This work intends to outline the theoretical explanations of grief, in particular Worden's tasks of grief. Further this work intends to explore the role of the nurse in the support and care of an individual who is grieving.
In this instance of study the focus is a 15-year-old girl who will be called Elaine Brown. She has been tired for some time, losing weight and is constantly thirsty. She has just been informed that she has Type 1 diabetes. The nurse is in process of formulating a care plan for this patient in dealing with this news.
Grief is something that is experienced universally with practically everyone experiencing the loss of a loved one at some point in his or her lives. Grief is coped with better by some than by others.
However, those who do not cope as well with grief should not be blamed but assisted through counseling of some form. In effort to address grief and the understanding of grief there are several models that have been developed by the medical profession. The models are slightly different one from the other and have been named:
1. The Stage Theory
2. The Task Theory
3. The Phase Theory
4. Worden's Four Task Theory
I. Elizabeth Kubler- Ross and the Five Stages of Grief:
Elizabeth Kubler-Ross wrote "On Death and Dying" in 1969, in which she introduces five stages of progression of the terminally ill individual. She states that she presents them as:
"An attempt to summarize what we have learned from our dying patients in terms of coping mechanisms at the time of a terminal illness."
The five stages presented by Kubler-Ross are as follows:
These five stages are used by Kubler-Ross to define the necessary process of the bereaved individual in the resolution of their grief. If an individual is not progressing through these stages, and doing so in proper sequence, and in a matter that is considered timely, then it can be assumed that the individual is in need of professional counseling or help.
Unresolved grief can lead to mental as well as physical problems inclusive of sociological problems that is contributory to dysfunction in families that extends from one generation to another.
The actions required by professionals in assisting individuals with these fives stages are as follows:
1. Denial: Keep trying to get an affirmation of response acknowledging the grief.
2. Anger: Assure the individual that it is okay and natural to feel angry.
3. Bargaining: In this stage supportive assurance as the individual tries to bargain with God or what they perceive to be the higher or controlling power.
4. Depression: Again, supportive assurance.
5. Acceptance: This is the resolution stage of grief wherein the individual finds their own personal peace.
Grief professionals refer to this concept as "Grief Work" based on a definition from the work Four Tasks of Mourning written by J. William Worden. Using the acronym TEAR for summarizing the concept the letters stand in representation of the following:
T = To accept the reality of the loss.
E = Experience the path of the loss.
A = Adjust to the new environment without the lost object.
R = Reinvest in the new reality.
II. Phase Theory:
Colin Murray Parkes introduced the phase theory for describing the emotions and feelings of individuals. Dealing with only the time of bereavement and going no further the phases are as follows:
1. Acute episodic Component: The "pang of grief" inclusive of restlessness and anxiety that is sharply felt.
2. Chronic Background Disturbance: Feeling dejected and/or having no life purpose.
III. Genskow, Jack Ph.D.: On Grief and Worden's Four Tasks
Grief related to disability and other aspects related to that loss are the focus of this specific work of Genskow's. Although he has written this directly related to Polio patients, the scope of grief is still applicable in the case of Elaine Brown. Genskow relates that "no size fits all" and that "we must all take responsibility for ourselves" however; he does recommend most firmly the use of Worden's Four Tasks, which are:
1. Accept the reality of the loss.
2. Work through to the pain of grief.
3. Adjust to an environment in which that which was lost is missing.
4. Emotionally relocate that which was lost and move on with life.
Gerskow explains by stating that:
"Some losses are clear and unambiguous, such as death, job loss, amputation, or a severed spinal cord. But their reality may be still be hard to accept. Defense mechanisms such as denial operate to shield us from being overwhelmed by the full impact of the loss. Coming to the acceptance of loss takes time, since it means not only an intellectual acceptance, but also an emotional one."
Working through to the pain of grief is the second of Worden's tasks in which identification and expression of feelings connected to the loss are necessary. It is important, at this stage, for the individual to be in touch with exactly what they are feeling. Gerskow states that the hardest feelings to work through are those of "anger, guilty, anxiety, and helplessness."
The usual method of avoiding this is to avoid the feelings by "burying" them. Gerskow points out that:
"Anger turned inward can cause depression or lowered self-esteem. Feelings ignored can contribute to substance abuse, stomach problems, skin irritations, or acting out behavior."
The third of Worden's tasks is making the environmental adjustment within the environment of that which was lost. Rehabilitation programs focus on this aspect of the losses associated with disability both "physical and functional"
losses. Rehabilitation teaches the individual how to approach self-care, in this case medication and checking of blood sugar levels by Elaine Brown.
Elaine will also have to learn dietary restrictions as well as making the commitment to practice self-restriction of dietary items that are off-limits for her condition.
The fourth of Worden's tasks, the relocation of that which has been lost and then moving on with life is considered "key" to successful "grief work." This is the stage that the counselor offers positive focus toward adjustment for the individual.
IV. Adolescents and Grief:
Elizabeth Kubler-Ross wrote in reference to adolescent grief that:
"The adolescent and the family members move through give stages of grief. The stages are denial, anger, bargaining, depression and acceptance ... "not everyone goes through all of them, at the same rate or progresses through them in the same order."
A task-based model presented by J.W. Worden (1991) for the grieving teen and the family suggests his four tasks in the following specific instructions for the adolescent and coping with grief.
1. Share acknowledgment of the reality of death with open communication.
2. Share the experience of pain and grief, partaking in one another's feelings concerning the loss.
3. Reorganize the family system stating that the adolescent and his or her family must, "delineate new role functions and realign old relationships." The family members along with the adolescent have an imbalance or change within the family unit that must be coped with.
4. Redirect the family's relationships and goals by "imagining a future without the deceased" (Worden, 1991, p. 46) This task never ends for the adolescent or family members.
IV. Elaine Brown: Care Plan for Diabetes:
All members of the care team in diabetes play crucial roles in education of the diabetic patient. Inclusive are physiologists, physiotherapists, dietician-nutritionists.
This is essential for health in adolescents, particularly those with diabetes. The earlier and more thorough the adolescent with diabetes education in self-care the better for establishment of the habits of physical activity for life.
Necessary topics to cover are:
* Family lifestyle and activity level
* Current physical activity level and limitations
* Benefits, risks and optimum levels of activity
* Glycemic awareness and control before during and after physical activity
Trained health professional such as the diabetes educator, general practitioner, endocrinologist, pediatrician or physician as well as podiatrists will be involved in foot screening.
It is imperative that the adolescent diabetic learns proper foot care. Topics that are included are:
* Foot care
* Footwear Facts
* When to seek help
* Good glycaemic control and its relationship to feet.
The general practitioner will manage the general care of the adolescent inclusive of immunizations, regular and specialized visits. During a visit with the general practitioner the following will be addressed:
Presenting any problems
* Review of blood glucose levels
* Current state of health and well-being
* Necessary medication adjustments and checking of supplies of insulin and glucagon
* Family adjustments to care, stress and other issues that are associative of diabetes.
It is imperative that continuing diabetes education is addressed as well as healthy eating and the psychological and social aspects of the diabetes disease. Sometimes there are problems of depression, anger, anxiety that will most likely be demonstrated through behavioral problems.