Grief and Loss

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After completion of this course you will receive 2 Continuing Education Units
Is this course for me? This course is for RNs, LVNs, Psych Techs, Administrators & Workers for Adult Residential Facilities, Residential Facilities for the Elderly & Group Homes
Course Synopsis:

   The chance to be a part of these experiences is what draws many people to work in healthcare and human services-related jobs. However, there are also many sorrows–treatments that fail, clients that are facing disability or pain, families dealing with the news of their loved one’s death, people coming to the end of their life.  It’s not as easy to provide excellent care in the bad times as it is in the good; but since grief and loss are part of the human condition, we need to be prepared to support patients and their loved ones in times of grief, and also be able to manage our own emotions as we deal with people who are enduring sadness and loss.

   This course will familiarize you with the typical signs and patterns of grief and how to recognize them in others, give you strategies for helping patients face difficult times, and enable you to develop your own emotional management and coping strategies as a healthcare or human services worker. At the end of this course you will be filled with hope and gain a new understanding of grief and loss so that you can aid others and yourself.

Sample CEU Certificate for ClickPlayCEU

Sample CEU Certificate

Course Objectives:
Upon completion of this course you will be able to:

  • Define grief and some of its common causes
  • Describe the typical stages or experiences of one experiencing grief and loss
  • Understand and state the physical, mental, and societal impact of grief and loss=
  • Develop strategies and responses in order to help your patients/clients and their loved ones who are experiencing grief and loss
  • Recognize signs of your own emotional involvement with patients or clients who are experiencing grief, and develop coping mechanisms to provide excellent care while maintaining your own mental health

Total Video Run Time: 1 hr. 25 min

Author Profile:

 Donn-Kropp1-288x300Donn Kropp founded CLiCKPLAY Continuing Education University out of a desire to bring others to greater levels of health and wellness. With over ten years of emergency and trauma room experience, Donn brings a seasoned, yet fresh approach to continuing education.

Course Approvals

This course is approved by the following governing boards & organizations:

  • CA Board of Registered Nursing: CA Provider # CEP 15849
  • District of Columbia Board of Nursing: CE Provider #50-14108
  • California Board of Vocational Nursing Provider # V10810
  • Psychiatric Technicians Provider # V10806
  • DSS/CCL Division for Adult Residential Facilities (ARF) Vendor Approval # 2000149-735-2: Course Approval #149-0212-24791
  • DSS/CCL Division for Residential Facilities for the Elderly (RCFE) Vendor Approval # 2000149-740-2: Course Approval #149-0212-24790
  • DSS/CCL Division for Group Homes (GH) Vendor Approval # 2000149-730-2: Course Approval #149-0212-24792
  • Far Northern Regional Center

Transcript

Grief & Loss

1. INTRODUCTION
“To everything there is a season…. A time to cry and a time to laugh”. One of the things that binds all humans together is the experience of both joy and sorrow in life. This is especially evident when working in the healthcare and human services field.  In our profession, there are great joys: seeing a sick person made well, a new baby come into the world, a successful treatment, the restoration of a person’s health and function.  The chance to be a part of these experiences is what draws many people to work in health-care-related jobs.  However, there are also many sorrows–treatments that fail, clients that are facing disability or pain, families dealing with the news of their loved one’s death, people coming to the end of their life.  It’s not as easy to provide excellent care in the bad times as it is in the good; but since grief and loss are part of the human condition, we need to be prepared to support patients and their loved ones in times of grief, and also be able to manage our own emotions as we deal with people who are enduring sadness and loss.  This course will familiarize you with the typical signs and patterns of grief and how to recognize them in others, give you strategies for helping patients face difficult times, and enable you to develop your own emotional management and coping strategies as a healthcare worker. Hi,my name is Donn Kropp, my hope is that at the end of this course you will be filled with hope and that you gain a new understanding of grief and loss so that you can aid others and yourself. I wanted to teach on this subject of loss and grief because of my own experiences of witnessing traumatic events and loss day-in and day-out as an ER and trauma nurse. In the ER there isn’t a day that doesn’t go by without some kind of loss or situation that causes grief. Grief and loss can strike you at the very core of your being. It is important and essential to have the skills to cope and eventually move Thank you for joining me on this journey toward hope.

2. OBJECTIVES
After watching this course you will be able to :

  • Define grief and some of its common causes
  • Describe the typical stages or experiences of one experiencing grief and loss
  • Understand and state the physical, mental, and societal impact of grief and loss
  • Develop strategies and responses in order to help your patients/clients and their loved ones who are experiencing grief and loss
  • Recognize signs of your own emotional involvement with patients or clients who are experiencing grief, and develop coping mechanisms to provide excellent care while maintaining your own mental health

3. DEFINING GRIEF & LOSS
We’ve all experienced grief and loss in some form in our lives, and we know how bad it feels. Grief comes about as a reaction to some type of loss or sad event in a person’s life.  Just as there are many types of physical pain, there are many types of the emotional pain of grief and loss. Grief can be an agonizing, searing emotional experience that can incapacitate a person’s ability to function; it can also be a continual dull pain in the background of life that casts a shadow over all the experiences a person is going through. People experience grief as the result of major catastrophic life events- the sudden death of a loved one; a person being told they can never have children; a fatal car accident; a diagnosis of incurable cancer.  Grief can also come as a result of smaller, but still significant circumstances- losing a leg from diabetic complications; an eye disease that will lead to blindness; a stroke victim learning that they will never recover their speech; a miscarriage.  People’s experiences with grief are as unique as people themselves, and everyone goes through grief and loss in their own way. No one can dictate or gauge the appropriate amount of grief that accompanies a given event; if two different patients learn that they must have their leg amputated, one patient may accept the news with only a small measure of sadness, while the other may consider it a terrible loss and mourn the event with a great deal of grief and pain.  Neither response is “right” or “wrong”; each person reacts to the news in the context of their life experiences, personality, hopes, and expectations.  You might be thinking right now of a time in your life when you experienced a loss and the pain that it brought you.  It’s something that every person will experience in some form or other.  Listen now as some people share how they felt when they experienced a loss of some sort that caused them grief. As these people can attest, grief stems from many different types of experiences and loss.  And while each person’s experience is unique, there are some common forms and stages of grief that are helpful to know about as we support and work with those experiencing grief and loss.  Let’s turn now to the topic of these stages of grief and how they manifest themselves in people’s experiences and reactions.

4. STAGES & REACTIONS TO GRIEF & LOSS
Hearing bad news about a diagnosis, a test result, or the loss of a loved one is an extremely difficult thing to deal with.  People who receive difficult news can react silently, emotionally, stoically, or angrily.  According to psychologist Michele Reiss, there is no ‘right’ or ‘wrong’ way to react to bad news; everyone reacts differently based on their personality and life circumstances.  As healthcare professionals and workers, our job is to offer support and assistance in dealing with the emotional fallout from bad news, and recognize that support as part of our treatment of the whole person.  However, that support and assistance must be carefully and gently given, because inconsiderate or ill-timed counsel for the grieved can hurt people in some of their most vulnerable moments.  That’s why it’s important to keep in mind that people need time to process the loss they’re dealing with, and that they can’t be rushed or hurried through the process of grief. Although everyone experiences grief in a unique way, there are some general patterns and cycles of how many people grieve, which can be helpful in understanding what type of support a person needs from the healthcare professionals and workers around them.  One well-known explanation of the grieving process is the “5 Stages of Grief”,developed by Elisabeth Kubler-Ross through her work with terminally ill patients.  These five stages are not present in every person’s process of grieving, but many people experience some form of these stages as they deal with loss or death.  It’s important to note that even though the 5 stages are often listed in order as “first stage”, “second stage”, etc, people can experience these emotions at the same time or move in and out of stages over the course of their grief. The first stage is denial; many people may refuse to believe at first that the event is happening to them.  Someone may say, “I can’t have cancer!” or “No, he’s not going to die; we’ll find a treatment that works!”  This is a normal reaction and is a psychological defense mechanism that the brain uses to help get through the first intense wave of pain that comes with receiving bad news.  Sometimes the grieving person may not show much of a reaction to the bad news at all, appearing to “take it well”.  However, this too is a symptom of denial- because the reality of death has not sunk in, survivors can appear to be quite accepting of or relatively unaffected by the loss. Other times the person can have seemingly illogical responses to the news. The mother of a soldier who had been killed in Afghanistan described the day that army personnel came to tell her about her son’s death.  She said, “I opened the door and I saw the man in the dress greens and I knew.  I immediately knew.  But I thought that if, as long as I didn’t let him in, he couldn’t tell me.  And then it- none of it would have happened.  So he kept saying, “Ma’am, I need to come in”.  And I kept telling him, ‘I’m sorry, but you can’t come in’.”  This woman knew intellectually what had happened, but her immediate emotional reaction was to attempt to deny the devastating news.  This is called “magical thinking” in anthropological terms- following illogical ideas or actions in order to try to reverse the tragedy that has occurred.  This is very common, especially in a sudden, catastrophic situation.  The writer Joan Didion, after the sudden death of her husband, recalls how she began to box up his clothing and take it to a donation center, a few months after his death.  However, she couldn’t bring herself to go through with the process because when she came to his shoes, all she could think was “He will need these when he comes back”.  This is another example of “magical thinking” and is part of the denial of reality that accompanies grief.

To support someone at this initial stage of grief, it’s not necessary to try to force them to confront reality by harshly contradicting their denial.  The person will move past the stage of denial, but it’s a necessary and healthy part of the grieving process for most people.  Gentle repetition of the news, and sincere sympathy, such as saying “I’m so sorry, but there aren’t any more treatments we can try”, is the best response to give someone who’s just received bad news.  Many patients, who are so upset that they don’t seem to notice sympathy from health care workers, later say that it gave them comfort, even if they weren’t able to communicate it at the time. The second stage of Grief and loss is anger. As you just witnessed, in this stage the individual will become angry and upset at the news they’ve been given, sometimes including the person who delivers the news. This anger is a mask for the pain and hurt an individual is feeling in the situation; pain feels too overwhelming, but anger gives the person’s feelings direction and purpose.  Many times it feels safer for the grieving person to become angry at someone or something else than at themselves or their loved one.  People can extend their anger towards their family, God, the world in general, the doctor who failed to find a cure, or the nearest available healthcare worker.  While this is another normal part of the grieving process, it’s not easy on health care workers to be on the receiving end of that anger.  This is again a time where it’s vital to remember that this is an expected, necessary part of the grieving process and that you are providing needed psychological support for the hurting person by quietly receiving that anger and continuing to act in a professional, caring manner.

Many grieving people also at some point move into a third stage, known as bargaining. At this stage, people begin to think about what they could have done differently, or how they wish they could go back and change the past.  Some bargaining is directed at God or the universe; someone might promise “God, if you will just heal me, I promise I will devote more time to helping others and be less selfish” or “If only my child will get better, I will be a more patient and loving parent”.  Another form of bargaining is to dwell on the past and what could have been changed to avoid the bad news: “If only I had stopped smoking years ago”, or “If she’d only left 5 minutes later, she wouldn’t have gotten into the accident”.  Even though people might logically realize that nothing can undo the past or change the circumstances, emotionally they cannot yet admit this and bargaining is an attempt to try to lessen the pain by changing its reality. A fourth stage of grief is depression; this often happens when the person finally comes to realize that the bad news, and the pain and grief that came with it, can’t be avoided or changed. Many psychologists point out that this sadness shouldn’t be confused with depression as a mental illness; it is the natural response to a devastating event.  Depression can affect people in a very physical sense as well as mental; a grieving person may experience loss of appetite, sleeplessness and insomnia, fatigue, forgetfulness, and the sense of going through life “in a fog”.  The writer Clive Lewis, in his book A Grief Observed, wrote this about his grief after his wife’s death from cancer:  “No one ever told me about the laziness of grief.  Except at my job- where the machine seems to run on much as usual- I loathe the slightest effort.  Not only writing but even reading a letter is too much. Even shaving.  What does it matter now whether my cheek is rough or smooth?” On an emotional level, since the person is no longer trying to avoid the pain through denial, anger, or bargaining, the grief may feel worse than ever before and seem as if it will last forever.  It’s hard for a person in this stage to think that life will ever get better or see the “light at the end of the tunnel”.  Well-meaning but hurtful remarks such as “You’ll get over it” or “Don’t worry, things will get back to normal eventually” may compound the person’s pain by implying that they should be hurrying through their grief.  While medication may help a person in the depression stage with their physical symptoms or with functioning in their day-to-day responsibilities, it will not help the person skip over this stage or take away their grief. Depression caused by grief can come and go for many years in a person’s life, sometimes even for the rest of their life.

The last stage of the grieving process is known as acceptance; this happens when the person moves past depression into the reality of their new existence.  Acceptance does not mean that the person no longer grieves; in many cases, they will always carry grief with them in some form and miss the person or circumstances that are gone forever.  However, they are coming to terms with their changed circumstances and able to function more normally in everyday life again.  Remember, though, that the stages of grief are fluid, and a person who begins to move into acceptance may still have times when they return to other stages, such as bargaining or depression.  However, as time goes on, most people will experience longer-lasting periods of acceptance until they seldom revisit the other stages of grief.  Grief may always be a part of them, but it is not such a dominant emotion as it once was.  They have accepted the reality and finality of their loss.

5. PHYSICAL RAMIFICATIONS OF GRIEF
How did you do on the rapid review? I know you aced it. You’re a very smart person. As we have learned, while grief is an emotional state, it can cause physical symptoms too. Our emotions are closely tied to our bodies, and just as anxiety or fright can cause physical changes, so can grief and sadness. Let’s look at these effects more closely, as they sometimes mirror other physical ailments and can be confused with other medical problems. Physical symptoms of the early stages of grief, especially within the first few hours of being confronted with a loss, are similar to those of panic attacks and anxiety.  Dizziness, shortness of breath, racing heartbeat and palpitations, and a feeling of unreality are common in patients who are confronting a tragic event, especially if it comes upon them with no warning.  Some people may even throw up or faint, partly due to the adrenaline their body produces in reaction to the news.  Sudden terrible news, like other threatening events, activates the “fight or flight” responses of the body that accompany fear.  Stress hormones are released that affect many different bodily systems.  The digestive tract slows down and its chemical balance changes, causing physical discomfort.  Many people, after receiving bad news, say that they felt like they were “punched in the stomach” or that their “stomach was tied in knots”.  These aren’t imaginary descriptions; stress and adrenaline really do bring about physical changes in the body. Even beyond the initial shock of receiving bad news and the first burst of grief, stress hormones remain high for much of the grieving process.  Elevated levels of cortisol, due to high stress, can lead to many long-lasting physical problems. People experiencing grief often don’t sleep well, and the fatigue that results makes daily life even more difficult.  The skeletal and muscular systems are also affected, with muscle tension, headaches, and shoulder and back pain very commonly reported among people dealing with grief.  Memory problems can also occur. Grieving people report feeling like they’re “in a fog”, and have trouble remembering things, concentrating, and paying attention.  Some people have problems with their coordination, tripping and dropping things more easily. These symptoms are also a result of the increased stress hormones produced during the process of grief.  The immune system is also affected by these hormones-as the body is more stressed, it loses resistance to pathogens, and the person is more susceptible to colds, infections, and viruses.  There are many other illnesses that can be initiated or made worse by the stress of grief, such as heart disease, high blood pressure, lupus, glaucoma, ulcerative colitis, cancer, and many more.  These conditions need their own dedicated treatments, but it’s important to acknowledge the role that grief and sadness plays in people’s health.  This is an excellent reminder that if we want our patients to be in the best physical health possible, we cannot ignore their emotional health.  Helping our patients and their loved ones to effectively deal with grief and loss can actually help them get physically better as well.

6. PROVIDING SUPPORT DURING GRIEF & LOSS
So now that we’ve learned a lot about the devastating effects of grief and loss, both emotionally and physically, what are some things that can help people remain as healthy and stable as possible while dealing with it?  Also, what can you as a health-care professional or worker do to help people cope with their grief?  When you’re faced with a patient who is struggling not only with a health issue, but also dealing with grief and sadness, you want to be able to assist them with both their physical and emotional health. Many grieving people also agree that there are many things that people say or do for the grieved which, while well-intentioned, cause the person more pain. Let’s look at what to do and what not to do. It’s critically important to remember that each person’s grief and sadness is uniquely their own, and causing them pain, and that pain is seldom helped by being compared to other pain.  Many people who have struggled with grief report that it felt very hurtful to be told things that tried to minimize their pain, such as, “Well, it could have been worse” or “At least you are still alive” or “You can have another child”.  These remarks are well-meaning, attempting to cheer the person up and put their sorrow in the context of other, worse events.  But this is one of the least helpful things to say to a grieving person, because it doesn’t help them feel better; it only makes them feel guilty for being sad and feeling grief.  Instead of giving comfort, these kind of statements imply that the person should “get over it” or “look on the bright side” and that their sadness is a form of ungratefulness that they shouldn’t be feeling.  Instead, a simple, genuine statement of sympathy such as, “I’m so sorry this happened” is much better.  This shows that you care but are not trying to somehow “fix” the situation.

Another common mistake that people make when trying to comfort someone who’s grieving is to say, “I know how you feel”.  But very often, this too is more hurtful than helpful.  Why?  Because, as we’ve said before, each person’s grief is unique to them and isn’t going to be helped by comparisons.  This is especially true when comparing different kinds of losses, such as saying, “I’m sorry that your mother died.  I know how you feel, because my mother died last year and I was heartbroken too”.  However, if your mother died at 88 in a relatively peaceful way, and the other person’s mother died at 62 from cancer, those are very different circumstances.  There are so many factors that influence a person’s grief that most comparisons are going to sound hollow and unhelpful to the grieving person.  It also takes the focus away from the grieving person’s loss and puts it on another person’s experience, with the implication that they need to stop and offer you sympathy, which would drain them of additional emotional energy.  Unless you are very close to the grieving person and know that a comparison would be legitimate and helpful, it’s best to stay away from “I know how you feel” as a comfort.  Instead, you can offer yourself as an open and compassionate listener.  Asking the person,“How are you feeling?”  or“How can I help you?” shows your support and lets them take the lead in conversation. Another pitfall that those of us in the health-care world in particular need to avoid is that of making callous comparisons between patients or clients. As we build years of experience in our profession, interacting with many patients who may be suffering similar circumstances, we need to remember that we have a different perspective than patients do.  A grieving patient or family will not know that they are the 5th diagnosis of lung cancer this month in the clinic, and it won’t help them to be told.  While we might find cases or patterns of cases interesting or remarkable, patients and families in the midst of grief do not want to be made to feel like case studies or specimens under observations. In the 2011 movie 50/50, a young cancer patient named Adam is given his diagnosis by a doctor who tells him that he has spinal cancer and that it’s “interesting” because the position of his tumor is a rare one.  Adam’s shock at hearing this bad news is compounded by the fact that the doctor seems fascinated by his illness instead of expressing any sympathy for his misfortune.  Again, one of the most important things that we can do for our patients and clients, is to try to support emotional health just as much as we do physical health.  Give each patient and family your full and undivided attention, even though it is often more uncomfortable than making small talk about comparisons, and they will feel more reassured and supported in their time of grief. It’s also very unhelpful to try to rush a grieving person through their grief, or tell them what they “should” be feeling.  Remember that every person’s response to grief and sadness is unique, just as people’s personalities are uniquely their own.  It’s very easy to view our own response to grief, or how we imagine we would respond- as the “right” way; but there is no “right” or “wrong” way to grieve.  So if you are with someone who just received a diagnosis of cancer, and your first reaction would be to start asking questions about your condition and gathering information, you might be tempted to encourage the patient to do this.  But they might need some time to quietly think, cry, and process the news before they’re ready to take any action.  Trying to force them into action mode could be hurtful and callous as they grapple with the bad news they’ve received.  Keep in mind as well that, since grief and sorrow can last for years, it can also be hurtful to try to hurry people through the stages of grief.  There is no timetable for the process of grieving.

When trying to figure out what to say to a grieving person, remember that it’s natural to feel awkward and uncertain when you interact with them.  Most of us want so badly to say and do the right things that we can become paralyzed with indecision or say something without thinking.  Remember that it’s sometimes helpful and honest to acknowledge this uncertainty; for instance, saying, “I’m not sure what to say, but I want you to know that I am sorry that this happened and that I care for you”.  Sometimes we are tempted to say nothing, thinking that we might bother the person, but many people who have suffered a loss report that this makes them feel isolated and ignored.  It’s best to offer simple concern and let the grieving person direct the conversation in ways that are most helpful to them.  Be aware of their need to process their grief in their own ways, and take their cues as to how they want to go about it. Besides expressing our care, concern, and availability to someone dealing with grief, there are many ways to tangibly help as well. As we’ve already learned, one of the hallmarks of grief is the feeling of being out of touch with reality or “in a fog”. Many people who have suffered through a period of grief and loss say that the actions that meant the most to them were small acts of practical assistance.  Offering to bring a meal to a grieving family, arranging transportation after daily life has been disrupted, helping with medical bills and paperwork- these are all examples of concrete, practical ways to help those dealing with grief.  In a hospital or medical office setting, this could include helping the person with transportation arrangements, collecting personal belongings, or making arrangements for the person or the family to eat their next meal. Don’t be afraid to gently make suggestions as to what you might be able to help with; for example, saying “I’m going to the grocery store.  Can I get you anything while I’m there?” or “Would you like me to sit with you and help you fill out these forms?” might be easier for a grieving person to answer than an open-ended question like “Is there anything I can do?”.  Many people find it hard to ask for help or think of what they might need when they are overwhelmed with emotion, and may reflexively refuse an offer that’s too vague.  Even the slight difference between “What can I help you with?” and “Is there anything I can help you with?” can mean a lot to a grieving person, since the first question invites a specific response while the second question is a matter of “yes” or “no”.

Just as we should use sensitivity, however, in speaking with a grieving person, we should also be sensitive in our manner of helping in practical ways as well.  Be careful not to persuade or force a grieving person into an action that they are not ready to take or a decision with which they disagree.  Practical help can become intrusive and hurtful if forced upon the person while they are struggling to make decisions. For example, “I’m coming over to clean your house for you” might cause the person additional stress and emotional strain if they would rather spend time alone or do their own cleaning in order to restore a sense of normalcy.  Practical help should be offered, not forced upon the person.  Actions that rush the person through the grieving process can be hurtful as well, such as pressuring the person to give away possessions or change their daily habits.  Many people cling to daily rituals or objects to remind themselves of the person or ability that they have lost, and they should be allowed to let them go at a time of their choosing. As time goes by, and the initial shock of grief is gone, offers of support and help become fewer and fewer. It can be very helpful and appreciated to continue to offer both tangible and emotional support in the months and years after the event that caused the grief.  Inviting a grieving person over for the holidays, calling them on the anniversary of a death, or offering a meal or babysitting months after the fact can be some of the most welcome types of help.  This lets the person know that their grief, which is still very real and painful for them, has not been forgotten or dismissed by others. Now, many times we health-care workers will not have the time or opportunity to do some of these practical things for a grieving person, since we may only have contact with the person for a short time.  However, we can become familiar with coping strategies and supports in order to make the grieving person aware of resources available to them, or suggest things that might help them deal with their grief when we’re no longer around to support them.  With that in mind, let’s look at some coping strategies that a grieving person can use to help manage their sorrow and sense of loss, so that we can be ready to suggest or refer to them when needed. Once again, let’s do a Rapid Review to really let that information set in your brain.

7. COPING STRATEGIES
There are some concrete steps that people can take, in the midst of grief, to help themselves cope as well as they can under the circumstances.  Not all of these ideas will be appropriate for every person- one person might be helped by seeking quiet and solitude, while another might find the most comfort from surrounding themselves with friends and support- but some combination of these steps can be helpful for almost everyone who is experiencing grief. One important step, when experiencing grief, is to safeguard your health as much as possible. Eating healthy meals and drinking enough water might be the farthest thing from a grieving person’s mind, but the effects of sadness and grief will be hard enough without compounding the problem through poor nutrition.  Even if the grieving person is too overwhelmed to think about eating well, their family, friends, and health care team can help step in and make sure that skipping meals or forgetting to keep hydrated does not add to their pain and suffering.  In the same way, it’s also important to rest, even if sleep itself does not come easily. People experiencing grief should simplify their schedules as much as possible, they shouldn’t feel guilty about taking a break from obligations and responsibilities, and they should give themselves time to process the emotions. This does not mean ceasing all activities, to the point that the person gives up things that they would still take pleasure in doing, even in the midst of grief; but stepping back from obligations that might add more stress to an already overly-stressed person. During trying times Light exercise may be beneficial, such as walking or swimming, in order to help burn off excess energy and aid in relaxation.  Many grieving people find that too much inactivity leads them to over-thinking the traumatic event or going over and over the “What if?” questions that come as a part of grief.  Exercise helps provide an outlet for their energy and quiets the mental stress that grief brings. Massage can also be helpful, by helping to relieve, not only the mental stress caused by grief, but also some of the physical pain that comes from tense muscles, digestive issues, and other physical reactions to grief.  Don’t forget Regular checkups with a medical professional, to discuss both physical and mental health, are also important. Finding a community of support is also critical in coping with grief.  Many people mention the sense of isolation that comes with being grief-stricken, both from the awkwardness or avoidance of friends who don’t know what to say or do, and the grieving person’s sense that no one understands the severity of their sense of loss.  Clive Lewis writes, of his grief, “There is a sort of invisible blanket between the world and me.  I find it hard to take in what anyone says.  Or perhaps, hard to want to take it in.  It is so uninteresting.  Yet I want the others to be about me.  I dread the moment when the house is empty.  If only they would talk to one another and not to me.”

This feeling, of both wanting to be alone and with others, is very common in grieving people.  This is why many people find it helpful to join support groups of others suffering from similar losses, because it helps remove the feelings of isolation and separation.  Many grieving individuals resist this at first, when they are still in the initial stages of denial and anger, not wanting to accept that their loss is the new reality with which they are faced.  However, once the reality has sunk in, many people find comfort in being with those who understand much of what they’re going through.  Support groups of all kinds can be found in hospitals, community centers, as well as online, so that even people with rare medical conditions or situations can often find people to help cope with struggles. Professional counseling can also offer a grieving person a safe outlet to work through their sorrow, especially if they feel overwhelmed or isolated. People who are grieving, particularly those who tend to be self-reliant, need to remember that it’s okay to ask for help.  Many people are usually willing and desirous to help those in crisis, but may not know what to say or how to say it.  As we’ve already discussed, we can all feel awkward around a grieving person and sometimes avoid saying anything at all.  Ideally, every person would know the perfect phrase to convey sympathy and support to a grieving person, but that’s not usually the case.  Someone struggling with grief should feel free to delegate tasks and request practical help as needed, and they will usually find that friends and family are more than eager to fulfill such requests. Now that we’ve covered some positive steps to suggest to those dealing with grief, let’s discuss warning signs that indicate someone is having an especially hard time with their loss.  Just as there are healthy ways of coping with grief, there are also unhealthy patterns that can interfere with a person’s quality of life.  This is sometimes known as “complicated grief”, meaning grief that is particularly severe, long-lasting, or limiting to the person’s health and well-being.  If we are to care for our patients’ or client’s emotional health, we need to understand the warning signs that show that someone might need extra help and support to deal with their grief. Some of these warning signs include bitterness over a loss, preoccupation with the loss, intense pining for a lost loved one, withdrawing from social activities and circles, distancing oneself from others, or numbness towards life.  You can probably tell, just from this list, that there is not a clear distinction between healthy and unhealthy grief, since many of these symptoms would be expected in a grieving person.  However, the duration and the intensity of these signs of grief are what make them problematic to a person’s well-being; if a person seems “stuck” in the initial stages of grief or seems to feel just as much intense pain years later as they did when the event occurred, it could be a sign that they are not coping with grief in a healthy way and may need some extra help.

In addition to extended or complicated grief, another common unhealthy coping mechanism is that of avoidance.  Some people may try to avoid or suppress their grief through the over-use of substances or pastimes. Alcohol dependence, drug use, and over-medication are common indicators of unhealthy coping mechanisms, as are excessive shopping, gambling, or video game playing.  Avoidance creates problems not only by suppressing grief and preventing any sort of healing from taking place, but also may create more problems based in whatever the person is using for this avoidance- gambling debts, alcoholism, etc.  These are very difficult problems to address; like many other addiction issues, the person must have a part in acknowledging the problem and being willing to get help.  However, those of us in the health and human services industry, as well as friends and family, can be aware of these warning signs and develop a plan to gently and lovingly address the issue in a way specific to the grieving person’s struggles. As you can imagine, the negative effect that grief has on individuals also translates into negative effects in families and society. Grief not only disrupts a person’s normal ability to function in life, it also can have a tremendously hurtful effect on relationships with friends and family.  When one member of a family suffers a medical tragedy or passes away, the other family members all must deal with their own grief while still trying to function as a family unit. This can put additional strain on each person, since people grieve in their own unique ways that may conflict with other family members’ management of their grief.  This can be especially true when children are involved, because children often grieve in very different ways than adults.  Let’s take a moment to look at a few quick highlights of how grief often manifests in children: Children, especially very young children, often don’t have a grasp on the permanence of death.  They may ask over and over again when the person is coming back, which can cause adults more pain from having to explain the permanence of death over and over. Children can become very confused by some of the euphemisms our society uses for death, such as “He went to sleep and won’t wake up” or “He’s gone away”.  With their concrete understanding of the world, they may hear these phrases and become afraid of sleeping or separation from loved ones, since people are telling them that sometimes people never wake up or come back.  It’s best to use terms like “He died” or “His body became sick and stopped working”, though this might be more painful for adults, in order not to confuse children.

Children may not show obvious reactions to grief right away, and may process the new and confusing information internally. They may continue to play; this is normal and healthy, and often children may use play as a way to process what happened. They may act out death or illness scenarios with dolls, and draw pictures depicting events; this is a good way for children to come to terms with grief and should be encouraged, even though, as before, it may be painful for adults to watch this. With their egocentric view of the universe, children and adolescents may express anger at the dead person for leaving or abandoning them.  They can also feel like it was their fault that the person got sick or died, or that something they did caused the tragedy to happen.  They may need extra reassurance that it’s okay to feel angry as well as sad, and that it was not their fault this happened.  Children may not even realize that they feel this way, instead becoming withdrawn or hostile at school, with friends, and at home, and may need a loving adult or professional counselor to help them articulate these feelings of anger and abandonment. Grief can also be extremely hard on marriages and other family relations, particularly when two people grieve in different ways. One person may want to talk about their grief and sense of loss, while the other may want to process silently.  One may find solace in work and quickly going back to a “normal” routine, while the other might feel that to go back to “normal” means that their loved one has been forgotten.  To avoid creating resentment or anger on top of the grieving process, it’s important that family members recognize that grief takes many different forms and that people deal with emotions in various ways.  Each person should try to be as aware as possible of the ways in which their actions or statements affect those around them, and find confidants outside their family circle if necessary.  Talking with counselors or support groups, instead of only with family members, can allow one person to process their grief through conversation without causing hurt to others in the family who might conversation painful. As health-care professionals, if we are aware of the extra strain that grief brings to family dynamics, we can gently guide grieving people towards resources to help them grieve while minimizing the negative effects on their family.  For many of the reasons we’ve discussed throughout this course, it’s a wise idea to keep referrals and contacts to support groups, counselors, and therapists always nearby.  Being prepared to offer help in this way can be one of the most caring and meaningful things that you can do for patients and their families who are dealing with grief. Let’s take a little break by taking a rapid review.

8. DEVELOPING CULTURES OF HOPE
Now that we’ve talked at length about how to help patients manage their grief and how to interact with them in helpful, not hurtful ways, it’s time to think for a little bit about ourselves.  Working in the health and human industries field means that we will be faced with heartbreaking and difficult situations, just as we will get to take part in joyful, encouraging events.  So how do we manage our own feelings about tragic situations that we might encounter?  How do we keep our own emotions healthy, so that we can be strong enough to offer our full support and attention to our patients?  While the answers to these questions depend partly on your own personality, there are some helpful principles to keep in mind. Let’s now go over the principles of developing a culture of hope for ourselves in the midst of witnessing and dealing with loss and grief. Principle one- Safeguard your own physical health, just as you help patients do the same.  It’s easier to manage our emotions and maintain a positive focus when we are healthy.  Make sure that you are well-hydrated and are eating healthy meals and snacks during your shift.  Try to watch your sleeping habits so that you are as rested as possible when you are at work.  Since our physical health and emotional health are intertwined, as we’ve already learned, attending to our physical health will make it easier to manage the emotional toll that comes from working with grieving people.

Principle two-Form your own network of support among people who know what you’re going through. For many people, talking with coworkers after a difficult experience helps relieve stress and discouragement. This can be through formal “debriefing” sessions, or informal chats in the break room. Taking time to acknowledge the sadness of what happened, whether the death of a patient, a bleak diagnosis, or an encounter with an angry family member, can help you emotionally resolve the issue instead of dwelling on it for hours or days after the fact. Colleagues can also be a great source of encouragement when it comes to focusing on the positive aspects of your workplace and acknowledging the humor or absurdity in situations. Some people, however, are not fortunate enough to have supportive colleagues or a positive work environment. If you find that your colleagues focus on the negative aspects of the job and spend most of their time complaining, and you feel more drained than refreshed after being around them, then minimize the time you spend  with them and find your support network elsewhere. Online support groups and message board for caregivers and health-care professionals can be a great asset when you lack supportive and positive colleagues. Principle three- Keep a written record of positive moments or events that take place, using a journal, a blog, or an email account. This can be a very helpful reminder, in times when you’re feeling discouraged, of the moments you’d like to remember and the positive elements of your work.  Jot down positive patient outcomes, times when patients thanked you for your work, joyful moments, and encouraging successes.  Over time you’ll build up a significant profile of the positive aspects of the work you do, which can sustain you through times of discouragement.

Our fourth and final principle to help us develop an environment and culture of hope is to remember the value of the work you do. Health care is one of the most basic needs that all humans have, and the part you play is a noble and worthwhile one.  It’s critical for patients and clients to have a knowledgeable, caring team in times of crisis, and the support you provide can help individuals and their families cope during the worst times of their lives.  Countless patients and families, years after their experience with grief and loss, express thankfulness for the caring staff they interacted with, even though at the time they never said anything.  They were consumed with their grief and focused on getting through one hour, one moment at a time.  Yet after the intensity of their loss subsided, and they were able to reflect on their experiences, they remarked how meaningful and helpful it was to be surrounded by a caring, competent staff. You are one of the people that can give people this positive experience, and while they may not be able to express their gratefulness at the time, you have given the gift of support and care.  This is a profoundly important thing!

9. SUMMARY & CONCLUSION
We’ve covered a lot of information about the grieving process and its effects on people in the last couple hours, and this isn’t an easy topic to dwell on, either.  Take a deep breath and let’s recap some of the key points we’ve learned. Key Point One, grief can be caused by various kinds of sadness and loss, from the catastrophic to the expected. There is no threshold or gauge for what should or should not cause grief.  Severe grief is not caused only by death; the loss of function, life expectancy, mental ability, or lifestyle can also trigger tremendous sadness and grief. Key Point two: Health-care workers interact with people all the time who are going through some form of grief or loss, and our job is to support them emotionally as well as physically. Key point three- People grieve in many different ways, and each person’s experience with grief and loss is as unique as their own personality.  There is no “right” or “wrong” way to grieve. However, there are some common and recognized patterns of grief that many (not all) people commonly experience.  In particular, many researchers recognize five common “stages” of grief; however, not all people go through each stage in order, or even experience all five. The processes and stages of grief can continue for years or even decades of a person’s life. Keep point 4- understanding the five stages of grief is vital to the recovery process. Five Stages of Grief Remember the five stages of grief? They are denial, anger, bargaining, depression, and acceptance.  People may move from one stage to the next, only to return to a previous emotion later.  It’s helpful to know these stages as you try to support and comfort those who are grieving.

Point 5- Grief can affect people physically as well as emotionally. Grief can cause its own physical problems or make existing conditions worse.  Competent health-care and human service workers should evaluate patients holistically, we must look at the whole person, and devise care plans that address emotional as well as physical issues. Point 6. The best expressions of concern are simple ones, telling the person that you’re sorry for what has happened to them and asking how you can be of assistance to them. It’s often hard to figure out what to say to a grieving person in order to comfort them without causing any additional pain. Our seventh point is- allow a grieving person to set the tone and direction of conversations; take their cues as to how and when they want to discuss their grief. Point 8-Grieving individuals often need practical help, with meals, paperwork, transportation, or logistics. However, they may not be in the frame of mind to express these needs.  Making a specific offer of help can be better than a general inquiry of “Can I help in any way?” Point 9-People struggling with grief and loss can implement some coping strategies to help themselves weather the storm. These include safeguarding their physical health, finding a supportive community to be surrounded by and to share with, and asking for help.  We as health-care professionals can point people towards resources that will help them in these areas, if we’re not able to personally assist. Point 10- Early identification of unhealthy responses to grief can make a significant difference in getting the person extra help and support. Those around a grieving person, including a health-care team, should be on the lookout for evidence of unhealthy coping mechanisms, such as complicated grief and avoidance techniques like substance abuse or excess in a certain area. Our eleventh point is, Grief has tremendous effects on families and society. Families are often strained by different forms of grieving, particularly in children and between spouses, and may need additional help and support to work through their grief without allowing it to damage family bonds and relationships. And our final point is that health-care workers and those in the human services industry need to remain aware of their own mental health, and take measures to minimize the strain that comes from working with grieving people. These measures include caring for your own physical health, finding a supportive community of colleagues, and keeping a record of positive moments. By educating yourself about grief and loss, you’ve helped ensure that you’re better prepared to meet the challenges that come with our profession.  Grief, sadness, and loss are a natural part of life, and can’t be avoided; but by knowing more about patterns of grief and healthy coping mechanisms, you’ll be able to raise the standard of care for patients & clients, their families, and yourself.  You’ll make a difference in the people you serve by supporting emotional health as well as their physical-  and at the end of the day, when grief and loss come, making a positive difference is one of the best outcomes possible.  Well, you did it. You’ve finished the course. Unfortunately this is the end of this module but we have plenty more for you to choose from. Thanks again and have a beautiful day. We’ll see you next time. But first take this rapid review so you can ace the final quiz and get your certificate of completion!

Writers and References

Writer(s): Margaret Petry & Donn Kropp, RN, BSN

References:

  • Axelrod, Julie. “The 5 Stages of Loss and Grief”. PsychCentral, 2012. http://psychcentral.com/lib/2006/the-5-stages-of-loss-and-grief/
  • Didion, Joan. The Year of Magical Thinking. New York: Alfred A. Knopf, 2005.
  • Kubler-Ross, Elizabeth, and David Kessler. “The Five Stages of Grief” (adapted from the book of the same title). Grief.com, 2012. http://grief.com/the-five-stages-of-grief/
  • Lewis, C.S. A Grief Observed. San Francisco: Harper Collins, 2001 (original copyright 1961).
  • Neeld, Elizabeth, PhD. “Physical Stress of Grieving” LegacyConnect, 2012. http://connect.legacy.com/inspire/page/show?id=1984035%3APage%3A2521
  • Reiss, Michele, PhD. Lessons in Loss and Living. New York: Hyperion, 2010.
  • Smith, Melinda, PhD and Jeanne Segal, PhD. “Supporting A Grieving Person”. HelpGuide.org, 2012. http://www.helpguide.org/mental/helping_grieving.htm

 

Lessons

Stages & Reactions

Length: 20 minutes

In this lesson we will explore the various stages of grief and loss as well as the reactions to these stages.

Providing Support

Length: 15 minutes

In this lesson we’ll explore ways to help support someone who is experiencing grief and loss.

Coping Strategies

Length: 16 minutes

In this lesson we’ll explore strategies of coping when experiencing grief and loss.

Developing Cultures of Hope

Length: 5 minutes

In this lesson learn how to develop cultures of hope so that you can help those or yourself who are suffering from grief and loss.