- Situations in practice that can lead to grief/ bereavement
Bereavement refers to a period of grief after one has lost a loved one. It also refers to “the entire experience of friends and family members in the anticipation of the death of a loved one and the subsequent adjustment to living after the death of a loved one (Care, 2006 ).”
On the other hand, grief refers to “the emotional affective reaction to the loss of a loved one.” It has both psychological and physical manifestations (Care, 2006 ). Bereavement can be complex and can affect individuals on many levels including emotionally, cognitively, spiritually, socially and physically. The period of mourning after the death of a loved one is normal and it may take time to adjust.
When a person losses something or someone with which they had a bond, for instance a relative or a friend, they will have to grieve (Egan & Arnorld, 2003). For them to adjust, it will take quite sometime. Some of the feelings which are associated with the grief are; sadness, loss of appetite, loss of sleep (insomnia), and failure or inability to concentrate. The extent of grief is not definite. It varies from individual to individual. It is also determined by the strength of the bond that existed between the two people. Culture and religious beliefs also affect grief.There are various situations in practice that lead to bereavement. In the palliative care setting, the death of an individual who has been under care for a long time can lead to bereavement. The loss of a spouse in old age can prove to be an emotionally challenging period for the surviving spouse as a result of grief. The loss of a parent to a debilitating disease, murder, a disaster such as a terror attack, a hurricane or a fatal accident can be a source of grief to the surviving child.
- Models or theories of grief
A central and consistent theme in thanatological literature is that grief is influenced by a variety of factors and the interactions between these factors (Winokuer & Harris, 2012). There are various models that have been put forward in an attempt to explain the nature of grief. There is no clear cut definition as to what constitutes normal grief but there is an inclination towards the following definition: Normal grief refers to “the initial period that leads to numbness following by depression, disorganization and finally reorganization.” There is no definite duration for normal grief hence the clinician needs to discern whether a person is undergoing normal grieving or complicated grieving (Zishook & Shear, 2009). During the normal grieving process, the feelings of pain are mixed up with positive feelings of relief, joy, happiness and happiness as the person goes through the process of grieving (Bonanno & Kaltman, 2001).
One of the foremost models is the Sigmund Freud model of personal attachment. According to the Freud, an individual who is mourning is looking for a personal attachment that has been lost. He went to describe mourning as “a state of melancholia as a result of detachment from a loved one. It is speculated that in grieving the grieved party is letting go of multiple attachments that were components of the personal relationships. Once the loss has been accepted, the ego accommodates the loss hence the bereaved party can search for new attachments (Centre for the advancement of health, 2004 ).
The Kubler Ross Cycle offers a perspective that is important in understanding the personal grief and other people reaction to traumatic events. According to this theory, there are five stages in the grief cycle: denial, anger, bargaining, depression and acceptance. Denial refers to the refusal to come to terms to reality whether it is conscious or unconscious. Anger can be directed at the person who is grieving or the deceased person. Bargaining entails appealing to a higher power on behalf of the dying person or the deceased. Depression is characterized by sadness, fear, uncertainty and death. When the person comes to terms with the situation, they can move forward with their life.
According to Bowlby’s theory of attachment, attachments are formed early in life and are a source of security for the individual later on in life. The loss and the disruption of these attachments of affection is what triggers anger, sadness and crying in the person. He categorized the phases of grieving as: numbing, yearning and searching, disorganization and reorganization (Egan & Arnold, 2003 ). The numbing phase is characterized by shock that death has taken place and lasts for a short while. Yearning and searching is the phase that follows after numbing fades: it is marked by anger and frustration. During the disorganization phase, an individual evaluates their life without the deceased. During the reorganization phase, the bereaved attempts to accept the reality of their new life (Shear et al., 2007).
The dual process model was developed by Schut and Stroebe. According to these scholars, based on the circumstances avoiding grief could be of benefit or a detriment. Controlling and expressing feelings as a result of grief are both vital aspects of the grieving. Grief is a dynamic process in which an individual alternates between losing their loved ones (loss orientation) and avoiding thoughts on the deceased (restoration orientation). The process of orientation entails focusing on dealing with secondary losses that are a consequence of death. For instances, a surviving spouse may have to execute the duties that the deceased used to carry out as handling finances. Loss orientation and restoration orientation are two aspects of grief but the degree to which an individual focuses on these two aspects will be dependent on the cultural background, the personality and the circumstances of death.
These models on grief make the following assumptions: to begin with there is an assumption that grief is a process that is marked by distinct phases; it is short term and finite, for people who are bereaved by illness often grieve in anticipation of death of their loved one (Breen & O'connor, 2007 ). In the practice setting, the aforementioned assumptions can have deleterious effects on practice. For a setting such as a grieving child, adolescent, a grieving elderly man or woman who has lost their spouse in a hospital set up, the support offered by nurses or counselors is based on the assumption that there are distinct phases that are universal. This can be detrimental to the grieving party given that it could cause the bereaved party to be detached from the deceased thus their grief could become pathological (Mallikson, 2001 ). The nurses or the counselors fail to take into account the fact grieving is a unique personal experience. It is not uncommon in practice to find the nurses requiring the bereaved to forget the deceased. This can be a source of distress who feel uncared for by the support staff in addition to isolated given that their grieving process is not similar to the “normal grieving process (Mallon, 2008).
In spite the limitations of the grief theories, this is not to say that they are entirely wrong. They are however limited to the particular setting of the group of participants or culture from where they were drawn such as North America, United States of America or a specific category of people such as middle class individual, working class individuals, women or men. The discourses from the theories are therefore may not necessarily apply to other settings. 3. Features of complicated grief
Complicated grief is a symptom that affects about 10% of individuals who are bereaved (Shear & Mulhare, 2008 ). Individuals whose loved ones die as a result of untimely events such as accidents and natural catastrophes or violent acts such as murder are often more prone to experiencing complicated grief. It is characterized by the following features: to begin with, the bereaved person expresses prolonged and recurrent periods of yearning and longing for the person who is deceased. The bereaved person spends a considerable amount of time thinking about the deceased in addition to expressing their thoughts of longing. The bereaved individual has a difficult time accepting the reality of death hence the pain resulting from separation with their loved one may last for well over six months. The longing and yearning for the deceased is often accompanied by frustration, anger and anxiety (Shear, E.Frank, & Houck, 2001).
People who undergo complicated grief often view their grief as a shameful and frightening process. They often express the belief that their life is over and that their pain will never come to an end. As a consequence of the complicated grief, the bereaved often overindulge in activities that are associated with the deceased or excessively avoid activities that were associated with the grief. The obsession with the deceased could be manifested in the form of spending too much time at the cemetery or the room of the deceased or daydreaming.
In the 1990’s, two research teams came up with a criteria which formed the basis for the classification of chronic grief. This criterion was later renamed and become known as prolonged grief disorder. Based on this criterion, the treatment of a bereaved individual is only prescribed if the individual exhibits the chronic grief reactions. The symptoms of chronic grief as per this criterion are different from those of anxiety disorders, mood disorders and mood disorders. The reactions that are associated with chronic grief disorder include: hypertension, cardiac problems, sleep interruptions, depression, anxiety, work and social impairments. The diagnosis of grief from a clinical perspective takes into account the anxiety and depression that the bereaved individual is experiencing which supports the diagnosis of prolonged grief disorder (Hall, 2011).
- Coping strategies that are employed by the patient in dealing with grief
It is important to the bereaved in that it will help them to adapt and continue with their productive work. However, of utmost importance is the bereaved person. Grief can cause other complications in the health of an individual if not addressed with the urgency it requires. It can lead to energy depletion within a very short time (Moules et al., 2004).
When a person is grieving, he or she needs much support from other people and therefore, it is important for them to share the grief of the loss with others so as to get support. The following tips can help one to get support from other people (Moules, 2004 ).
When a loss occurs, inform friends and family members who will help you get through the grief period. This is the time that the bereaved person needs other people the most. He or she needs to draw them as close as possible (Kleiman, 2012). He needs to ask for any kind of assistance that they need. In fact, there are many people who will be willing to help but most of them do not know the kind of help they can offer (Kacel, Gaio, & Prigason, 2004 ). Therefore, telling them what you need might be helpful. The bereaved person could join a support group. These are groups whose members have also experienced grief. It is possible for one to feel lonely despite having friends and family around. In fact, that alone might not be helpful. Joining a group that offers support to the bereaved is important (Moules et al., 2004).
The grief period is one of those times when one could to be in close contact with their religious community, as well as other traditional groups. The mourning rituals that are offered by these groups can be very helpful to the bereaved person. One can talk to their clergy and other members of the church. Religious activities can be very helpful at such a time. They may offer solace (Bright, 1996).
A counselor or a therapist can be very important, as well (Winokuer and Harris, 2012). They will give advice and support that can help one recover more quickly. It is also important for one to look at their emotional needs, which will help in overcoming the situation. Following are some of the tips that can help one to meet his or her emotional needs (Kacel, Gao, and Prigerson 2011).
It is important to face your feelings. It is not possible to avoid grief. However, one can suppress it. In fact, trying to avoid the feelings associated with grief may prolong the period that one takes to recover. It might also lead to other complications which include health related issues. The bereavement counselor and palliative care team can assist with this process. It can be of much help to express the feelings one has towards losing a loved one in a manner that is tangible. For instance, one can put their feelings into writing. In such writing, putting down the things that you feel you had not told the deceased can help a lot. In addition, it can also help when the bereaved person engages themselves in the organizations or the movements that the deceased was a member (Kacel, Gao, and Prigerson 2011).
Keep a close check on your physical health. It is not advisable to try and lift your moods artificially by engaging in drugs and alcohol consumption (Gamino, Sewell, & Easterling, 2000). The best way to get rid of stressful moments is by trying to get enough sleep and doing some exercise. Also, try to eat enough and eat a well balanced diet. Do not be embarrassed by your feelings (Altamier, 2011). Whatever you feel is normal and it is alright to feel like that. It is hard to resist the feelings and, therefore, the best idea is to express your feelings with no fear. It can also be of much help to plan ahead for situations that are likely to trigger the grief. These are situations such as the celebrations of birthday’s and anniversaries. Such celebrations are likely to bring a renewed feeling of grief (Care, 2006 ). It is, therefore, advisable to plan ahead for them. You should be aware of what to expect during such celebrations and, therefore, be prepared. For the preparations, you can make arrangements with the family members and those who will be involved in the preparation on the strategies that will be followed in honoring the deceased (Kacel, Gao, and Prigerson 2011).
- Clinical interventions of dealing with grief
The most common form of clinical intervention is the provision of counseling. Health care providers often have to provide counseling services to the bereaved in order to help them cope with their loss. Counseling can be done by the nurses, the doctors or a grief counselor. In addition to this, the nurses often have to provide moral and social support to the bereaved family member not only after the death of the patient but also during the dying process. The nurses often have be the voice of reason given that the bereaved may be far too overwhelmed by emotion for them to be able to function well socially and physically. The focus of this study however shall be on health care providers with examples of case studies on nurses and grief counselors being provided.
The development of clinical frameworks to explain grief has resulted in the enhancement of the grief counseling in the clinical set up. There are various situations in practice that lead to bereavement. In the palliative care setting, the death of an individual who has been under care for a long time can lead to bereavement. The loss of a spouse in old age can prove to be an emotionally challenging period for the surviving spouse as a result of grief. The loss of a parent to a debilitating disease, murder, a disaster such as a terror attack, a hurricane or a fatal accident can be a source of grief to the surviving child.
In helping the bereaved cope with their loss, there is a gap that exists between what `has been found through research and what is practiced in clinical set ups. To begin with, the most preferred sources of information according to a survey that was conducted by the Centre for the Advancement of Health are books, workshops and colleagues. Journals which often contain the most recent information on helping the bereaved cope were ranked by those who were surveyed as the least helpful source of information. Based on the disconnect with recent research findings, the health care providers provide coping mechanisms for the bereaved based on information that is outdated and would quality as hearsay. As a result, it is not unusual for health care professionals to be disjointed from the bereaved parties in their attempts to provide them with coping strategies (Care, 2006 ).
Health care professionals often rely on the information available on health discourse in order to help the bereaved in coping with their grief (Stroebe & Hanson, 2001). A survey of 29 grief counselors who were drawn from the United Kingdom revealed that in spite the fact they recognized that the grieving process was unique to the individual and the duration of the grieving process varies, they were still keen on treating grief as a linear process comprising of discrete steps that ultimately came to an abrupt end (Wortman & Silver, 1989). As a result, their counseling efforts were informed by the need to prevent the bereaved party from being stuck in a particular phase. To most of them, their main priority was to assist the bereaved party to come to a closure regarding the demise of their loved one. In spite the fact that this practice is informed by Bowlby’s theory of attachment and Freud’s theory, it contravenes the more recent dual process model. The dual process model states that both loss orientation and restoration orientation are critical aspects of the grieving process.
According to grief theories, grief is a process that is stage based and finite. In the clinical set up, many health care providers often view grief as a static process that needs to fit a particular model in addition to progressing as per the model. It has been found that health providers often view the apply the grieving discourse with little empirical evidence to back them up therefore the bereaved persons end up being the recipients of theorized counseling that is not tailored to match their needs or consider variables such as their cultural background, their religious background, the circumstances surrounding the death of the deceased and the personality of the bereaved. For instance, in the paediatric setting, a researcher observed that the health care providers termed unusual absent mindedness or overreacting to issues as grief given that they had learned this from the grief discourses (Winokuer & Harris, 2012).
Grief interventions are often complicated by the mentality of most health providers that most of their interventions are efficient. However, this is often not the case. According to research, it has been found that the interventions that were provided by health care providers to those who were undergoing normal grieving often had little or no effect at all. In some instances, it would have been better for the healthcare providers to offer no help to the bereaved party (Jordan & Neimeyer, 2003).
The provision of support during grief is further complicated by the fact most people are afraid of death and are often anxious about it. As a result, research has shown that grief counselors often express little or no empathy for the bereaved in helping them to cope with death and dying. In another study, 30% of the nurses who participated reported that they felt uncomfortable when dealing with the family after the critically ill patients they were looking after died or was dying (Kojlak, Keenan, Plotkin, Giles-Fysh, & Sibbald, 1998).
- Areas of support for the professionals coping with bereavement
Based on the review of literature and case studies, it is important to note that a different approach ought to be applied in order to equip health professionals who are dealing with the bereaved. Training ought to be carried out in a more practical clinical set up with the training material having been drawn from recent research findings on grief. In addition to that, the health care professionals ought to undergo debriefing sessions in order to help them conquer their own fears and anxiety regarding death. This would enable them to empathize with the bereaved and therefore offer support that is practical to the needs of the bereaved.
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