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Chapter: Psychiatric Mental Health Nursing : Grief and Loss

Cultural Considerations - Grief and Loss

Although all people grieve for lost loved ones, rituals and habits surrounding death vary among cultures.



Universal Reactions to Loss


Although all people grieve for lost loved ones, rituals and habits surrounding death vary among cultures. Each cul-ture defines the context in which grieving, mourning, and integrating loss into life are given meaningful expression. The context for expression is consistent with beliefs about life, death, and an afterlife. Certain aspects of the experience are more important than other aspects for each culture.


Universal reactions include the initial response of shock and social disorientation, attempts to continue a relation-ship with the deceased, anger with those perceived as responsible for the death, and a time for mourning. Each culture, however, defines specific acceptable ways to exhibit shock and sadness, display anger, and mourn. Cul-tural awareness of rituals for mourning can help nurses understand an individual’s or a family’s behavior.


Culture-Specific Rituals


As people immigrate to the United States and Canada, they may lose rich ethnic and cultural roots during the adjust-ment of acculturation (altering cultural values or behav-iors as a way to adapt to another culture). For example, funeral directors may discourage specific rites of passage that celebrate or mourn the loss of loved ones, or they may be reluctant to allow behavioral expressions they perceive as disruptive. Many such expressions are culturally related, and health care providers must be aware of such instances. For example, the Hmong (people of a mountainous region of Southeast Asia) believe that the deceased person enters the next world appearing as she or he did at the time of death. This may lead to a request for removal of needles, tubes, or other “foreign objects” before death.


Because cultural bereavement rituals have roots in sev-eral of the world’s major religions (i.e., Buddhism, Christi-anity, Hinduism, Islam, Judaism), religious or spiritual beliefs and practices regarding death frequently guide the client’s mourning. In the United States, various mourning rituals and practices exist. A few of the major ones are summarized next.


African Americans


Most ancestors of today’s African Americans came to the United States as slaves and lived under the influence of European-American and Christian religious practices. Therefore, many mourning rituals are tied to religious tra-ditions. In Catholic and Episcopalian services, hymns may be sung, poetry read, and a eulogy spoken; less formal Bap-tist and Holiness traditions may involve singing, speaking in tongues, and liturgical dancing. Typically, the deceased is viewed in church before being buried in a cemetery. Mourn-ing also may be expressed through public prayers, black clothing, and decreased social activities. The mourning period may last a few weeks to several years.

Muslim Americans

Islam does not permit cremation. It is important to follow the five steps of the burial procedure, which specify wash-ing, dressing, and positioning of the body. The first step is traditional washing of the body by a Muslim of the same gender (Facing bereavement, 2009).


Haitian Americans


Some Haitian Americans practice vodun (voodoo), also called “root medicine.” Derived from Roman Catholic rit-uals and cultural practices of western Africa (Benin and Togo) and Sudan, vodun is the practice of calling on a group of spirits with whom one periodically makes peace during specific events in life. The death of a loved one may be such a time. This practice can be found in several states (Alabama, Louisiana, Florida, North Carolina, South Carolina, and Virginia) and in some communities within New York City.


Chinese Americans


The largest Asian population in the United States, the Chi-nese have strict norms for announcing death, preparing the body, arranging the funeral and burial, and mourning after burial. Burning incense and reading scripture are ways to assist the spirit of the deceased in the afterlife journey. If the deceased and family are Buddhists, meditat-ing before a shrine in the room is important. For 1 year after death, the family may place bowls of food on a table for the spirit. 


Japanese Americans


Buddhist Japanese Americans view death as a life passage. Close family members may bathe the deceased with warm water and dress the body in a white kimono after purifica-tion rites. For 2 days, family and friends bearing gifts may visit or offer money for the deceased while saying prayers and burning incense.


Filipino Americans


Most Filipino Americans are Catholic, and, depending on how close one was to the deceased, wearing black clothing or armbands is customary during mourning. Family and friends place wreaths on the casket and drape a broad black cloth on the home of the deceased. Family members commonly place announcements in local newspapers ask-ing for prayers and blessings on the soul of the deceased.


Vietnamese Americans


Vietnamese Americans are predominately Buddhists, who bathe the deceased and dress him or her in black clothes. They may put a few grains of rice in the mouth and place money with the deceased so that he or she can buy a drink as the spirit moves on in the afterlife. The body may be displayed for viewing in the home before burial. When friends enter, music is played as a way to warn the deceased of the arrival.

Hispanic Americans

Hispanic or Latino Americans have their origins in Spain, Mexico, Cuba, Puerto Rico, and the Dominican Republic. They are predominately Roman Catholic. They may pray for the soul of the deceased during a novena (9-day devo-tion) and a rosary (devotional prayer). They manifest luto (mourning) by wearing black or black and white while behaving in a subdued manner. Respect for the deceased may include not watching TV, going to the movies, listen-ing to the radio, or attending dances or other social events for some time. Friends and relatives bring flowers and crosses to decorate the grave.


Guatemalan Americans may include a marimba band in the funeral procession and services. Lighting candles and blessing the deceased during a wake in the home are com-mon practices.


Native Americans


Ancient beliefs and practices influence the more than 500 Native American tribes in the United States even though many are now Christian. A tribe’s medicine man or priestly healer, who assists the friends and family of the deceased to regain their spiritual equilibrium, is an essential spiritual guide. Ceremonies of baptism for the spirit of the deceased seem to help ward off depression of the bereaved. Perceptions about the meaning of death and its effects on family and friends are as varied as the number of tribal communities.


Death may be viewed as a state of unconditional love in which the spirit of the deceased remains present, comforts the tribe, and encourages movement toward life’s purpose of being happy and living in harmony with nature and oth-ers. Belief in and fear of ghosts and believing death signi-fies the end of all that is good are other views. Yet another view is the belief in a happy afterlife called the “land of the spirits”; proper mourning is essential not only for the soul of the deceased but also for the protection of community members. To designate the end of mourning, a ceremony at the burial grounds is held during which the grave is covered with a blanket or cloth for making clothes. Later, the cloth is given to a tribe member. A dinner featuring singing, speech-making, and contributing money com-pletes the ceremony.


Orthodox Jewish Americans


An Orthodox Jewish custom is for a relative to stay with a dying person so that the soul does not leave the body while the person is alone. To leave the body alone after death is disrespectful. The family of the deceased may request to cover the body with a sheet. The eyes of the deceased should be closed, and the body should remain covered and untouched until family, a rabbi, or a Jewish undertaker can begin rites. Although organ donation is permitted, autopsy is not (unless required by law); burial must occur within 24 hours unless delayed by the Sabbath. Shivah is a 7-day period that begins on the dayof the funeral. It represents time for mourners to step out of day-to-day life, and to reflect on the change that has occurred (Weinstein, 2003).


Nurse’s Role


The diverse cultural environment of the United States offers nurses many opportunities to individualize care when working with grieving clients. In extended families, varying expressions and responses to loss can exist depend-ing on the degree of acculturation to the dominant culture of society. Rather than assuming that he or she under-stands a particular culture’s grieving behaviors, the nurse must encourage clients to discover and use what is effec-tive and meaningful for them. For example, the nurse could ask a Hispanic or Latino client who also is a practic-ing Catholic if he or she would like to pray for the deceased. If an Orthodox Jew has just died, the nurse could offer to stay with the body while the client notifies relatives.


Acculturation may have caused some people to lose, mini-mize, modify, or set aside specific culture-related rituals. Many Americans, however, have experienced a renewed and deepened awareness for meaningful mourning through rit-ual. An example of such awareness is the creation of the AIDS quilt. The planting of a flag in the chaotic debris at Ground Zero during the immediate aftermath of the terrorist attack on the World Trade Center in September 2001 signaled the beginnings of such a ritual. As bodies were recovered and removed, the caring diligence and attentive presence of those facilitating their transport continued this meaningful rite of passage. Through the media, the United States and much of the world became companions in grief. In April 2000, a memorial was dedicated for the 168 persons who died in the bombing of the Alfred P. Murrah Federal Building in Okla-homa City. During the ceremony, a police chaplain delivered a message to grieving family and friends to “live in the pres-ent, dream of the future.” Memorials and public services play an important role in the healing process.


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