The nurse’s guidance helps the client examine and make changes. Changes imply movement as the client progresses through the grief process. Sometimes the client takes one painful step at a time. Sometimes he or she may seem to go over the same ground repeatedly.
Cognitive responses are connected significantly with the intense emotional turmoil that accompanies grieving. Exploring the client’s perception and meaning of the loss is a first step that can help alleviate the pain of what some would call the initial emotional overload in grieving. The nurse might ask what being alone means to the person and explore the possibility of others being supportive. It is par-ticularly important that the nurse listens to whatever emo-tions the person expresses, even if the nurse doesn’t “agree” with the feelings. For example, anger at the deceased per-son or God, or criticism of others who aren’t “there for me” or supportive enough, may seem unjustified to the nurse. But it is essential to accept the person’s feelings without trying to dissuade them from feeling angry or upset. The nurse needs to encourage the person to express any and all feelings without trying to calm or placate them.
When loss occurs, especially if it is sudden and without warning, the cognitive defense mechanism of denial acts as a cushion to soften the effects. Typical verbal responses are, “I can’t believe this has happened,” “It can’t be true,” and “There’s been a mistake.”
Adaptive denial, in which the client gradually adjusts to the reality of the loss, can help the client let go of previous (before the loss) perceptions while creating new ways of thinking about himself or herself, others, and the world. While taking in the loss in its entirety all at once seems over-whelming, gradually dealing with the loss in smaller incre-ments seems much more manageable. The person may have had assumptions about how others should act or respond to the loss—but those assumptions prove incorrect.
Effective communication skills can be useful in helping the client in adaptive denial move toward acceptance. Note the intervention the nurse makes in the scenario with Ms. Morrison. The nurse enters Ms. Morrison’s room and sees her crying and her full tray of food untouched.
Nurse: “You must be quite upset about the news you received from your doctor about your sur-gery.” (using reflection, assuming the client was crying as an expected response of grief; focusing on the surgery is an indirect approach regarding the subject of cancer)
Client: “I’m not having surgery. You have me mistaken for someone else.” (using denial)
Nurse: “I saw you crying and wonder what is upsetting you. I’m interested in how you are feeling.” (focusing on be-havior and sharing observation while indicating concern and accepting the client’s denial)
Client: “I’m just not hungry. I don’t have an appetite and I’m not clear about what the doctor said.” (focusing on phys-iologic response; nonresponsive to nurse’s encouragement to talk about feelings; acknowledging doctor’s visit but un-sure of what he said—beginning to adjust cognitively to reality of condition)
Nurse: “I wonder if not wanting to eat may be related to what you are feeling. Are there times when you don’t have an appetite and you feel upset about something?” (suggesting a connection between physiologic response and feelings; promoting adaptive denial)
Client: “Well, as a matter of fact, yes. But I can’t think what I would be upset about.” (acknowledging a connection between behavior and feeling; continuing to deny reality)
Nurse: “You said you were unclear about what the doctor said. I wonder if things didn’t seem clear because it may have upset you to hear what he had to say. And now, tonight, you don’t have an appetite.” (using client’s experience to make connection between doctor’s news and client’s physiologic response and behavior)
Client: “What did he say, do you know?” (requesting in-formation; demonstrating a readiness to hear it again while continuing to adjust to reality)
In this example, the nurse gently but persistently guides the client toward acknowledging the reality of her impend-ing loss.
The nurse can help the client to reach out and accept what others want to give in support of his or her grieving process. Note the assessment is developed into a plan for support.
Nurse: “Who in your life would really want to know what you’ve just heard from the doctor?” (seeking information about situational sup-port for the client)
Client: “Oh, I’m really alone. I’m not married.”
Nurse: “There’s no one who would care about this news?” (voicing doubt)
Client: “Oh, maybe a friend I talk with on the phone now and then.”
Nurse: “Why don’t I get the phone book for you and you can call her right now?” (continuing to offer presence; suggesting an immediate source of support; developing a plan of action providing further support)
Many internet resources are available to nurses who want to help a client find information, support groups, and activi-ties related to the grieving process. Using the search words “bereavement” and “hospice,” the nurse can link to numer-ous organizations that provide support and education throughout the United States. If a client does not have inter-net access, most public libraries can help to locate groups and activities that would serve his or her needs. Depending on the state in which a person lives, specific groups exist for those who have lost a child, spouse, or other loved one to suicide, murder, motor vehicle crash, or cancer.
Promoting Coping Behaviors
When attempting to focus Ms. Morrison on the reality of her surgery, the nurse was helping her shift from an unconscious mechanism of denial to conscious coping with reality. The nurse used communication skills to encourage Ms. Morrison to examine her experience and behavior as possible ways in which she might be coping with the news of loss.
Intervention involves giving the client the opportunity to compare and contrast ways in which he or she has coped with significant loss in the past and helping him or her to review strengths and renew a sense of personal power. Remembering and practicing old behaviors in a new situation may lead to experimentation with new methods and self-discovery. Having a historical perspective helps the person’s grief work by allowing shifts in thinking about himself or herself, the loss, and perhaps the meaning of the loss.
Encouraging the client to care for himself or herself is another intervention that helps the client cope. The nurse can offer food without pressuring the client to eat. Being careful to eat, sleep well, exercise, and take time for com-forting activities are ways that the client can nourish him-self or herself. Just as the tired hiker needs to stop, rest, and replenish himself or herself, so must the bereaved person take a break from the exhausting process of grieving. Going back to a routine of work or focusing on other members of the family may provide that respite. Volunteer activities— volunteering at a hospice or botanical garden, taking part in church activities, or speaking to bereavement education groups, for example—can affirm the client’s talents and abilities and can renew feelings of self-worth.
Communication and interpersonal skills are tools of the effective nurse, just like a stethoscope, scissors, and gloves. The client trusts that the nurse will have what it takes to assist him or her in grieving. In addition to previ-ously mentioned skills, these tools include the following:
· Using simple nonjudgmental statements to acknowl-edge loss: “I want you to know I’m thinking of you.”Referring to a loved one or object of loss by name (if acceptable in the client’s culture)
· Remembering words are not always necessary; a light touch on the elbow, shoulder, or hand or just being there indicates caring
· Respecting the client’s unique process of grieving
· Respecting the client’s personal beliefs
· Being honest, dependable, consistent, and worthy of the client’s trust.
A welcoming smile and eye contact from the client during intimate conversations usually indicate the nurse’s trust worthiness, but the nurse must be aware that nonverbal behaviors may have different meanings or connotations in other cultures.