Just as the seasons of the year change from fall to winter to spring and finally to summer as we journey through life, we experience the seasons of life: wellness, illness, and finally death. The seasons of life will be different for every person, unique to each of us. This article focuses on the incredible relationship between patients and nurses during these times of change, changes that can lead to a profound sense of loss and therefore grief. With the appropriate tools to recognize grief, assess, and gently intervene, it will be the nurse who makes the difference.
To be sure, every nurse has witnessed the changing seasons of a patient’s life. It is the nurse who is at the hospital bedside, facility, care center, patient’s home, or hospice, advocating, guiding, directing, and caring for patients and their families. It is a privilege to be in this position. Patients and families allow nurses a window into their souls, their needs, their delights, and, yes, their fears.
The experience of grief
It is a myth that one needs to experience death in order to experience grief. Grief will creep into patients’ lives when their lives have changed, and they have experienced an important loss. For example, a patient who loses a leg may grieve for the lost limb, knowing full well that life has changed, never to return to the way it was. Grief will occur when patients are told that they must transition from their home to a care facility. Life changes and a new season are ushered in. Although patients express their grief in unique ways, some keep their sadness, fears, and regrets to themselves. It is the astute nurse who recognizes the sometimes silent issues, gently bring them to the surface, and helping the patient move forward through the new and unchartered territory.
Grief may be manifested physically by restlessness, dry mouth, difficulty breathing, loss of appetite, nausea, vomiting, diarrhea, weakness, difficulty sleeping, headaches, generalized aches, and chills. Emotionally, grief may manifest as detachment from others, anger, shock, guilt, preoccupation, lack of focus, helplessness, and powerlessness.
Patients and families may detach spiritually. A lifetime of faith may disappear in an instant, leading patients to ask, “Is there a God?” “Where is God?” Nurses must take care to avoid all judgments or assumptions about patients’ or their family members’ ways of expressing their spiritual/religious feelings–or lack of such feelings. People need these moments of personal inventory in order to build again. Some patients may find the pastoral care staff helpful and a caring presence of support—whether the patient and family have a defined spirituality, belong to a faith community, or not. The important thing is to respect the individual ways each person experiences faith, spirituality, and the varied views and traditions of death and grief that patients and their families bring to the situation. Nurses are especially adept at building rapport and providing active listening without attaching a value judgment—the greatest kindness and intervention that can be provided.
The stages of grief
The stages of grief, while expected, do not necessarily run in a linear fashion. (See Stages of grief.) All patients move through the stages of grief at their own pace and may vacillate between one stage and the next. The patient does not move predictably and gracefully through the stages. The grief journey can be fraught, with many twists and turns and stages entered, experienced, closed, and revisited.
Depression: what is normal?
Depression, while it may not feel normal to a patient, is a completely normal response to the loss of a loved one or a significant change in life. However, it is critical that the nursing assessment differentiate between the normal depression that can accompany grief and more complicated grieving, which can include clinical depression. (See Comparison of normal grief and clinical depression.)
It is vital that nurses recognize the difference between normal grief and depression. Each requires different care and follow-up. Alan Wolfelt, PhD, one the great pioneers in the area of understanding grief work, succinctly cites the differences between normal grief and clinical depression. The American Psychiatric Association website incorporates Dr. Wolfelt’s work thus: “For some people, the death of a loved one can bring on major depression. Losing a job or being a victim of a physical assault or a major disaster can lead to depression for some people. When grief and depression co-exist, the grief is more severe and lasts longer than grief without depression. Despite some overlap between grief and depression, they are different. Distinguishing between them can help people get the help, support or treatment they need.”
A key difference between a normal grief response and clinical depression lies in how long the feelings last and to what extent the feelings disrupt activities of daily life. Normal grief will soften over a period of time and will begin to fade as the shock and chaos of the immediate passing decline; people experiencing normal grief gradually begin to reintegrate into a normal daily schedule. Caution must be exercised because patients may experience a resurgence of grief in the coming years at such times as anniversaries, weddings, and births.
For those who experience clinical depression, the feelings of sadness and despair do not fade but linger and negatively impact the person’s daily life. For these patients, a referral for psychiatric counseling is necessary, as a deeper level of expertise is needed to address the issue. Needless to say, patients and families who are in the throes of depression must also be assessed for risk of suicide and be supported accordingly.
Facing and surviving grief
Several strategies can help in addressing grief.
The temptation for everyone confronting unpleasant thoughts is to run away, to flee to a comfortable, familiar zone. Those experiencing grief need to be encouraged to face it squarely and experience it fully. Mindfulness can help one survive grief. “Being mindful is about being fully present, aware and awake moment by moment,” Grief-Healing-Support.com notes. “Paying attention with mindful contemplation to each experience and situation without resistance, without judgment, without analyzing and without reacting. Moment to moment awareness is being fully awake in this moment right now.”
In his book on grieving, Sameet Kumar, PhD, addresses the importance of mindfulness and its impact on grieving, asserting that “grieving is not a pathological disease to be treated but rather the tangible evidence that we’ve loved someone.”
By not living in the moment or grieving mindfully, patients may always feel a nagging sense of something being left undone and incomplete. By completely experiencing life’s events to the fullest, even something as painful and difficult as grief, patients can move forward and feel complete about the emotional work that has been done.
Nurses are touched throughout their careers by a wonderful array of patients and families. The death of a patient may trigger unresolved grief in the nurse. Nurses must also grieve mindfully and assess their own grief reactions. Caring for ourselves and each other is critical to the success of caring for patients and families. In the course of busy days and hectic schedules, it can be most helpful for the grieving nurse to take even a few moments for self-care and awareness. It is vital that nurses be allowed to grieve and remember cherished patients for their own health and well-being. Many hospitals and healthcare facilities have employee assistance programs that exist to help counsel staff and support them as they move through grief work. Hospital chaplains frequently help staff as well as patients. Seeking the support of fellow nurses and forming support groups can be extremely helpful.
Facilities fortunate enough to have a palliative care program are uniquely positioned to provide expertise in symptom management, discussions about goals of care, and end-of-life care. All of this is done not solely for the patient but in partnership with the patient and family. Providers can and should access the expertise of the palliative care staff as needed, as they are an invaluable source of information, support, and advocacy. As Matthew Gordon, MD, a radiation oncologist with Salem Health in Salem, Oregon, explained (June 2015), “Almost every cancer patient we see is experiencing some level of grief as their lives change from wellness to illness. Each patient experiences a loss of their health as they have known it. Their lives will never be the same again. Some patients with significant alterations in their health status literally lose their identity as well. They may not be the strong, driving force in their family any longer but are now the family member most in need of help.”
At each step of the journey and season of life, the patient’s needs and desires are considered, utilizing an interdisciplinary team of healthcare providers. The team consists of a palliative care physician, nurse, social worker, dietitian, spiritual provider, and perhaps an ethicist. Each patient’s wishes are respected, even if those wishes conflict with the nurse’s personal feelings.
Nurses are positioned to effectively assist the patient and family with lasting strategies to help conquer grief. Specifically, nurses can help by being in touch with their patients, being present, and knowing that a silent presence conveys caring and supportive messages. Being genuine is essential, expressing true concern that can be communicated by a simple touch (if the patient wishes to be touched) or by companionable silence; allowing someone to cry without handing them a tissue, which can in some cases imply that the person should stop crying. Nurses can take their cue from the patient by discerning what the patient needs right now.
Guiding and being present
The nurse-patient bond provides a solid foundation for nursing intervention. Nurses can provide gentle guidance to patients and their families who are grieving. Such interventions include assessing for specific needs, symptom management to help improve quality of life, and discerning family dynamics. The nurse bonds with a patient by simply being present. Words aren’t always necessary. A supportive silence can be a key element of support.
It is important that patients and families understand that the coming year will be a year of painful “firsts”… first anniversary, first birthday, first holidays without their loved one. Nurses can listen to these concerns and collaborate with the patient and family on developing new family traditions while keeping all the dear memories alive.
Community resources must also be brought into the arsenal of care available to continue grief support, including local houses of worship, funeral homes and mortuaries, hospices, and the services of counselors.
Supporting through the seasons
This article has focused on the journey of grief and the nurse’s role in caring for patients, families, and each other in situations of grief in order to help nurses become better positioned to support and guide patients through the seasons of life.
Rebecca Ruppert, RN, MS, is a radiation oncology staff nurse in the department of radiation oncology at Salem Health, Salem, Oregon.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. DSM-5. Arlington, VA; American Psychiatric Publishing, 2013.
Coping with grief. WebMD website.
Depression is different from sadness or grief. American Psychiatric Association website.
Kumar SM. Grieving mindfully: a compassionate and spiritual guide to coping with loss. Oakland, CA: New Harbinger Publications, Inc., 2005.
Loss, change and grief. Journey of Hearts website.
Seven stages of grief: through the process and back to life. Recover From Grief website.
Survive grief and live: being mindful. Grief Healing Support website.
Wolfelt AD. Understanding your grief: Ten essential touchstones for finding hope and healing your heart. Fort Collins, CO; Companion Press, 2003.