sense of self-worth, which the person may
experience as a loss. A loss of role function
and the self-perception and worth tied to that
role may accompany the death of a loved one.- Loss related to self-actualization.An external
or internal crisis that blocks or inhibits striv-
ings toward fulfillment may threaten per-
sonal goals and individual potential (Parkes,
1998). A change in goals or direction will pre-
cipitate an inevitable period of grief as the
person gives up a creative thought to make
room for new ideas and directions. Examples
include having to give up plans to attend
graduate school or losing the hope of mar-
riage and family.
The fulfillment of human needs requires dynamic
movement throughout the various levels in the hier-
archy. The simultaneous maintenance of needs in the
areas of physiologic integrity, safety, security and
sense of belonging, self-esteem, and self-actualization
is challenging and demands flexibility and focus. At
times, a focus on protection may take priority over pro-
fessional or self-actualization goals. Likewise, human
losses demand a grieving process that simultaneously
challenges each level of need. Specific examples in-
clude the loss of a pregnancy or loss of sight or hearing.
THE GRIEVING PROCESS
Nurses interact with clients responding to a myriad
of losses along the continuum of health and illness.
Regardless of the type of loss, nurses must have a
basic understanding of what is involved to meet the
challenge that grief brings to clients. By understand-
ing the phenomena that clients experience as they
deal with the discomfort of loss, nurses may promote
the expression and release of emotional as well as
physical pain, thus supporting the grieving process.
Supporting this process means ministering to psy-
chological as well as physical needs.
The therapeutic relationship and therapeutic
communication skills such as active listening are para-
mount when assisting grieving clients (see Chaps. 5
and 6). Recognizing the verbal and nonverbal commu-
nication content of the various stages of grieving can
help nurses to select interventions that will meet the
client’s psychological and physical needs.
Theories of the Grieving Process
KUBLER-ROSS’S STAGES OF GRIEVING
Elisabeth Kubler-Ross (1969) established a basis for
understanding how loss affects human life. As she
attended to clients with terminal illnesses, a process
of dying became apparent to her. Through observa-
tions of and work with dying clients and their families,
Kubler-Ross developed a model of five stages to explain
what people experience as they grieve and mourn:
1.Denialis shock and disbelief regarding
the loss.
2.Angermay be expressed toward God, rela-
tives, friends, or health care providers.
3.Bargainingoccurs when the person asks
God or fate for more time to delay the
inevitable loss.
4.Depressionresults when awareness of the
loss becomes acute.
5.Acceptanceoccurs when the person shows
evidence of coming to terms with death.
This model became a prototype for care providers as
they looked for ways to understand and assist their
clients in the grieving process.BOWLBY’S THEORY OF
ATTACHMENT BEHAVIORS
John Bowlby, a British psychoanalyst, proposed a
theory that humans instinctively attain and retain
affectional bonds with significant others through
attachment behaviors,which are crucial to the
development of a sense of security and survival. Ex-
amples of attachment behaviors include following,
clinging, calling out, and crying. Bowlby saw that
human beings modified these attachment behaviors
as they matured from childhood into adulthood, but
that patterns of attachment behavior formed early
endure throughout the life cycle. People experience
the most intense emotions when forminga bond such
as falling in love; maintaininga bond such as loving
someone; disruptinga bond such as in a divorce; and
renewingan attachment such as resolving a conflict
or renewing a relationship (Bowlby, 1980).
An attachment that is maintained is a source of
security; an attachment that is renewed is a source
of joy. When a bond is threatened or broken, however,
the person responds with anxiety, protest, and anger.
Actual loss leads to sorrow. According to Bowlby,
these emotions reflect affectional bonds. Loss strongly
activates or arouses attachment behaviors. Thus the
clinical picture of increased anxiety, sorrow, anger,
looking for the lost person or object, calling out, cry-
ing, and protesting is an attempt to restore the lost
affectional bond through attachment behaviors.PHASES OF THE GRIEVING PROCESS
Bowlby’s understanding of grieving will serve as the
predominant framework for this chapter. Bowlby de-
scribed the grieving process as having four phases:- Experiencing numbness and denying the loss
- Emotionally yearning for the lost loved one
and protesting the permanence of the loss
12 GRIEF ANDLOSS 241