Grief and loss is something that all people will experience in their lifetime. The loss may be actual or perceived and is the absence of something that was valued. An actual loss is recognized and verified by others while others cannot verify a perceived loss. Both are real to the individual who has experienced the loss. Grief is the internal part of the loss; it is the emotional feelings related to the loss. Nurses may experience this personally, or they may be the support system for patients and their families going through grief and loss. There are normal stages of grief that people experience; however, every person’s experience is individual. The feelings of loss are commonly associated with the death of a loved one, but they can be experienced for a number of reasons. People may experience grief and feelings of loss about a significant change such as the loss of a job, loss of function, loss of a limb, loss of a pet, the feeling of loss of control, and loss of loved ones. It is the nurse’s role to provide compassionate care to the patient and loved ones, and this care will be different from person-to-person. It is also important for the nurse to maintain emotional resiliency, so they are able to provide the best care for those experiencing grief. 
Grief, when permitted, helps process the pain of loss and allows for the pain to heal.
Dr. Elisabeth Kübler-Ross first identified the five stages of grief in her 1969 book Death and Dying. Later, she co-authored On Grief and Grieving: Finding the Meaning of Grief through the Five Stages of Loss with David Kressler, an expert on death and grieving. Their explanations of the stages of grief are widely accepted and taught throughout the world. Initially, they explained five stages of grief, but more recently, David Kressler has discussed an additional two stages (* denotes the additional two stages). They are as follows:
As a nurse, one has the honor of taking care of the most vulnerable populations. This includes patients and loved ones who experience loss. It is important to assess characteristic signs of grief and loss and address them appropriately. It is important for the nurse to start this process by building rapport with the patient and any present loved ones. Encourage them to speak, openly and honestly, about their emotional and physical feelings. Utilize active listening skills and provide a nonjudgmental environment.
The American Association of Critical Care Nurses supports a method for therapeutic communication during emotional conversation topics called the NURSE technique. Utilizing this technique when communicating with people experiencing grief will help demonstrate empathy and build rapport by utilizing the NURSE pneumonic as this example below shows:
When a family member mentions: “This is overwhelming.”
The nurse may respond:
These techniques can be used individually or as a bundle.
It is important for the nurse to assist the patient and loved ones in their coping with their grief to include anticipatory grief. Educate them on what is expected to include the stages of grief and what are some normal feelings as well as what are some resources to help adjust to this loss they are experiencing. Evaluate how they are handling this experience and address any fears related to grief and loss.
Grief may affect individuals differently but can be exhibited through signs and symptoms such as altered immune responses, distress, anger, sleep disturbances, withdrawal, pain, panic, and suffering. It may be evident by one’s lack of understanding of death and its severity and finality of the loss. Encourage loved ones at the bedside to remember to take care of their own health. Remind them or help them have access to food and hydration. Encourage adequate sleep and hygiene.
It is important to be able to provide your patients and their loved ones with resources to adjust to their loss and help them through their grieving process. This may mean chaplain services, their own clergy or spiritual support, psychological referrals, individual therapy, group therapy, and community peer support groups as well as social work referrals. 
Anticipatory grief may be experienced before an actual loss. This type of grieving gives the patient and their loved ones an opportunity to begin the grieving process together. This is often displayed when a patient learns of a terminal illness diagnosis or has a planned amputation surgical procedure.
Complicated grief is when the feelings of loss are debilitating and do not improve after a long amount of time passes. There is no set amount of time that one moves through the stages of grief; however, there is a general movement toward growth and healing in a normal grief experience. A generally accepted amount of time is one year. In complicated grief, the painful emotions are so consuming that the individual has trouble recovering from the loss to resume their life. In the beginning months after a loss, normal grief and complicated grief appear very similar; however, complicated grief will likely worsen instead of gradually fade. Individuals experiencing complicated grief generally need support and resources to help them reclaim a sense of acceptance and peace. 
Signs and Symptoms of Complicated Grief
Some types of relationships to the loss are at a higher risk of complicated grief such as the loss of a child, the loss of a spouse, and the loss of a loved one whom the bereaved may not be able to show their grief such as in an affair or a divorced partner. 
The goals of care are for the patient and their loved ones are to be free of complicated grieving and to have access to adequate resources to allow for the natural grieving process. It is important for them to verbalize and express their true feelings and seek the help and support of others. When they do so, they are more likely to be able to identify their own strengths and weaknesses. It is important that they utilize the necessary resources to help them process their grief and understand the meaning of their loss so that they may learn to live their new life.
Nursing Diagnosis Related to Grief and Loss
Sometimes it is hard to know what to say to someone experiencing grief and loss. The most important thing is to be there and to listen. Allowing a loved one to share a memory or a feeling about the person they are grieving can be invaluable. It is okay not to know what to say. Acknowledge that by saying, “I wish I had the right words, just know I care.” Or, “I am so sorry for your loss.” It is important to understand that not everyone experiences feelings the same, so it is not appropriate to say “I know how you feel.” Instead, say, “I don’t know how you feel, but I am here to help in any way I can.” Then follow through by providing any help that you can, be that an appropriate referral or simply a hot drink or listening ear. 
|||Sombans S,Ramphul K,Sonaye R, The Impact of a Sibling's Death in Intensive Care Unit: Are We Doing Enough to Help Them? Cureus. 2018 Apr 22 [PubMed PMID: 29942721]|
|||Gamino LA,Sewell KW,Prosser-Dodds L,Hogan NS, Intuitive and Instrumental Grief: A Study of the Reliability and Validity of the Grief Pattern Inventory. Omega. 2018 Jan 1 [PubMed PMID: 29983097]|
|||Bibi S,Rasmussen P,McLiesh P, The lived experience: Nurses' experience of caring for patients with a traumatic spinal cord injury. International journal of orthopaedic and trauma nursing. 2018 Aug [PubMed PMID: 29934253]|
|||Mughal S,Siddiqui WJ, Grief Reaction null. 2018 Jan [PubMed PMID: 29939609]|
|||Li T,Wang SW,Zhou JJ,Ren QZ,Gao YL, Assessment and Predictors of Grief Reactions among Bereaved Chinese Adults. Journal of palliative medicine. 2018 Jun 18 [PubMed PMID: 29912611]|
|||Stylianou P,Zembylas M, Dealing With the Concepts of "Grief" and "Grieving" in the Classroom: Children's Perceptions, Emotions, and Behavior. Omega. 2018 Aug [PubMed PMID: 29940830]|