 2002).

Consequences

According to Walker and Avant (1999), consequencesare the events or incidents that occur as a result of theoccurrence of the concept. As Brosche (2003) tells us,the consequences of not going through the grievingprocess for the nurse can range from burnout to poten-tially harmful addictions, such as alcohol and drugs oreven to thoughts of suicide. Furthermore, staff moraleand delivery of patient care can be affected. The conse-quences for the hospital can lead to high turnoverand decreased customer service and satisfaction. Thenationwide consequence being an even larger nursingshortage.

Similarly, Furman (2002) states that helping nursesdeal with death and process grief guards against burn-out, maintains a therapeutic presence, and, in return,leads to better patient care.



. . . helping nurses deal with death and

process grief guards against burnout,

maintains a therapeutic presence, and, in

return, leads to better patient care.

Model Case

A model case is constructed to illustrate the conceptof the grieving process. This case, which includes allthe defining attributes and no other attributes, is anabsolute instance of the concept (Walker & Avant,1999). I was the patient’s primary nurse. I deliveredher chemotherapy. I taught her and her family theroutine and not-so-routine side effects of her treatmentand prepared everyone involved for the possiblyrocky road ahead. I was working the days when shewas developing ARDS. One day, the patient’s motherstarted to cry as she asked me if her daughter wouldlive. I held her as she wept and became angry becauseI could not tell her “yes” anymore. I cried with herand her daughter as they said goodbye to each otherbefore the patient was sedated then intubated. No oneknew if she would ever wake up again.

I often found myself unorganized or disheveledespecially at home as I wondered how my patient wasdoing. In my prayers, I prayed for her recovery andI swore I would never complain about working toohard or being understaffed again. As time proceeded,I became depressed. It became hard to even go towork. I felt a lump in my throat every time I had to gointo her room and face the agony she and her familywere experiencing. I was present the day the doctorhad the “end of life and do not resuscitate (DNR)”talk with the patient’s family. I remember her motherdiscussing with me if she made the right decision by

making her daughter a DNR. I was present the night thepatient had a massive myocardial infarction then wentpulseless. I cried with her parents and said goodbye toher before she died. After the patient’s death, I attendeda grieving support program for nurses at the hospital.I went through the grieving process and, as a result,maintain close relationships with patients. They, in return,received excellent nursing care.

Borderline Case

A borderline case is a case that contains some ofthe defining attributes of a concept but not all of them(Walker & Avant, 1999). Jennifer was not my patient’sprimary nurse, she was my orientee when I cared for thepatient. She assisted me when I delivered the patient’schemotherapy. Jennifer was present when I taught thepatient and her family the routine and not-so-routineside effects of her treatment and prepared everyoneinvolved for the possibly rocky road ahead. We wereworking the days when the patient was developingARDS. I knew my patient was taking a turn for theworse and I made sure Jennifer also knew this. I sawJennifer start to try to block out her feelings. One day,the patient’s mother started to cry as she asked me ifher daughter would live. I held her as she wept. WhenI left the room, Jennifer was waiting for me and saidthat she was not sure she could do this job. I tried todiscuss her feelings, but she just walked away. Shestarted to find herself unorganized at work. As timeproceeded, Jennifer showed signs of being depressed.She told me that sometimes it was even hard for her tocome to work. She changed preceptors so she did nothave to take care of my patient. When Jennifer didhave to work with me, which meant taking care of mypatient, she did only immediate patient care, limitingher personal presence in the room so conversationscould not get too in-depth. Jennifer was not workingthe night my patient died. She sent a sympathy card tothe family for closure. She also attended the grievingsupport group at the hospital. I notice, however, thatwhen our unit gets an especially young patient, Jennifer


tries very hard to avoid taking care of that patient.When she does take care of these patients, she givesexcellent nursing care, but stays distant.

Contrary Case

A contrary case is a clear example of what theconcept is not (Walker and Avant, 1999). Sue was mypatient’s other primary nurse. She took care of mypatient during the days I was not working. She knewthat the patient’s prognosis was poor from the verybeginning. She mentally tried to block out any caringor link between herself, the patient, and patient’sfamily. Seeing the patient decline in status and developARDS, Sue became angry. She said phrases like, “Theyall die anyway. Why even try?” Sue displaced her angeron the other nurses and became confrontational witheven the slightest disagreement. She left the room whenthe patient’s parents cried because she just could notdeal with the emotion. When the patient died, Sue shedno tears. She left the room while the family viewedthe body. Sue left the floor so she did not have to saygoodbye to the patient’s parents.

Sue eventually became depressed and felt worthless.She hated her job and everything about it. She refusedto talk about her feelings with anyone, includingher husband. She eventually quit bedside nursingaltogether and now works at an insurance company.

Related Case

Related cases are instances of concepts that aresimilar to the concept being studied but do not containthe critical attributes (Walker & Avant, 1999). Thefollowing is a related case on sadness. My son is in hisfirst year of coach pitch baseball. He is the only 6-year-old on the team. The rest of the boys are aged 7 to 9.My son is very tender hearted. He asked his coach toplay pitcher during one of the biggest games the teamhad this year. All the kids on the other team were aged9. Therefore, they hit the ball much harder than theother teams did. The other team was also undefeated.

The coach told my son that he could not play his usualposition because the team needed someone bigger onthe pitcher’s mound so that if they got hit by a ball, theywould not get hurt. My son was crushed. He told meafter the game with tears in his eyes that he was sad.I told him that when he gets older and bigger, he willbe the one hitting the ball hard, making the smallerkids go to the outfield because he will hit the ball evenharder than any of the other kids on his team. My sonlooked at me and smiled and said, “I will hit a home runevery time and show coach that I am not a baby! I’mnot sad anymore, Mommy.” My son had worked throughhis sadness by reasoning that he would also be bigsomeday. By the way, his next game he went three forthree and hit a triple over the third baseman’s head.

Invented Case

According to Walker and Avant (1999), an inventedcase is a case that uses the ideas of the concept but out-side our own experience. The following is an inventedcase. An Indian chief who had ruled his tribe for manydecades dies from old age. The tribe must go throughthe grieving process in relation to his death. During thecremation of the leader, the women cry while the menchant and beat drums. The medicine man speaks to theGreat Spirit and tells him that if the great leader couldcome back, even in another form, to lead their people,he would do any thing that the Great Spirit asks of him.The chief’s son becomes angry and confrontational withanyone who even mentions his father’s name. The sonis distracted and cannot even hunt because he cannotshoot his bow straight enough to hit his prey. During atime of chanting, the chief’s son receives a message fromthe Great Spirit that his father’s spirit will be by his sidethrough all his decisions as new chief. The young sontells the medicine man of his premonition. After the tribehears of the promise of hope, the tribe rejoices. The chiefwill live on in his son’s actions and deeds. The tribe saysgoodbye to their leader, and every year on the anniver-sary of his death, they sing his praises. The son becomesa great and decorated leader as his father was.



Implications for Nursing

As nurses, we will all experience the loss of a patientat some time in our career. For nurses who work insettings that revolve around patient diagnoses that havepoor prognoses, the repetitive loss of patients puts notonly a physical, but also mental and spiritual burdenon us not only as nurses, but also as humans. Recog-nizing that nurses need to work through the grievingprocess and come to a healthy resolution with a patient’sdeath is the first step to helping maintain physical,mental, and spiritual health. As a result, maladaptivegrieving can lead to emotional distancing and depression,non-caring, anger, and burnout. This maladaptive griev-ing results in the loss of nurses to other professions ornurses who give poor nursing care (Brosche, 2003). At atime when we live with a continuing nursing shortage,we need to take care of ourselves so we can surviveand thrive in our environment.

Nursing needs to stand up and say, “Hey, wehurt too.” Hospitals need to recognize the need forgrieving support groups where multidisciplinary teamsare involved to include nursing, physicians, pastoralcare, and psychology. Three to four times a year,memorial services need to be held for the ones thathave passed, either in the chapel or in a church. Thesememorial services need to be mandatory for anyonenot working that day. After the short service, all peoplepresent, including the deceased patient’s family mem-bers and staff, need to have time to eat, drink, laugh, tellstories, and just have some closure together. The resultswould be less burnout and less unhappy non-caringnurses, with the final result of fewer nurses leavingthe field. This intervention may not completely curethe nursing shortage, but it is a very healthy start.

Conclusion

In summation, the concept of the grieving processas presented in this paper is related to nurses whoexperience the loss of a patient. The grieving processinvolves going through steps to arrive at a resolution

or acceptance of the loss or death. The grieving pro-cess needs to be recognized by nursing and healthadministration as a necessity for good health, includingnot just physical but mental and spiritual as well.

“. . . it’s okay for you to grieve too.”

I believe Reese (1996) says it all when he wrote, “It’sonly human to hurt, to cry, to grieve, when a personwho’s influenced you in some way has died. Pleasecry with your patients and their families; it’s okay foryou to grieve too.”

Acknowledgment.

Acknowledgment is to be given toDr. Joanette McClain for her guidance and encouragement.

Author contact: [email protected], with a copy to the Editor:[email protected]

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concept analysis -grieving process

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