Grieving Theories

Grieve According to Nursing Theories

The purpose of  grieving theories is explain philosophical approach of grieve it include,
Kubler-Ross's Stages of Grieving and Bowlby's Phases of Grieving.

Theories of Grieving

    Among well-known theories of grieving are those posed by Elizabeth Kubler-Ross, John Bowlby, George Engel, and Mardi Horowitz.

Kubler-Ross's Stages of Grieving

    Elisabeth Kubler-Ross (1969) established a basis for understanding how loss affects human life. As she attended clients with terminal illnesses, a process of dying became apparent to her. Through her observations and work with dying clients and their families, Kubler-Ross developed a model of five stages to explain what people experience as they grieve and mourn:

1. Denial is shock and disbelief regarding the loss.

2. Anger may be expressed toward God, relatives, friends, or health care providers.

3. Bargaining occurs when the person asks God or fate for more time to delay the inevitable loss.

4. Depression results when awareness of the loss becomes acute.

5. Acceptance occurs when the person shows evidence of coming to terms with death.

This model became a prototype for care providers as they looked for ways to understand and assist their clients in the grieving process.

Bowlby's Phases of Grieving

    John Bowlby, a British psychoanalyst, proposed a theory that humans instinctively attain and retain affectional bonds with significant others through attachment behaviors. These attachment behaviors are crucial to the development of a sense of security and survival. People experience the most intense emotions when forming a bond such as falling in love, maintaining a bond such as loving someone, disrupting a bond such as in a divorce, and renewing an attachment such as resolving a conflict or renewing a relationship (Bowlby, 1980). ). 

    An attachment that is maintained is a source of security; an attachment that is renewed is a source of joy. When a bond is threatened or broken, however, the person responds with anxiety, protest, and anger. Bowlby described the grieving process as having four phases:

1. Experiencing numbness and denying the loss

2. Emotionally yearning for the lost loved one and pro testing the permanence of the loss

3. Experiencing cognitive disorganization and emotional despair with difficulty functioning in the everyday world

4. Reorganizing and reintegrating the sense of self to pull life back together.

Engel's Stages of Grieving

    George Engel (1964) described five stages of grieving as follows:

1. Shock and disbelief: The initial reaction to a loss is a stunned, numb feeling accompanied by refusal to acknowledging the reality of the loss in an attempt to protect the self against overwhelming stress.

2. Developing awareness: As the individual begins to acquaint himself with the loss, there may be crying, feelings of helplessness, frustration, despair and anger that can be directed at self or others, including God or the deceased person.

3. Restitution: Participation in the rituals associated with death, such as a funeral, wake, family gathering, or religious ceremonies that help the individual accept the reality of the loss and begin the recovery process.

4. Resolution of the loss: The individual is preoccupied with the loss, the lost person or object is idealized, the mourner may even imitate the lost person. Eventually, the concern decreases, usually in a year or perhaps more.

5. Recovery: The previous preoccupation and obsession ends, and the individual is able to go on with life in a way that encompasses the loss.

    Horowitz's Stages of Loss and Adaptation Mardi Horowitz (2001) divides normal grief into four stages of loss and adaptation:

1. Outcry: First realization of the loss. Outcry may be out ward, expressed by screaming, yelling, crying, or collapse. Outcry feeling can also be suppressed as the person appears stoic, trying to maintain emotional control . Either way, outcry feelings take a great deal of energy to sustain and tend to be short-lived.

2. Denial and intrusion: People move back and forth during this stage between denial and intrusion. During denial , the person becomes so distracted or involved in activities that he or she sometimes isn't thinking about the loss. At other times, the loss and all it represents intrudes into every moment and activity, and feelings are quite intense again.

3. Working through: As time passes, the person spends less time bouncing back and forth between denial and actions as well as through their physiologic responses. Therefore, nurses must use a holistic model of grieving that encompasses cognitive, emotional, spiritual, behavioral, and physiologic dimensions (Lobb et al., 2006).

Cognitive Responses to Grief

    In some respects, the pain that accompanies grieving results from a disturbance in the person's beliefs. The loss disrupts, if not shatters, basic assumptions about life's meaning and purpose. Grieving often causes a person to change beliefs about self and the world, such as perceptions of the world's benevolence, the meaning of life as related to justice, and a sense of destiny or life path. Other changes in thinking and attitude include reviewing and ranking values, becoming wiser, shedding illusions about immortality, viewing the world more realistically, and reevaluating religious or spiritual beliefs ( Zisook & Zisook , 2005).

    Questioning and Trying to Make Sense of the Loss The grieving person needs to make sense of the loss. He or she undergoes self-examination and questions accepted ways of thinking. The loss challenges old assumptions about life. For example, when a loved one dies prematurely, the grieving person often questions the belief that "life is fair" or that "one has control over life or destiny." He or she searches for answers to why the trauma occurred. The goal of the search is to give meaning and purpose to the loss. The nurse might hear the following questions:

"Why did this have to happen? He took such good care of himself!"

"Why did such a young person have to die?" "He was such a good person! Why did this happen to him?"

    Questioning may help the person accept the reality of why someone died. For example, perhaps the death is related to the person's health practices-maybe he did not take good care of himself and have regular checkups. Questioning may result in realizing that loss and death are realities that everyone must face one day. Others may dis cover explanations and meaning and even gain comfort from a religious or spiritual perspective, such as believing that the dead person is with God and at peace ( Neimeyer et al., 2006). 

    Attempting to Keep the Lost One Present Belief in an afterlife and the idea that the lost one has become a personal guide are cognitive responses that serve to keep the lost one present. Carrying on an internal dialogue with the loved one while doing an activity is an example: "John, I wonder what you would do in this situation wish you were here to show me. Let's see, I think you would probably..." This method of keeping the lost one present helps soften the effects of the loss while assimilating its reality.