Loss and Grief

Nurses often care for people who are dealing with the various stages of the grieving process. It can range from discomfort to debilitating and may last a day or a lifetime.

An understanding of some major theories of loss and grief can give nurses a framework for patient-centred care.

Grief is an emotional response to loss. The loss of a job, goal, loved one and so on may trigger grief.

Types of loss:

  • Death, health, body part, social status, lifestyle, relationship, reproductive function, sexual function

Factors that can affect peoples responses to loss can include:

Age, rituals of mourning, social support, families, cultural and spiritual practices.

Summary of theories of loss

Freud: psychoanalytic theory

Freud (1917/1957) referred to grief and mourning as reactions to loss. An inability to grieve loss results in depression.

Bowlby: Protest, despair and detachment

Argued the grieving process started with loss or separation and ends with the grieving person experiencing feelings of emancipation. Three phases were identified.

  1. Protest: Lack of acceptance. A person protests the loss. Anger towards self/others. Crying and anger characterise this phase
  2. Despair: Behaviour becomes disorganised. A desire for the lost person or object to return coupled with sadness and crying. Despair mounts as efforts to deny loss begin to be juxtaposed with acceptance of permanent loss.
  3. Detachment: As the person realises permanent loss, both positive and negative memories are remembered. Expressions of readiness to move forward characterise this stage.

Engel: acute grief, restitution and long-term grief

3 stages of grief.

  1. Acute: shock and belief, along with denial. Blame, anger rise to the surface
  2. Restitution: Mourning is institutionalised. Painful void still felt, preoccupied thoughts of loss.
  3. Long term: Lost relationship put into perspective

Kubler-Ross: Stages of coping with loss

Kubler-Ross argued not all people dealing with loss go through these stages. Agued some or all of these ‘stages’ may or may not occur.

  1. Denial – Shock and disbelief
  2. Anger – resist to loss
  3. Bargaining – Postpone the reality of the loss
  4. Depression – Person works through the struggle of separation, the full impact of loss is actualised/realised
  5. Acceptance – Comes to terms and resumes activities with hopefulness.

Caplan: stress and loss

Period of psychological crises is precipitated by hazardous circumstances. 3 factors influence a person’s ability to deal with loss.

  1. The psychic pain of the broken bond and the agony of coming to terms with the loss.
  2. Living without the assets and guidance of the lost person or resource
  3. Reduced cognitive and problem-solving effectiveness associated with the distressing emotional arousal

Some nursing roles (Lemone et al., 2015):

  • Promote trust. Show empathy, caring.
  • Demonstrate respect for the person’s values and culture.
  • Be honest and engage in active listening
  • Assist in identifying the person’s feelings: anger, fear, loneliness, guilt, isolation
  • Explore previous loss and how they coped
  • Encourage a review of their relationships with the person they lost
  • Reinforce expressions of behaviours associated with normal grieving


Bolby, J (1973). Attachment and loss: separation anxiety and anger (Vol. 2). New York: Basic Books

Engel, G. (1964). Grief and grieving. American Journal of Nursing, 64, 93.

Freud, S. (1917/1957). Mourning and melancholia. In J. Strachey & A. Tyson (eds), The Complete psychological works of Sigmund Freud (Vol. 14). London: Hogarth Press

Roy, D. (2011). Editorial: Does ‘spiritual’ indicate a limit to palliative care? Journal of Palliative Care 27(4), 259-260

Caplan, G (1990). Loss, stress, and mental health. Community Mental Health Journal, 26(1), 27-48