June | July 2006 © 2006, AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses 241

It’s the Journey, Not the Destination

Grief and Its Complications

QQ: What can I do to help patients and families

dealing with overwhelming grief?

A: In this issue’s “Conversations With Colleagues,”

author Marcy Rein, RN, BSN, speaks from per-

sonal experience and sheds light on what nurses

need to know about grief and its complications.

I know what it is to lose a child and to grieve.

I learned to “swim in the ocean” and, indeed, to

Marcy Rein, RN, BSN

“live wet” (see Box 1). Grief never really ends. It’s

a journey that continues as one adapts to the loss

and gets to a place where life can continue—albeit

a life that has changed forever and will forever

remain touched by the deep ocean of grief. This

journey applies to anyone who experiences loss in

his or her life. Grief is normal and it’s individual.

It’s continual and all consuming (Rando, 1993).

All grief is complicated; it’s only a matter of degrees

as to the level of complication (Attig, 2002).

242 AWHONN Lifelines Volume 10 Issue 3

Complicated Grief

Many professionals have attempted to come

to agreement on defining grief that becomes

too complicated. Grief becomes complicated

when it’s prolonged, delayed or exaggerated

(Enright & Marwit, 2002). Delineating grief

into categories is both helpful and dangerous.

By placing people in groups, it’s easy to com-

municate the message that there’s one right

way to grieve. But this contradicts the individu-

ality of grief. Conversely, in order to identify

and provide support to those who need assis-

tance in their journey, professionals must have

criteria on which to base their assessment.

Prolonged grief is the extended length of

particularly intense grief. One year of intense

symptoms may be outside the norm (Joyce,

McCallum, Ogrodniczuk, Piper, & Rosie,

2002). Professionals must also understand

the nature of the waves that continue to rock

the bereaved, even after their feet have found

ground beneath them. The journey often

involves two strokes forward and one stroke

back. Prolonged grief is truly complicated

when the individual is unable to recover from

one wave before the next one hits.

The common understanding that grief is

painful leads some to actively avoid it. No one

can control the losses they might suffer in life.

Eluding the pain delays the journey but does

not bypass it. People can try to avoid grief, but

they can’t hide from it forever. Substances like

alcohol provide a temporary float, but the indi-

vidual is still in the deep ocean. Eventually one

has to cast aside the float and begin the jour-

ney. Delaying the experience of grief is nearly

as much work as grieving itself. Symptoms can

express themselves through somatic means and

social withdrawal, in addition to reliance on

substances (Joyce et al., 2002).

Difficulty accepting the reality of the death,

avoiding experiencing the pain of death, fail-

ing to adapt to an environment without the

deceased or being unable to have loving

relationships are all complications of grief

(Cutcliffe, 1998). There can be intrusive

thoughts and recurrent dreams. One avoids a

certain place or person that reminds them of

whom they’ve lost. There is a longing for the

dead, even when we intellectually know there

will never be a return to the way things used to

be (Attig, 2002). Normal daily activities are no

longer normal or easy. These are all perfectly

acceptable grieving behaviors. It becomes com-

plicated when the behaviors and feelings con-

tinue without improvement (Hall, Hodgson, &

Weaver, 2002).

The labyrinth is more complex for some.

Those who have failed to deal with a previ-

ous loss, death or otherwise, find their jour-

ney compounded (Rando, 1993). Coexisting

conditions such as mental illness, life stress,

Box 1.

A Nurse’s Personal Journey with Grief

I went to sleep and awoke in the middle of a deep ocean. I kicked and swam, but couldn’t keep my head above the water. Breathing required so much effort, but I couldn’t concentrate on more than one simple task at a time. Kick, kick, kick … arms back and forth, back and forth … breathe … kick. Everything around me was shrouded in a haze. I knew I needed to get out, to look for an end, but … kick, kick, back and forth, breathe …. Then arms reached out for me in the darkness. They came from above me. They came from around me. I was not alone in the water. When I was tired, they held me up. They showed me how to move toward the shore.

It seemed like a lifetime before I came to a place where my feet touched ground beneath me. I was still in the ocean, but I could keep my head above the water, except for those rogue waves that occasionally crashed over me. There was light in my end of the ocean now. And I had been in the water long enough to encounter new souls floundering in their own ocean. Reaching out to those struggling seemed only right—to return the act of kindness once shown to me. Show them that they’re not alone. Show them how to kick and breathe at the same time and show them where their feet can touch the bottom. Show them hope. They may never get out of the water, but they can learn to live wet, all while remembering what it was like to be dry.

Marcy Rein, RN, BSN, is

with the Division of Senior

& Disabilities Services

with the State of Alaska in

Anchorage, AK.

DOI: 10.1111/j.1552-6356.2006.00044.x

Delaying the

experience of grief is

nearly as much work

as grieving itself.

June July 2006 AWHONN Lifelines 243

developmental disability or physical impairment

consume energy otherwise needed to move

through the ocean (Attig, 2002; Hoogerbrugge,

2002; Rando). One of the most important indi-

cators of the ability to move through grief is the

perceived availability of social support (Rando).

Support when the circumstances of the death,

or the relationship with the deceased, were

especially difficult is most significant in the abil-

ity to navigate the ocean (Rando).

The ocean seems never ending after the

death of a child. Lost dreams, hopes and expec-

tations swirl around the water, always out of

reach. The realization that something so good

and pure could die takes away breath and

makes muscles ache. The future seems irrel-

evant and unattainable. The past holds only a

few precious memories that swirl together with

the lost future, which seems confusing and dis-

tant. Even years later, each birthday, anniver-

sary or other significant event that “would have

been” becomes another wave crashing over.

How Nurses Can Help Those Experiencing Grief

The most immediately complicating aspect of

grief is the confusion. The death of a loved one

requires immediate action with little prepara-

tion. Knowing what to do and what to expect

in that deep ocean of grief is not intuitive.

Support from others is needed to assist in

decision-making.

A nurse rides in a boat over the ocean of

grief. It’s possible she doesn’t realize where she

is. Maybe she doesn’t realize how important her

presence is to those bobbing along in despera-

tion. Nurses must learn what, and who, is in the

ocean. Nurses must watch for struggling souls,

reach out to hold them up and show them the

way. Nurses can be the link between the griev-

ing and the rest of the world. They can gently

identify the priorities of the moment and the

strengths obscured by pain. Nurses can encour-

age memories to cherish and mementos to keep.

Nurses can monitor progress toward shallow

water. Nurses can show the grieving that they’re

not alone. Nurses can shine a light on hope.

For me, the waves are now fewer and far-

ther between. Someone told me long ago that

it would someday be that way. It’s a valuable

message to pass along to someone just begin-

ning the journey in that deep, dark, lonely

ocean.

References

Attig, T. (2002). Relearning the world: Always

complicated, sometimes more than others.

In G. R. Cox, R. A. Bendiksen, & R. G.

Stevenson (Eds.), Complicated grieving

and bereavement: Understanding and

treating people experiencing loss (pp. 7-

19). Amityville, NY: Baywood Publishing

Company.

Cutcliffe, J. R. (1998). Hope, counseling and

complicated bereavement reactions. Journal

of Advanced Nursing, 28(4), 754-757.

Enright, B. P., & Marwit, S. J. (2002). Diagnosing

complicated grief: A closer look. Journal of

Clinical Psychology, 58(7), 747-757.

Hall, P., Hodgson, C., & Weaver, L. (2002). Can

we predict complicated grief before the

bereavement? A report on bereavement

risk assessment in a palliative care setting.

In G. R. Cox, R. A. Bendiksen, & R. G.

Stevenson (Eds.), Complicated grieving and

bereavement: Understanding and treating

people experiencing loss (pp. 193-208).

Amityville, NY: Baywood Publishing

Company.

Hoogerbrugge, S. J. (2002). Complicated grief:

Family systems as a model for healing.

In G. R. Cox, R. A. Bendiksen, & R. G.

Stevenson (Eds.), Complicated grieving and

bereavement: Understanding and treating

people experiencing loss (pp. 289-302).

Amityville, NY: Baywood Publishing

Company.

Joyce, A. S., McCallum, M., Ogrodniczuk, J. S.,

Piper, W. E., & Rosie, J. S. (2002).

Interpersonal prediction of group

therapy outcomes for complicated

grief. International Journal of Group

Psychotherapy, 52(4), 511-524.

Rando, T. A. (1993). Treatment of complicated

mourning. Champaign, IL: Research Press.

Get the Facts

Compassionate Friends, Inc.: http://www.compassionatefriends.orgM.I.S.S. Foundation: http://www.missfoundation.orgFirst Candle: http://www.firstcandle.orgDougy Center for Grieving Children and Families: http://www.dougy.orgCentering Corporation Grief Resources: http://www.centeringcorp.com/catalog/

Maybe she doesn’t

realize how important

her presence is to

those bobbing along

in desperation.