Concept Analysis: Effective Grieving

CONCEPT ANALYSIS – EFFECTIVE GRIEVING

Concept Analysis:

Effective Grieving

Shawn Blankenship

Chamberlain College of Nursing

NR 501: Theoretical Basis for Advanced Nursing Practice

February, 2014

Concept Analysis: Effective Grieving

Concept analysis is a powerful tool that can provide insight for nursing practice enabling others to see components of the nursing profession (CCN, 2014). This paper is an analysis of the concept of effective grieving and is derived from the Kubler-Ross model, commonly known as the five stages of grief (Axelrod, 2006; Roos, 2012). Within the context of this class, the Kubler-Ross model serves as a theoretical construct within the Theory of Modeling and Role-Modeling (MRM), (Erickson, 2010, p. 212). Furthermore, the author of this paper will utilize Walker and Avant’s concept analysis method to evaluate effective grieving. The eight steps of Walker and Avant’s concept analysis are: (1) selection of a concept, (2) identification on an aim of the analysis, (3) identification of concept uses, (4) determining attributes of the concept, (5) identifying model cases of the concept, (6) identifying alternate cases of the concept, (7) identifying antecedents and consequences, and (9) defining empirical referents (Walker & Avant, 2011). Additionally, the author will provide a review of several scholarly sources as they relate to effective grieving. Last but not least, in conclusion, the author will summarize the sections of the paper as well as the knowledge gained while conducting the concept analysis of effective grieving.

Selection of concept

According to Walker and Avant (2011), “The first step of concept analysis is to choose a concept of interest”. The concept of effective grieving was chosen because it is a specific derivative of many related concepts that a nurse, his/her patients, and the families of patients commonly encounter secondary to terminal illnesses. Effective grieving is commonly associated with death anxiety, and anticipatory grieving; however, there hasn’t been much research related specifically to effective grieving. If effective grieving is properly utilized by patients and their families, and reinforced by nursing professionals, then positive outcomes can be accomplished and the nurse-patient relationship can flourish, as well.

Aim of the analysis

The second step of concept analysis is to develop an aim for the analysis (Walker & Avant, 2011). Within this paper, the goal is to understand the concept of effective grieving as it relates to patients and their families facing terminal illnesses and secondarily how the findings may further the nursing profession by better understanding the concept of effective grieving.

Literature review

The following are three brief literature excerpts regarding the concept of effective grieving as they appear within scholarly sources; this is essential to see how the principle may apply to, and appear within real research. Example one, according to Hottensen (2010, p. 107), “patients who have received a diagnosis of terminal cancer will most likely exhibit manifestations of anticipatory grief, … by allowing patients and their loved ones to express their feelings, … the health care providers can help them to deepen their relationships and to experience growth, even at the end of life”. Example two, According to Braun, Gordon and Uziely (2010, E47), “attitudes toward death and caring for dying patients may influence the behavior of caregivers”. Example three, according to Gardiner, et al. (2009, p. 22), “Improved patient education is needed in order to improve patients understanding of their condition and prognosis, … open communication regarding death … to alleviate patients fears”. Simple observation of these excerpts provides a foundational need for reviewing effective grieving.

Uses

The third step of concept analysis is to define uses of the concept (Walker & Avant, 2011). To grieve (Merriam-Webster’s online dictionary, 2014) is to: feel or show grief or sadness; to cause or feel sad. Effective is defined (Merriam-Webster’s online dictionary, 2014) as producing a result that is wanted. Effective grieving is defined as reaching stage five of Kubler-Ross’ model where, “the ultimate stage of acceptance will be reached” (Axelrod, 2006). According to Ralph and Taylor (2011) a nursing intervention for effective grieving is to, “help the patient and family identify, discuss, and resolve issues related to patient dying, removing emotional blocks”. Gardiner, et al. (2009) argues, “Good communication and management of symptoms toward the end of life are central features of a palliative care approach”. Effective grieving is a process not a simplistic definition, nor an excerpt; it is a concept that does not afford a score, but an acceptance and realization of being at the end of life’s journey.

Defining attributes

The fourth step of concept analysis according to Walker and Avant (2011) are to define the attributes of effective grieving. One needs to search for characteristics that distinguish the concept from similar concepts. Effective grieving is an abstract concept however; several perspectives can be drawn from (1) definitions and (2) Kubler-Ross’ model to set it apart from similar concepts. By combining the definition of grieve and effective one arrives at “producing a result of wanted grief”, and by placing that into the context of Kubler-Ross’ model and adding “acceptance” to the concept, one arrives at “producing a result of wanted and accepted grief”. What is unique regarding effective grieving is that it not only applies to the patient who is obviously facing extenuating circumstances, but it also applies to the family, too. Effective grieving is a higher plain, a peace of mind and soul recognized when a holistic acceptance is recognized.

Model cases

According to Walker and Avant (2011), a model case provides an example of the chosen concept; this is the fourth stage of concept analysis. Furthermore, the model case contains the defining attributes of the concept and serves as an example to portray the concept to others. John is an 83-year-old man who has been battling advanced chronic pulmonary disease for nearly a decade. Unfortunately, over the past six months John’s condition has worsened to the point where he has been placed in Hospice, and given a very short amount of time to live. The combination of machines and medications were no longer sufficient, and unfortunately the pain and suffocating feeling has been overwhelming resulting in John, and his family deciding future intervention unnecessary. According to Gardiner, et al. (2009, p. 692), “there is a growing recognition of a need for patients with advanced COPD to receive palliative care, an approach that centers on the management of symptoms, maintaining quality of life and good communication”. John has been placed on comfort care and his family has been visiting, having had ample discussions with his hospice nurse regarding expiration and the fact that death is imminent; there are to be no future attempts at intervention, and comfort measures will enable John to pass comfortably. This case serves as a model example because it contains all of the defining attributes of anticipatory grieving. The patient, as well as the family was able to recognize that death was inevitable, grieving was effective, and together made a decision to let John expire with dignity.

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Mary is a 69-year-old woman who has been combating advanced non-small cell lung cancer for years. However, even after extensive chemotherapy she has recently been informed that her cancer has metastasized to her liver and pancreas and is being provided hospice in her home. Mary has become septic, and is suffering through organ failure as her cancer is progressing; consequently, Mary is being placed on comfort care and is not expected to live much longer. According to Hottensen (2010, p. 107), “A key component in adapting to and coping with the crisis of terminal illness is the flexibility of family functioning”. Mary and her family have a signed DNR/DNI on file and realize that the continuous morphine drip that she has been placed on will help her ease into death, peacefully. Mary’s family is with her as she expires within forty-eight hours of the drip. This case serves as another model case of anticipatory grieving, containing all of the defining attributes. The patient and family proceeded through effective grieving, recognized all that could be done was done, and similar to John’s case, allowed Mary to pass having recognized the stages of grieving, and provided support and stability, as both John and Mary accepted death.

Borderline case

Walker and Avant (2011) state that a borderline case is an example scenario whereas most of the defining attributes of a concept are present; however, there are inconsistencies related to the model cases above. This is part of the sixth stage of concept analysis. Jeff is a 45-year-old father of three with terminal brain cancer that is quickly progressing. Jeff has been sent home from the hospital, his cancer is inoperable. Jeff’s parents have moved in to help him and his family. Together Jeff, his wife, and his parents have recognized his impending death and have made final arrangements; however, Jeff’s primary care physician stopped by to check in on him and Jeff suddenly becomes very ill, and has a seizure. The primary care physician, Dr. Lewis, instructs the family that this may be it, as Jeff is unresponsive, and he’s begun agonal breathing. In a moment of weakness, Jeff’s father beings crying and tells the doctor that he’s just not ready to see Jeff go. This case contains all of the attributes of the model scenario except that Jeff’s father has not come to acceptance stage of effective grieving.

Contrary case

A contrary case is a case that is completely opposite of the model cases; within a contrary case, all defining attributes of the model case are missing (Walker & Avant, 2011); a contrary case is also part of the sixth stage of concept analysis. Tom is a military veteran that has returned home from the Iraq war and he has severe brain damage and with recent complications is now being kept alive by a ventilator, and tube feeding, with no chance of survival. However, Tom’s wife has refused to sign the order to remove tube feeding and the ventilator. Tom suddenly aspirates, and codes, nevertheless, Tom’s wife will not let him go and insists that Tom be resuscitated. Tom does not revive from the code and dies minutes later. This case represents a contrary case because effective coping has not taken place at all; to the contrary this case clearly illustrates the complete opposite of effective grieving.

Antecedent

According to Walker and Avant (2011), an antecedent takes place or precedes an instance of a concept; this is part of the eighth stage of concept analysis. In order for effective grieving to take place there must first be an acceptance of the fate of the terminal patient. For the patient, he/she will acknowledge acceptance, and subsequently die with dignity analogous to the grieving process by Kubler-Ross (Roos, 2012). With regard to the family, effective grieving permits them to relieve anxiety, regret, and guilt (Ralph & Taylor, 2011).

Consequence

The outcome of an instance of a concept results in a consequence (Walker & Avant, 2011); this too is part of the eight stage of concept analysis. Therefore, a person dying without interference, complications, and the natural progression of Kubler-Ross’s final stage of acceptance being is reached permits then the patient and family are able to reach effective grieving (Roos, 2012).

Empirical referents

According to Walker and Avant (2011), empirical referents serve as a way to demonstrate a concept exists, this stage is ninth and last stage of concept analysis. Particular to effective grieving, there is no way to statistically to specifically measure effective grieving because each person grieves at their own pace. However, effective grieving parallels the fifth stage of Kubler Ross’ model, acceptance. Within this stage, Ross argues, “the individual begins to come to terms with their mortality or that of their loved one”. Effective grieving is abstract, nevertheless, in model case (1) John and his family conveyed that he had come to terms with John’s impending death, accepted his fate, and effectively grieved. In model case (2) Mary and her family also realized her expiration was soon, planned in advance, and came to terms with her passing effectively.

Conclusion

This paper provided an interesting journey for the author. To be able to fully explore Walker and Avant’s concept analysis (CCN, 2014, Walker & Avant, 2011) was enlightening. Grieving is a phenomenal concept that many nurses see on a daily basis; however, to review ‘Effective Grieving” and to truly try and understand the particular concept, was an experience like no other. Effective grieving is different for everyone; it is very difficult to narrowly define. Nevertheless, to gain insight, to truly be able to then take this experience back to one’s practice was rewarding.

References

Axelrod, J. (2006). The 5 Stages of Loss and Grief. Psych Central. Retrieved fromhttp://psychcentral.com/lib/the-5-stages-of-loss-and-grief/000617

Braun, M., Gordon, D., & Uziely, B. (2010). Associations between oncology nurses’ attitudes toward death and caring for dying patients. Oncology nursing forum, 37(1), E43-E49. doi:10.1188/10.ONF.E43-E49

Chamberlain College of Nursing. (2014).NR501 Theoretical basis for advanced nursing practice: Week 3 Lesson [PowerPoint]. St. Louis, MO Online Publication.

effective. In Merriam-Webster’s online dictionary. (2014). Retrieved fromhttp://www.merriamwebster.com/dictionary/effective

Erickson, H. (2010). Helen Erickson, Evelyn Tomlin, and Mary Ann Swain’s Theory ofmodeling and role modeling. In Parker, M. E., & Smith, M. C. (Ed.), Nursing Theories and Nursing Practice (3rd ed.)(pp. 202-223). Philadelphia, PA USA: F.A Davis Company.

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Gardiner, C., Gott, M., Small, N., Payne, S., Seamark, D., Barnes, S., & … Ruse, C. (2009). Living with advanced chronic obstructive pulmonary disease: patients concerns regarding death and dying. Palliative Medicine, 23(8), 691-697. doi:10.1177/0269216309107003

grieve. In Merriam-Webster’s online dictionary. (2014). Retrieved from http://www.merriam webster.com/dictionary/grieve

Hottensen, D. (2010). Anticipatory grief in patients with cancer. Clinical journal of oncology nursing, 14(1), 106-107. doi:10.1188/10.CJON.106-107

Ralph, S. S., & Taylor, C. M. (2011, 8th ed.). Sparks and Taylor’s Nursing DiagnosisReference Manual. Philadelphia: Wolters Kluwer / Lippincott Williams & Wilkins

Roos, S. (2012). The Kubler-Ross Model: An Esteemed Relic. Gestalt Review, 16(3), 312-315.

Walker, L.O., & Avant, K.C. (2011). Strategies for theory construction in nursing (5th ed.). Boston: Prentice Hall.