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ASSESSMENT OF SPOUSAL GRIEF IN THE
PRIMARY CARE SETTING

SchoTarly Project for the Degree of M. S. N.
MICHIGAN STATE UNIVERSITY
BONNIE L. LANDSCHOOT
199.7 '

 

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6/01 c'JCIRCIDatoDuepss-pJS

ASSESSMENT OF SPOUSAL GRIEF IN THE
PRIMARY CARE SETTING

By

Bonnie L. Landschoot

A SCHOLARLY PROJECT

Submitted to
Michigan State University
in partial fulfillment of the requirement
for the degree of

Master of Science in Nursing

College of Nursing
1997

ABSTRACT

ASSESSMENT OF SPOUSAL GRIEF IN THE
PRIMARY CARE SETTING

By

Bonnie L. Landschoot

Grief care relating to loss, that of recognizing, consoling and
supporting, is not readily available in the primary care setting. Losses
may be of a person, material, psychosocial or developmental. This
project addresses human loss and the needs of the newly widowed
woman. The death of her spouse catapults the woman into a difficult
transitional state. Schlossberg‘s Model for Analyzing Human
Adaptation to Transition addresses this transitional state. The purpose
of this project was the development of an assessment tool to identify
the high risk factors related to becoming a widow. Much of the
information, however, will be appropriate for all bereavement issues.
Advanced Practice Nurses working in primary care have a great
opportunity to identify, support and facilitate this transitional period of

grief to a more healthy conclusion.

DEDICATION

To Michael P. Landschoot who loved, believed and supported my
dream; sons Matthew and Nathaniel, friends and family for their
continued love and support.

iii

ACKNOWLEDGMENTS

Continued improvement for the quality of patient care is made
through challenging clinical and academic endeavors. I would like to
thank all of my professors and clinical instructors in holding me to that
challenge at hand. Thanks to my committee of Linda Keilman, Jackie
Wright and Linda Spence for their efforts and suggestions for this

project.

iv

TABLE OF CONTENTS

LIST OF FIGURES ........................................................................... vii
INTRODUCTION .............................................................................. 4
PURPOSE STATEMENT .................................................................. 4
CONCEPTUAL DEFINITIONS ......................................................... 4
LITERATURE REVIEW .................................................................... 4
Grief .......................................................................................... 4
Grief Process ............................................................................ 5
Grief Work ................................................................................ 8
Grief Care ................................................................................. 8
Health Problems ........................................................................ 9
Culture .................................................................................... 10
Depression .............................................................................. 10
Summary and Critique ............................................................ ll
CONCEPTUAL FRAMEWORK ...................................................... 13
ASSESSMENT TOOL DEVELOPMENT ........................................ 19
Identification ........................................................................... 20
Communication ....................................................................... 20
Demographics ......................................................................... 20
Quality of Relationship ............................................................ 20
Economic ................................................................................ 22
Health Insurance ..................................................................... 23
Education/Work ...................................................................... 23
Functional Status ..................................................................... 24
Current Stressors ..................................................................... 24
Nutrition ................................................................................. 24
Sleep ....................................................................................... 25
Other Complaints .................................................................... 25
Return to Normal Activities ..................................................... 26

Activity ................................................................................... 26

Drug/Alcohol Use ................................................................... 27
Physical Exam ......................................................................... 27
Emotional Status ..................................................................... 28
Previous Grief Work ............................................................... 29
Discussion of Future Plans/Anticipatory
Guidance ................................................................................. 29
IMPLICATIONS FOR NURSING .................................................... 31
APPENDICES .................................................................................. 35
Appendix A. ........................................................................... 35
Appendix B ............................................................................... 40
REFERENCES ................................................................................. 44

vi

LIST OF FIGURES

Figure luSchlossberg's Model for Analyzing Adaptation to
Transition .................................................................................... 14

Figure 2-Model for Analyzing Adaptation to Spousal Death ............ 17

vii

Introduction

Grief is a universal experience crossing all ages and cultures and is
normally experienced more than once during a life time (Cowles, 1996).
How grief is worked through can greatly impact the physical and
emotional health of an individual. The first year of grief has the greatest
potential for physical and mental health concerns (Dershimer, 1990;
Osterweis, Soloman & Greene, 1984). Compassionate, knowledgeable
primary health care for the grieving person is a universal need that can be
utilized by each and every person experiencing the death of a significant
person in their lives.

All people grieve at one time or another for various types of loss.
Loss is defined as being without something one once had (Peretz, 1970)
and results in grief. Four types of grief/loss are identified. There is loss
of a loved one through death, divorce, rejection or abandonment. The
second type of loss is of a physical or psychological nature such as ideas,
feelings of self worth or lovability. A third type of loss includes external
objects of money, home, or other material possessions. The last type of
loss is developmental, or tasks of development, that must be met in order
to proceed through the life cycle, such as parenthood (Pertez, 1970).
Significant losses, such as the death of a spouse, have great potential for
illness, depression (Harlow, Goldberg & Comstock, 1991; Steele, 1992)
and social adjustment (Jacob, 1993).

For the purpose of this project, grieving and loss will relate to
human life, specifically loss of a husband, and the bereaved will be the
female surviving spouse. The purpose of this project was the development

of an assessment tool to use in identifying the high risk factors related to

2

becoming a widow. Much of the protocol could be utilized for all
bereavement losses.

The primary care setting provides great opportunity to identify and
counsel a grieving individual. Starfield (1993), defines primary care as the
basic level of service provided to everyone including preventive, curative,
and rehabilitative. Basic assumptions of primary care include a patient
population seen over a long period of time, management of acute/chronic
illness, preventive care, and appropriate health screening that is offered in
an out patient setting. This care should be patient oriented, meeting
psychosocial and biological needs and is holistic in scope (Inglis &
Kjervik, 1993). The Michigan Primary Care Association (1988) defines
primary care as a basic level of health care rendered by a general or family
practitioner, obstetrician and gynecologist, pediatrician and/or Specially
trained non-physician health practitioner.

In the United States, 47.6% of married women 65 years and older
are widowed, in contrast to 14.3% of men 65 years and older (U S Bureau
of the Census, 1993). The surviving female, living alone and frequently
on a reduced income, has an extended number of years in which to cope
and tend to experience a disproportionately high level of poverty. Widows
can expect to survive an average of 14 years in widowhood compared to 7
years for men ( US Bureau of the Census, 1996).

With 48% of married women over 65 years expected to be
widowed, and women being the most frequent users of health care, a
primary care setting affords an excellent opportunity for the Advanced
Practice Nurse (APN) to identify the grieving person, facilitate healthy
grieving, monitor the. individual's response to the grief process, provide

information, and teach strategies to cope with common, but normal

3

transitional difficulties. In the primary care setting, the APN functions in
the role of patient advocate, support person and facilitator (J offiion &
Douglas, 1994), in addition to educator for patient and other health care
providers.

Circumstances surrounding the cause of death have implications for
the surviving widow's grief. Some circumstances include: 1) unexpected
or sudden death, 2) removing life support, or 3) if the widow was the
primary caregiver of the deceased. Each type of death has distinct issues
associated with it and APNs in primary care need to have the knowledge to
care for of all of these types of death events. Stigrnatized deaths, such as
those of suicide and AIDS, have many additional issues associated with
them and are beyond the scope of this project.

Age of the survivor is an important factor in the grieving process.
Widows age 76 to 85 frequently use denial of personal feelings and of the
death as coping mechanisms (Steele, 1992). The very young, age 25-35
years old, and the very elderly, experience more despair and hopelessness
than middle aged women. These two age groups must be carefully
monitored for despair, hopelessness, loss of meaning in life and any
suicidal tendencies. Severity of the grief reaction is more intense in
younger women who experience greater anger and hostility over the death
(Steele, 1992).

Sudden death without forewaming is defined as death with less than
two weeks (Carey, 1977) or fourteen days warning (Leahy, 1993).

Sudden death is known to be a major factor in the long term outcome of
the surviving spouse (Tye, 1993). The first two years after a sudden death
have the greatest potential for morbidity ( Lundin, 1984). The bereaved

may experience an increase in somatic and psychological illnesses,

4

experience greater shock, take a longer time to reorganize, demonstrate
increased psychological distress, and experience a longer period of social
withdrawal (Grabowski & Frantz, 1993).
Purpose Statement

The purpose of this scholarly project was to develop an assessment
tool for APNs that effectively assesses risks of spousal grief. This
assessment provides information necessary for the delivery of appropriate
care in the primary care setting for the newly bereaved female spouse, who
is living through the recent death of her husband. The goal of this grief
care is to avoid severe pathological outcomes related to unrecognized or
unsupported grief.
Conceptual Definition

Grief is difficult to define as it is dynamic, changing, pervasive, and
highly individualized (Jacob, 1993). The terms bereavement and
mourning are frequently used interchangeably with grief and further
complicate defining the experience. For the purpose of this paper, grief
will be defined as an individualized response to the loss of a significant
relationship, that of husband. This response is dynamic and
multidimensional, resulting in psychosocial transition and continued
growth.

Literature Review

Grief

Contemporary literature defines grief as phases between which the
individual moves back and forth (Cowles, 1996). Grief is conceptualized
"rather like a fingerprint, composed of identifiable universal characteristics
and yet uniquely individual" (Brost & Kenny, 1992, p. 459).

5

The concept of grief is vague and ambiguous (Rodgers & Cowles, 1991),
and is difficult to define accurately. Grief has been defined both as an
adaptation response (Bowlby, 197 3) and as a syndrome (Lindermann,
1944). Debate is ongoing as to the existence of complicated grieving, and
if grief is considered an illness (Attig, 1991).

Normal grief is defined as a self-limiting process, not requiring
psychotherapeutic interventions and is relatively benign (Zisook, 198 7).
Grief has been defined by Quint-Benoliel (1992) as a total organismic
response of a human being to the loss of a significant relationship. Jacob
(1996) redefines grief as a normal, dynamic, unique multidimensional
response to a perceived loss. Grief is a complex, intense internal response
to all perceived and felt losses (Dershimer, 1990). Grief is the emotional
(affective) response to loss, which includes a number of psychological and
somatic reactions ( Stroebe & Stroebe, 1987).

Grief Process

The grief process involves an interpersonal aspect that may last
years (Brost & Kenney, 1992) and may be experienced in three major
ways: 1) psychologically, 2) socially, and 3) physically. Grief is a highly
individualized, dynamic, pervasive process with strong normative
component (Rando, 1988; Rodgers & Cowles, 1991). Processing grief
becomes a complex coping process of psychosocial transition towards a
life without the deceased (Attig, 1991; Caplan, 1974; Hoff, 1984).

Variables that affect the grieving process include length of illness,
elapsed time since the loss, relationship of the deceased, perceived
appropriateness of the timing of death and quality of the relationship (Lev,
Munro, & McCorkle, 1993). In addition, type of death, age of the widow

or other survivors, past coping ability, social support system, and physical

6

and mental health of the individual influence this process (Jacob, 1993).
Providing timely support and care can assist an individual through the
process in a more healthful way.

Bailey (1988) outlines six stages of the journey of recovery through
grief. These six stages are not rigid or stagnant; individuals move back
and forth frequently on their unique journey. The individual must
recognize that the death has occurred and it is a loss. This first step must
be experienced in order to proceed with the journey and consists of shock,
denial and confusion that initially serves as a coping and protective
mechanism.

The second stage is that of protest. In this stage the reality of the
death penetrates and becomes more real for the widow. This protesting
may present in the form of anger, feelings of abandonment, or rage and be
directed at anyone and everyone. Searching for a new sense of normalcy
in her life becomes the third stage. During this stage, answers are sought
out from others, and assistance found through fi'iends, clergy, support
groups, coworkers and other types of support systems. Searching turns to
despair in the fourth stage and becomes the most painfirl period of grief.
Signs and symptoms of depression may appear in this stage. Action and
concentration is slowed, spontaneous crying occurs and the potential threat
of suicide is present. This despair stage is particularly taxing, and the
individual may experience extreme fatigue.

Reorganization is the fifth step in this journey of transition. During
this time the depression starts to resolve, and the widow can start to enjoy
life again in intervals. Seeking of some meaning for this painful event and

developmental growth is sought during this stage of reorganization.

7

In the last stage, that of reinvestment, energy has been detached
from the lost individual. The widow may reinvest in other relationships
and or activities.

Schneider (1994) describes grief as a transformation to a loss. Two
types of loss are presented, natural and developmentally disruptive.
Natural loss includes those in our maturation, such as loss of family,
friends, health, work and our own death. Developmentally disruptive
losses are not natural or tmiversal. Examples of this type of loss may be
missed milestones of independence, traumatic loss of life, rape or murder.
Grief involves all dimensions of our being-physical, emotional,
behavioral, spiritual, and cognitive.

Transformation is recognizing the opportunities that may result
from the loss. Grieving is a process of discovery including, 1) what was
lost, 2) what is left, and 3) what is possible. Discovering what was lost
and how it will affect us begins with shock, followed by holding on, letting
go and finally awareness. In phase two, healing starts through gaining
perspective and integrating the loss into new life. Phase three is
discovering what is possible through reformulating, self-empowering and
transforming.

Successful transformation requires recognition and validation of the
loss for the individual. Type of loss, and life stage, will impact on the
particular loss, but all losses need recognition and validation.

Recognition of a loss is necessary to grieve and move on. Death is easy to
identify as a loss, however other losses are not. Validation of grief includes
the acceptance of the current experience and that it is real. Reactions and
coping methods utilized are appropriate to this experience, and the

individual is doing the best they can under the circumstances.

Grief Work

The tasks of grief, or "grief work", have common themes and subtle
differences. These tasks include: 1) accepting the reality of the loss, 2)
experiencing the pain related to the loss, 3) readjusting to an environment
without the lost person, and 4) withdrawing energy from the deceased and
reinvesting in other relationships (Worden, 1982). In addition, Horacek
(1995) includes a life and relationship review.

Grief Care

For the purpose of this project, grief care consists of support,
counseling and monitoring of physical and emotional aspects of the grief
process of an individual or family. There are few guidelines available and
generally this type of care is not recognized as a need by the health care
provider (Osterweis, Soloman, & Greene,l984). Possible reasons for this
lack of care include: 1) health care professionals are not adequately
prepared, 2) work load is too heavy to incorporate time for this type of
care, and 3) financial restraints of third party reimbursement which do not
reimburse for this task in primary care.

Health care providers are frequently uncomfortable, or at a loss, to
identify grief and support the grieving individual. Misconceptions
regarding grieving are sometimes perpetuated by health care providers
through their lack of knowledge about the grief process. Some
misconceptions include: grief and mourning are the same event, grieving
occurs in a straight forward fashion without any regression, avoiding grief
is desirable, the goal is to "get over" it, and tears are considered a
weakness. None of these misconceptions are true (Brost & Kenney,
I992).

9

The impact of death results in initial shock which can last from
hours to months. Eventually the numbness wears off and intense grief
evolves. Widows have to become active in their own grief process.
Guidance through this process will result in better resolution, compared
with those who do not acknowledge their grief ( Attig,l991; Caine, 1988).
Health Problems

Health problems related to grief include depression, suicidal
ideology, numbness, restlessness, lack of concentration, crying, sleeping
problems and nightmares, overeating/anorexia, work related difficulties,
low self-esteem, feelings of insanity, lack of energy, and higher incidence
of chronic problems (Steele, 1992; Zisook & Shuchter, 1991).
Physiological changes associated with grieving include changes in immune
ftmctioning, endocrine changes, autonomic nervous system stimulation,
cardiovascular changes, increased vulnerability to external agents,
neuroendocrine findings such as depression and anxiety, and increased
adrenocortical activity (Kim & Jacobs, 1993). Assessment for increased
use of drugs and alcohol is essential as increased use indicates real
potential with the grieving process (Ewton, 1993).

Relationship quality and type of death are important predictors of
potential problems and needs of the surviving spouse. Death of the spouse
is frequently listed as the most traumatic loss for a woman (Curry & Stone,
1992; Leahy, 1993). Irmnersed in the relationship, women frequently bind
their identity on spousal social relationships. With the loss of the
relationship, identity and social support is frequently revised or lost, and
loneliness becomes an additional stressor, as the woman must "uncouple"

and become "I" (Saunders, 1981).

10

Culture

Culture of the survivor has substantial influence on the grieving
process, especially the individual's interpersonal aspects of grief (Cowles,
1996). Each culture has specific meanings attached to death, unique
customs of mourning and funerals (DuBray, 1993; Grabowski & Frantz,
1993). As APN's, working knowledge and resources are needed to
provide culturally effective care to the population being served. APNs
working with cultures outside their own must learn about that cultures
health care beliefs, traditions, excepted expression of emotions and
ceremonial practices. This knowledge may be acquired through research
of the culture, practical experience, and having a cultural mentor to confer
with. With knowledge of a widow's cultural grieving behaviors,
erroneous diagnosis of psychopathology may be avoided and healthy
effective grieving facilitated. Universally experienced emotions and
reactions to grief must be assessed and care provided, regardless of culture
(Cowles, 1996).
Depression

Wordon and Silverman (1993) estimate that depression occurs in 15
to 50% of bereaved spouses in the first year. Considered a normal
expected grief response, depression results from the re-examining and
reorganization of one's interpersonal world (Martinson, Davis, &
McClowery, 1991). The absence of grief may be an abnormal response to
bereavement (Rando, 1984). Other concurrent stressors and losses may
contribute to long term depression such as children leaving home,

menopause, or retirement.

11

Confusion exists regarding bereavement and depression and how to
distinguish the two (Worden & Silverman, 1993). It is important to not
label a person clinically depressed when they are experiencing grief. The
presence of feelings of worthlessness, frmctional impairment and
psychomotor retardation are not part of bereavement reactions (Diagnostic
and Statistical Manual of Mental Disorders -IV, 1994). The absence or
presence of low self-esteem is the major difference between depression
and grief reactions (Osterweis, Solomon, & Greene, 1984).

Depression was found to be greater in widows with children under
six years old (Worden & Silverman, 1993). Distinguishing between grief
and depression for these women could prevent additional problems for the
surviving children. With early assessment for depression of the parent,
development of appropriate interventions can be made to assist the whole
family (Osterweis, Solomon & Greene, 1984).

Summary and Critique

A review of the literature reveals much research related to grieving;
most being written within the last twenty-five years. Concentration has
been primarily on the surviving female spouse, prenatal and neonatal loss,
and loss of a child. Minimal research has been identified regarding loss of
the adult sibling, loss of parent as a young adult child, grief for the partner
related to HIV death, grief response of men, family-centered care, and
cultural differences. Spousal grieving has been studied mostly with the
fifty year and older population. Research of young widows under fifty has
been sparse. The only guidance for care during grieving has been found in
the lay literature. Studies of long term sequelae, greater than two or three
years are limited (Martinson, Davis, & McClawry, 1991). Research on the

12

grief of individuals, who have had to make decisions to remove life
support and allow the inevitable death to occur, are lacking.

Studies regarding interventions that are useful in reducing the
intense pain of grief, shorten the duration of grief, or intervene/reduce the
effect of long term negative effects of bereavement need to be done
(Houldin, McCorkle & Lowery, 1993). Additional studies are needed in
the area of grief outcomes related to ambivalence and quality of the
relationship, as other work has found this to be an important variable
(Parkes, 1985; Steele, 1992). Research to identify potential high risk
individuals is necessary as well as developing an updated comprehensive
theory of grief (Jacob, 1996; Steele, 1992). Recent literature has moved
towards theories that emphasize the greater context in which death occurs,
well in advance of the actual death, and extending for an indefmite time
after the death (Mullirr, 1992).

The loss of a significant other is a stressor affecting emotional and
physical health, and social adjustment (Jacob, 1993). While most widows
will not need extensive additional health care during this time, having a
caring health care provider to consult with, and monitor progression, can
assist the individual through the transition of loss. Periodic follow-up
assessments can detect early any maladaptive behaviors, reassure the
individual that what they are experiencing is probably normal and help
lessen their anxiety about whether their reactions, behaviors and feelings
are normal. Knowledge of the grieving process and its many variations
can greatly reassure the widow and reduce her feelings of going insane.
The APN, or primary care provider, can give permission for grieving (Dr.
Mark O'Brian, personal communication, Oct. 1996) and also permission to
reinvest in life ( Stroebe & Stroebe, 1987).

l3

Conceptual Framework

Thomas Attig (1991), believes that while the death of a loved one is
a choiceless event, the grieving process as an active process is not.
Grieving becomes a complex coping process, requiring energy for the
challenges and opportunities ahead. There is resistance to move from grief
to the active process of grieving, and this affords an opportunity for health
care providers to encourage and support the undertaking of tasks of coping
with the challenges presented by the loss. As a survivor, the person can
choose to remain in paralyzing grief, or choose to work through the grief to
a new life. Existing values, belief systems, convictions and hope that
affirm life decide the direction of grieving. Grief work includes a through,
comprehensive restructuring of personal integrity and transforming the
love/ relationship for the deceased person into a cherished memory.

The death of her spouse catapults the woman into an unwanted and
frequently unexpected transitional state. Schlossberg (1981, 1984)
addresses this time of transition in order to understand the continued
growth and development that adults experience in "A Model For
Analyzing Human Adaptation To Transition" (figure 1). Individuals have
different abilities to adapt to change and this ability may change during the
life span.

Transition can be defined as an event or nonevent that results in a
change in assumptions about oneself and the world requiring a
corresponding change in one's behavior and relationships. Inclusive in the
definition of transition are "nonevents," the other more subtle
disappointments in life. Transition may result in both negative and
positive aspects of growth or deterioration of the individual and includes a

person's perception of the event. With identification of these "events",

14

A MODEL FOR ANALYZING HUMAN ADAPTATION TO TRANSITION

TRANSITION

Event or nonevent resulting in change or assumption
Change in social networks resulting in growth or deterioration

/ \l/ \

 

 

 

CHARACTERISTICS OF

Piififigbflg': PRE-TRANSITION AND CHARACTERISTICS OF
TRANS'T'ON POST-TRANSITION INDIVIDUAL
- ENVIRONMENT

 

 

Role change: gain/loss lntemal Support Systems Psychosocial competence

Degree of stress Intimate relationships Sex (and role identification)
Affect: positive/negative Family unit Age (and Life Stage)
Source: intemallextemal Network of friends State of health

Timing: on time/off time Institutional supports Race/Ethnicity

Onset: gradual/sudden Physical setting Socioeconomic Status
Duration: permanent, Value Orientation
temporary, or uncertain Previous experience with a

transition of similar nature

ADAPTATION

Movement through phases following transition:
persuasiveness through reorganization
Depends on:
1) Balance of individual's resources and deficits
2) Differences in pre- and post-transitional
environments re-perception, supports, and the
individual

Figure 1: Schlossberg’s (1984) Model for Analyzing Adaptation to Transition.

15

assistance for an individual may be provided through anticipatory
guidance. Transition has ended when a new stable life organization has
occurred and a new identify of self is evident.

In adaptation to transition, the individual proceeds from being
totally preoccupied with the transition to integrating the transition into his
or her life. Viewed as dynamic, adaptation occurs overtime and requires
elements of adequate accurate information, maintaining good internal
condition, and keeping autonomy of the person intact. When viewed as
dynamic, measuring adaptation has a more productive approach.

Another aspect of adaptation to the transition is that of ease/effort,
which depends on the perception of the person experiencing the event,
the environment before and after the event, and the person's own inner
well-being and strength. Availability of resources such as social support,
health, and finances greatly influence adaptation. This resource-deficient
balance can help avoid labeling a person as ill, when adaptation is slowed
by an imbalance of resources. The process of transition also necessitates
the exploring of individual characteristics and other external events.
Factors that influence adaptation include role change, affect, timing, onset,
duration, and degree of stress.

Timing of the event is a great factor in transition. If the event
occurs in an expected social context, the transition may be less stressful
than that of untimely death. Source of transition, whether internal or
external, denotes the element of control over the event; less control results
in more stress.

Gradual transition allows for some time to adjust to the event.

Unexpected events provide no time to prepare or rehearse the future.

16

Expected duration of the stressful event helps to ease the transition.
Duration, whether temporary, permanent or an uncertain future, effects
one's coping with the event. An uncertain future produces the greatest
stress. Perception of stress with change, and accumulative stress, impacts
the ability to adjust and increases vulnerability to illness.

Factors that affect adaptation include pre-transitional and post-
transitional environments. The first of these environments are essential
interpersonal support systems. Three types of systems comprise the
interpersonal support system: 1) intimate relationships; involving support,
trust and sharing of confidences, 2) the family unit; having common
interests, affection, sense of economic interdependence and common
history, and 3) network of friends to help soften the shock of the event,
and help support the individual.

Institutional supports are the formal support of churches,
professional organizations, political and social-welfare groups.
Community support groups, and the ritual occasions of weddings, funerals
and retirement dinners, are also institutional support. Physical settings that
influence well-being and outlook include workplace, neighborhoods,
climate, seasons, and living arrangements. Important to physical setting,
and easily overlooked, are comfort, privacy and aesthetics. In addition, the
changing seasons influence the setting.

Individual characteristics influence adaptation. Competencies in
psychosocial assets including positive self-esteem and personal worth,
sense of internal locus of control and a sense of responsibility are needed
to survive. Having a world attitude of optimism and hope, a degree of trust

and the behavior attitudes of seeking and using information are required to

17

make future plans. Life stage also influences coping and adaptation to
crisis.

Adaptation and gender are very complexly related to transition.
Women have a much greater capacity for intimacy and mutuality with
others and have a much better capacity to adapt to change. Gender
socialization of men and women is an important factor to consider in loss.

Potential co-stressors that influence transition during times of crisis
include age, health status and culture. Age and life stage affect transition
as many transitions may already be occurring prior to the traumatic event.
Health status at the time of crisis affects the widow's ability to adapt and
cope with the transition and loss. Health may be an additional stressor,
and must be evaluated objectively and subjectively. The cultural aspects
of race and ethnicity affect values and cultural norms and may also be a
stressor. Risk of isolation may result in poor transition.

The socioeconomic status of a widow becomes critical during this
time of transition. Poor adaptations are linked to less educated, poor
women because of lack of material and psychological resources. An
individual's own value system is important, and may vary with life-stage.
These values include religious values and cultural norms, ideology, and
belief in life purpose. Previous experience with a similar transition, either
positive or negative, will impact on the current event and adaptation to it.

Figure 2 represents the potential risk factors and adaptation support
of being widowed. Spousal death results in an immediate change in
individual and social status. If the risk factors related to widowhood are
minimal, and the adaptation support is adequate, there is expectation of

successful transition in time.

18

SPOUSAL DEATH

IMMEDIATE TRANSITION TO SINGLE WOMAN

/ I

 

 

 

PERCEPTION OF SUPPORT FOR THE

 

 

 

DEATH WIDOW INDIVIDUAL TRAITS

Relief/ Devastation] Internal Support Systems Female:Strong/Dependent?
Indifference close friends Age: Young? New Mom?

Role change: No longer long-life. friends Elderly?
caregiver/Abused! Family unit: Health: Healthy, acute or
wire Aunts. Uncles. In-Iaws. chronic illness?

Stress: increased] adult/young Children. Race: minority or majority
decreased! no Parents, Grandparents Income: adequate/not?
difference Institutional supports Values: negative, hopeful,

Affect: grief, flat, relieved Work. Church altruistic

Source: extemal, no Network 0’ Friends Experience: Other death or
control Clubs, organizations, losses

Timing: young, middle teams. neighbors
aged, elderly Environment: Safe.

Onset: terminal/sudden] clean. adequate.
unexpected

Duration: permanent

I

Stabilized/Improved Resources

Economic

Social Involvement

Loved one cherished memory/not worshipped
Positive self image/confidence in own ability

RESOLUTION OF LOSS

Figure 2: Model for Analyzing Adaptation to Spousal Death (Adapted from
Schlossberg. 1984).

19

Assessment Tool Development

The Spousal Grief Assessment Inventory was developed for use in a
primary care setting by professional clinicians, such as physicians,
registered nurses, mid-level practitioners and social workers. This
assessment tool requires knowledge and expertise in therapeutic
communication. Utilization of empathy, excellent listening skills, use of
exploratory and open-ended questions will help assure that meaningful
answers are obtained, and appropriate grief care may be provided. The
tool is intended to identify trends and patterns of deficits and strengths of
the widow/ family.

Critique of the tool, by potential users of the tool, was accomplished
in a primary care setting. An APN, three registered nursed and two social
workers reviewed the tool's content and analyzed potential use in the
primary care setting. Positive comments included the thoroughness of the
questions and perceived need for such an assessment. Concerns were
expressed regarding the length, and "a lot of questions". While the tool
appears lengthy, utilization of one word (yes/no) answers, short phrases
and dates facilitates usage. Identified needs requiring additional evaluation
and intervention will be included in the SOAP note for that visit.

Implementation of the Spousal Grief Assessment Inventory requires
education of all primary care providers, nurses and clerical personnel in a
specific setting. This education would consist of defining the target
population, exploring why this type of information is important and useful,
and providing competent holistic care. Additional education is needed on
the potential long and short term benefits and outcomes for the widow, the
practice and the health care provider, how to document advantages for

collaborative care, and how this grief care may be interwoven in other

20

primary care health services to meet reimbursement requirements.
Education sessions can occur at regular intervals during staff meetings, or
one on one, especially when obtaining initial support for tool
implementation in the practice.

A timeline of when this grief care should be provided, and the areas
that need to be assessed and addressed, and time estimated time
requirements, during the grieving process is provided in Appendix B. This
guide was adapted form Curry and Stone (1992) and integrates
Schlossberg's Transition Model (1984), and a review of the literature. As
always, individual needs and priorities will guide the care and assessment.
It is expected that, over time, with utilization and evaluation of these
guidelines and assessment tool, changes will evolve.

Identification

Identification of the grieving person is necessary to assist widows
through the process of the grief transition. All individuals require
education regarding when it is appropriate to seek assistance in non-illness
situations, for example, bereavement. Re-evaluating each visit for major
changes/ stress may identify many of these losses.

Communication

The Spousal Grief Assessment Inventory was developed based on an
assessment tool for perinatal loss by Ewton (1993), an extensive literature
review of the concepts related to a widow's needs, concerns, anticipated
problems, risk factors and potential need for resources. The characteristics
of transition, environments and individual developed and presented in
Schlossberg's theory are incorporated into the tool. Utilization of the
Spousal Grief Assessment Inventory can help guide the assessment and

help assure addressing the needs of the widow in primary care.

21

Communicating efficiently and effectively in the clinical record will
allow another health care provider to follow the bereaved person
appropriately and address their unique needs. Possible ways to identify
the chart to grieving and loss issues may include a "sticker" or by using
different colored clinical notes for the chart. If the Spousal Grief
Assessment Inventory (Appendix A) is a different color, duration of the
transition may be better evaluated for appropriate interventions, and the
grief information or knowledge will not be not lost in the numerous pages
of the clinical record. When using the assessment inventory, any
identified areas requiring additional assessment, or re-assessment, can be
documented in the plan (P) section of SOAP charting format.
Demographics

As health care providers for grievers 65 years and older, there are
implications for the older widow. Horecek (1991) has found that the
grieving process may take longer for older widows. Signs of grief may be
mistaken for dementia, depression and other signs of deterioration.
Initially, older widows may cope effectively, only to find grieving and
coping more difficult after a year or so.

Quality of Relationship

When obtaining the history of a widow, Lamberti and Detner
(1993) suggest a genogram to help identify family patterns of grief
response, "traditions" of individual families, lack of rituals, and any
unresolved grief issues that may impede the current grieving process.
Assessment of the relationships within the family of origin are essential to
identify support and facilitate stronger bonds.

Identification of support systems is crucial for the widow to
recognize. It is the support system that provides emotional support,

22

provides material and service help, information and assistance in
developing a new social life. Support is needed in all areas of her life-
family, spiritual, work and/or school.

Social readjustment occurs with much effort for the woman.
Widows, still having young children at home, are even more stressed when
the single parenting aspect sets in: Caring for the children's needs may
overwhelm these women. Assisting moms to understand the probable
need for extra emotional support for an extended time is vital. Assistance
of grandparents, an aunt or uncle, or another trusted adult to help the
children through this time is appropriate. Educating the new widow to not
place inappropriate expectations on the children (adult or child) to be her
main support, is healthy for all those involved (Rando, 1988).

Economic Status

Complicating the grief experienced by widows are economic
aspects. Severe economic changes may occur with a death; particularly
vulnerable are widows (Zick & Smith, 1991). These economic changes
may become a major health risk factor for women due to the impact on a
widow's ability to receive health care, purchase medications and maintain
lifestyle. When widowed, women frequently lose the spouse's adequate
income and medical/health insurance, adding to the stressful event ( Zick
& Smith, 1991). Depression has a greater incidence and greater severity in
widows experiencing financial distress (Leahy, 1993; Steele, 1992).

Economic needs of the new widow include emotional,
physiological, social, and spiritual. Disorientation and denial results in the
widow feeling like she is going crazy, and act without thinking. In this
mental state, decisions about money, selling the house, and employment

are sometimes made with results that are not in the best interest of the

23

widow. Guidance education about waiting to make these decisions may
prevent problems and regrets.

Confusion is frequently present in the grieving individual for several
weeks to months after a significant loss. Fear and uncertainty may cause
the widow to make major decisions regarding finances, housing or moving
in with others without careful thought of long term effects. Postponement
of these major decisions for at least a year, if possible, is suggested.
Seeking the help of a competent, trustworthy person to assist widows in
making these decisions is prudent This helps widows avoid making
decisions they may regret later (Rando, 1988).

Health Insurance

Employers and retirement benefits vary greatly regarding surviving
spousal health insurance coverage. The widow may be covered under the
husbands policy for a specific length of time before losing the health
insurance coverage, or having to purchase the coverage (Personal
communication, UAW Local 375, March, 1997). Frequently, health care
benefits are terminated with the death of the husband. The widow needs
to have knowledge of the companies survivor benefit policies.
Education/Work

Education and work status of the widow impacts greatly her ability
to adjust and cope with death of her husband (Carey, 1977). Education
irrrpacts the ability of the widow to earn a wage that is adequate to meet
her needs and provide benefits of her own (Leahy, 1993). Work also
helps the widow maintain some normalcy, greater feelings of control, and
an additional support system (Steele, 1992).

24

Functional Status

Early interventions for the widow need to be identification of her
support systems, her own and family's coping abilities, and if there are
enough resources available to meet her and the family's needs.
Additionally, assessment of what has been done, what needs to be done,
and if she needs assistance with these tasks also needs identification.
During the acute early phase of grief, instrumental support is likely
needed. The widow may need assistance for many things depending on
her support systems, financial resources, if young children are in the home,
age, and functional, mental or physical status. Appropriate referrals need
to be made at this time.

Motivation and energy for the widow to care for herself are
frequently lacking. Many widow's have not learned to drive, pay the bills,
write checks, or deal with home and car maintenance. Physical and
emotional disabilities may prevent her fi'om being able to care for herself.
Practical support and referrals for transportation, financial management,
legal assistance, personal care and household tasks are frequently needed
by widows (Jacob, 1996).

Concurrent stressors

Widows of any age fiequently have concurrent stressors relative to
their age group. When already coping with other stresses or losses,
adaptive resources are at a minimum. This leaves the widow more
vulnerable and helpless (Sanders,l993). Heath (1990) found better coping
and adjustment with two or fewer losses.

Nutrition
In order to have the energy to proceed with grief work, eating

regularly and in a healthful manner are required. However, a widow

25

frequently does not have the desire, energy, or resources, to obtain food, or
to provide transportation to food stores in order to buy food necessary for
preparing nourishing meals. Altered nutrition in the newly widowed is a
potential problem if left undetected. Strategies to improve nutrition
include: frequent small meals, sharing a meal with others, family/friends
cooking and freezing some meals so they are readily available, and daily
multivitamin for nutrition maintenance. Good hydration is necessary.
Plenty of non-alcoholic and non-caffeined beverages are needed to replace
fluids lost during grieving.
Sleep

Sleep disturbance frequently becomes a major problem when
experiencing grief (Caine, 1988). Normal patterns of sleep are greatly
disrupted. Disruption ranges from either sleeping all the time or unable to
obtain restful sleep at all. Adequate rest is vital to do the "grief wor "
necessary to move through the process. Extreme fatigue, or intermittent
bouts of extreme fatigue, are common complaints of a grieving person.
Restorative rest is difficult to obtain due to the stress and many changes
the person is experiencing. Sleeping whenever possible, and giving in to
the fatigue, is helpful in the initial stages. This state is usually temporary
and will improve. Sleeping pills and other medications are normally not
desired, as they may cause other problems.
Other Complaints

Grief may result in vague somatic complaints and can be very
frightening to the widow who experiences them without any type of
reassurance. All complaints need to evaluated for underling pathology,

however, most are benign. Some common complaints may include

26

dizziness, chest pain, palpitations, sweating, difficulty breathing. and those
that are unique individual responses to the stress.
Return to Normal Activities

Return to normal activities of school, social obligations and work is
encouraged as soon as possible for the widow. Uphold and Graham
(1994) suggest return to previous activities within two weeks of the death,
if possible. This return to activity helps to regain some normalcy, receive
support, and assist in the difficult transition period.

Activity

Physical exercise provides a way to reduce some of the anxiety,
stress and depression that may be experienced by the widow and reduces
the impact these feelings have on mental and physical health. Alternative
therapies of breathing exercises, visualization and meditation will also
assist in regaining some sense of stress relief and regaining control over
feelings.

Grieving people are preoccupied, potentially resulting in accidents
and injury. Safety is a concern, especially to identify early and quickly any
idea of suicide tendencies/behavior. Other safety concerns include home,
car, and personal safety with instruction to use extreme care while
operating a car or other machinery. Personal safety regarding dangerous
risks or activity, that could result in harm or death, need to be emphasized
to the individual, during times of despair. While not suicidal, the grieving
individual does not really care about living either. Home safety for a
widow includes increased awareness of operational secure door locks and
windows and awareness of safety fi'om home invasions and personal
attacks.

27

Drug/Alcohol Use

Assessment for increased use of drugs and alcohol is essential as
increased use indicates real potential problems with the grieving process
(Ewton, 1993). Medications need to be used with great caution and
judiciously to prevent even more problems for the woman. Tranquilizers
are addictive, do not allow for problem solving at the psychosocial level
and serve as a "crutch" that does not alleviate the stressor. Individual
needs for these drugs must be assessed thoroughly before prescribing.
Rationale for use of these medications may include: (1) increased anxiety
causing the widow to feel out of control and preventing her participation in
the problem solving process, (2) inability to sleep over an extended period
of time, (3) if the widow is at risk for suicide, and (4) if they are unable to
communicate (Hoff, 1984; Parkes, 1985). In most cases, the use of
psychotherapeutic drugs are not helpful to the client as it does not allow
for the full impact of the death to be realized, and may prevent the
expression of grief through crying, verbalization of feelings and despair
that are a necessary part of the grief process.
Physical Exam

A health assessment of the widow should ideally be done within the
first three to four weeks after the death. If the widow was a caregiver for
the deceased, her own health care may have been neglected while caring
for that person (Jacob, 1996). Evaluating, identifying and stabilizing any
chronic or acute health conditions is important as grief aggravates or
accentuates preexisting health problems (Stroebe & Stroebe, 1987). Good

internal environment is critical to the grieving/ transition process.

28

Emotional Status

Denial becomes a temporary defense mechanism to protect the
widow from the intense magnitude of her loss, allowing her time to realize
the loss and to penetrate her reality at a controlled and manageable rate.
Allowed to go on too long, denial begins to interfere with the healing and
grieving process.

Anger is a very common emotion of protest for the widow to
experience and presents in many ways including irritation, depression,
injury to self, increased sensitivity and other unexplained behaviors
(Caine, 1988; Stroebe & Stroebe, 1987)). Permission and strategies to
release anger safely need to be provided the widow, as unexpressed anger
may result in both potential physical and somatic health problems (Steele,
1992)

Guilt is often an emotion experienced by grieving widows. Feelings
of "could have, should have" are intensified with the death of the spouse.
Identification of guilt feelings, and adequate explanation for the source of
the guilt, are vital to relieve the widow. Not all widows experience guilt.
If the marriage was not ideal, and the couple had many problems, there
may only be relief after the death of the spouse. This woman needs as
much support as any other widow. Early assessment of the meaning of her
loss must be made so that appropriate interventions and support can be
provided.

Crying and sadness are part of the grieving process and often a
widow perceives that she has to avoid crying because it makes others
uncomfortable. Stress and anxiety are part of a widow's grief, and
contributes a great deal to all of the potential problems related to being

widowed. A sense of control over these problems is necessary to continue

29

the grieving process and educating women on how to gain control is vital.
Previous Grief Work (if applicable)

Older widows are more likely to experience "bereavement overload"
of multiple losses. Care needs to be taken not to encourage an older
widow to become involved too soon in normal activities that can increase
their chance of depression, and decrease socialization. This may be a time
of suicidal ideology and they must be assessed for increased despair,
hopelessness and loss of meaning of life. Increased age results in more
tendency for widows to deny their feelings and use denial as a coping
mechanism (Steele, 1992).

Discussion of Future plans/Anticipatory Guidance

Education is important for the widow regarding the grief process, its
progression and regression, and potentially periods of renewed grief
intensity. This is equally important for the family and support systems to
understand to reduce any anxiety about behaviors. Intense renewed grief
may occur between four to nine months after the death. Grief may be
renewed when the head stone is placed, at anniversaries, birthdays,
holidays, certain music, pictures or scents causing the grief to reemerge.
This is not an uncommon event and there is nothing wrong with the
individual. Reassurance of being "normal" cannot be over emphasized.

Meeting with the widow and appropriate family/support person(s) to
educate about the grief process, how both young and adult children may
grieve and behave differently from the mom/widow, and gender
differences in grieving to help each family member understand their
behavior and prevent misunderstandings may be warranted. Providing
ideas of how they can be supportive to each other will help all involved to
proceed through the process with potentially fewer complications.

30

Strategies to keep the memory of their spouse alive, but in an
appropriate manner, are important. Activities such as planting a tree in
their memory, starting a memorial, talking about and recalling events about
the deceased, are a few ways to accomplish this. The goal for the widow
is not to forget the deceased and their life together, but have a loving
memory, and move towards the future and a new "normal" life.

Sexuality and the desire to reinvest energy to another relationship
eventually start to emerge out of the despair. Creating a new and safe
social life can be both frightening and challenging after many years in one
relationship. Starting over can be difficult for the widow as social and
moral attitudes have changed, new deadly diseases have emerged, and
being safe is more important than ever before. Education on birth control,
safe sex and safety in general becomes necessary when resuming dating.

Being touched is important for the good health of human beings,
and sexual expression is one aspect of this. Because of less opportunity
for the women to remarry, the widow may have to develop a new value
system, to meet her needs for sexual expression (Rando, 1988). Possible
solutions for sexual expression may include sex without marriage,
masturbation or exploring a lesbian lifestyle.

Rebuilding self confidence is a challenge to most widows.
Identifying their own strengths in the midst of this transition is most
difficult, but necessary to continue to grow. Identification of current and
future areas that need education and training requires tremendous support
and encouragement. Behavior patterns that need to be identified and
assessed are those of nonassertive, passive or aggressive tendencies. These

behaviors are not helpful to the woman in regaining control in her life.

31

Grief resolution has occurred when the widow becomes reconciled
with the physical, psychological and social aspects of her life and
reinvolvement is possible and starting to occur (Herth, 1990). While there
may always be some reoccurrence of grief, these are short periods of time
that occur infiequently. Other researchers believe that complete release of
emotional attachment to the deceased is neither possible or desirable, and
is not an indication of dysfunctional grieving (Zisook & Shuchter, 1991).

Implications for Nursing

Interventions for the grieving individual need to start prior to a death
event with education and evaluation of survivor skills and deficits (Collins,
Liken, King & Kokinakis, 1993). This evaluation becomes part of the
ongoing relationship between the APN and client. Among the possibilities
are vocational training, education, learning about financial and pension
matters, house and car maintenance (Mullan, 1992). All women need to
be encouraged to learn of these matters in the event they are widowed
unexpectedly.

Clients need instruction on when it is appropriate to seek help and
information in traumatic events such as the death of a spouse. In private
practice, the APN ideally would have knowledge of the individual's
significant others major health problems such as any chronic conditions,
cancer occurrences/remissions and hazardous work and inquire regarding
status on routine and acute visits.

With ongoing evaluation of the client's independence, support
systems, work and education abilities under "normal" conditions, the
health care provider can help the client to learn or identify skills and
support systems in the event of the spouse's death. Encouraging the
woman to be knowledgeable about the surveyor benefits from her

32

husband's employer may be a motivation for enhancing her job/educational
opportunities, in addition to advocating for greater surviving spouse
benefits.

Contact with the provider at regular intervals, that correspond with
the grieving process timeline, will allow anticipatory guidance for the
bereaved, be of support for the person, and assist them through that phase
of grief. Grieving is now believed to last much longer than a few months;
from one to four years and more (Stroebe & Stroebe, 1987). A grief
renewal, with increased grief behaviors, can occur between 4 and 9
months, at 18 months and 2 years and may occur especially in case of
sudden death (Caine, 1988; Mullin, 1992; Rando, 1988). Follow-up of the
individual, at anticipated times of crisis, would allow for appropriate
education and reassurance from the APN. Regular contact will allow the
provider to identify any emerging issues sooner and prevent additional
stress and problems. Maintaining contact with the widow, even when
things appear to be going well, is essential (Lev, 1993).

Intervention strategies suggested by Hoff (1984) include active
concerned listening and encouraging expression of feelings. Assisting the
person to gain understanding of the crisis, helping them accept their new
reality, developing new ways of coping, and linking to social networks if
more counseling is needed, are some interventions to consider. In
addition, reinforcing information and follow-up of post crisis are
paramount. With the death of the spouse, evaluation of immediate needs
and concerns must be addressed within three to four weeks. The primary
need at this time is to reassure the widow that her grief behaviors, feelings
and expressions are normal. It is also within the first 3 months post death,
that the immune function is at it's lowest (Houldin, McCorkle & Lowery,

33

1993). The first four months are when the level of grief is greatest
(Jacobs, Kasl, Ostfeld, Berkman, Kosten, & Carpentier 1986).

As APNs working with newly bereaved individuals, our role in their
care is to assist them and support their own active participation in their
grief. To do this, frequent and timely visits are necessary. Utilizing
assessment intervals developed by Caseatra and Lund (1992) for the
widow would be: within 3-4 weeks of the death, at 2 months, 6 months, 12
months, 18 months and 2 years to evaluate coping and stress. These
intervals roughly coincide with expected grief events and potential
difficulties. If there is a need, continue visits every 6 months until there is
some resolution and stabilization for the widow. However,
individualization of any schedule is needed.

Frequent visits with the APN assist the widow in transition by
providing ideas about their experience, and identifying and charting
strategies to cope with tasks and challenges. This helps to reduce the
"helplessness" widows experience. Support and identification of
meaningful activities to form a new and meaningful life helps to overcome
the passivity in grief. Support of active coping as their reality is beneficial.
As difficult tasks arise, assisting the widow in choosing her own preferred
way to act on, or deal with the problem is a role of the APN.

APNs can assist widows in recognizing the life enhancing aspects
of their grief, some of the personal growth and development that may
occur during the grief experience includes: recognition of the positive
aspects of greater confidence in their own strengths; better self-
understanding and self-esteem; greater understanding and sensitivity for
others; increased perspective on personal relationships, both current and

future; and a better perspective on their reality and man kind.

34

"It is in choosing to actively grieve, that the bereaved choose life"
(Attig, 1991).

APPENDIX A

35
SPOUSAL GRIEF ASSESSMENT INVENTORY

 

 

 

 

 

Date:

Name: DOB: __ Gender: _ Race:
Name of deceased: DOB: __ Years married:
Date of death: __ Cause of death: Where died:
Expected/Unexpected? __ Caregiver? __ Autopsy?

 

Who was present at time of death?

 

Memorial Service/Funeral? Buried/Cremated?

 

Genogram:

36

Quality of relationship:

With Spouse:

Extremely close _ Very close __ Somewhat close _ Not close
With children/age:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Extremely close __ Very close _ Somewhat close _ Not close _
Support Person(s) Relationship
Extended Family support:

Type of support provided?

Social support: Spirituality/church support:

Work: School: Other:
Economic status:

Increase: Decrease: Remain the same:

Is there enough for the Mortgage? __ Utility bills? __ Car? __
Groceries? __ Self maintenance?

Home? Hospital bills? Funeral bills?
Medical Insurance:

Lose? _ Maintained? __ For how long? __ Payments?
Office care? __ Hospital?____ Prescription coverage?
Education/Work:

Work outside the home? Occupation:

Years of education? Type of environment?
Stressful?

Functional status:

Able to care for self? Do own shopping/chores?
Banking/ pay bills? Care for house?

Children? Transportation?

 

 

Others in home?

 

37

Do you need any help at this time?

 

Concurrent stressors:

 

 

 

 

 

Retirement? __ Recent move? Menopause?
LMP (pregnant?) Children leaving home?

Grief issues/ recent losses?

Known health problems:

Physical Status:

General survey:

 

 

 

 

 

 

 

 

 

 

 

 

 

Appetite:

More? __ Less? Same? __ Previous weight?
Current Weight? _ Subjective reason for weight change:
What are you doing for meals?

Sleeping habits:

Can't sleep at all: Sleep all the time:

Experience overwhelming fatigue? When?

What are you trying for this?

Other complaints:

Numbness/tingling? Dental pain? Joint pain? __
Chest pain? Palpitations? Dizziness?

 

 

Change in vision? GI? Other?

 

 

38

Return to normal activity:

Work?

School?

 

 

Senior citizen activities?

Volunteer activities?

Use of alcohol:
What?

Church?

 

 

 

 

How often?

How Much?

 

When?

 

 

Use of Drugs:

Rx? Street?
What drug are you using?
When?

How Often?

Reason?

Smoking habits/changes:

Increased?

OTC? Herbal?

 

How much?

 

 

 

Decreased?

 

 

Activity level:
Increased?

Decreased?

 

 

Recent injtuy?

Falls? Tripping?

 

Other mishaps?

 

Near misses with car?

 

Regular exercise?

 

Other?

 

Pets:

Companion animal?

Emotional status:
General Affect:

 

Type? Name:

 

 

Suicidal?

Denial?

 

Anger?

 

Guilt?

 

Sadness?

 

Loneliness/isolation?

 

Other/comments:

 

 

39

Previous Grief Work (if applicable):

Other recent losses within one to five years:

 

Perception of loss:

 

Memorial/funeral service?

 

Resource information provided:

 

Ability to communicate with significant others/family:

 

Response to previous crisis:

 

Support systems:

 

Other Stressors:

 

Physical exam identified needs of the client:

 

 

Discussion of future plans/anticipatory guidance:

Change in life style: Work:

 

Grief renewal: 4-9 months Deceased birthday:
Death date: Coping:

 

 

Anniversary/Holiday reactions:

 

Preventive health services:

 

Grief process:

 

Resources:

 

Other/concems:

 

Medical/nursing diagnoses:

 

Follow-up referral made (if needed):

 

Plan:

 

Signature:

 

APPENDIX B

40
FOLLOW UP GRIEF PROTOCOL

Name: Client DOB: Deceased DOB:

 

Date of death: Marriage anniversary: Years of marriage:

 

Religious holidays/Significant Days:

 

 

 

 

Visit/Date Assessment

1. 2-3 wk Initiate Spousal Grief Assessment Inventory
Date Financial

1 Hr. Estate:

 

Insurance: Life/Health

 

Funeral Expenses:

 

Veterans:

 

Other:

 

Decision Making

 

Postpone decision

 

Trusted individual:

 

Living arrangements/home:

 

Selling home/possessions:

 

Dispensation of personal objects:

 

Other:

41

 

Interaction with Others

 

Empowerment/decision making:

 

Pressure from children/others:

 

Other:

 

Immunizations

 

Flu:

 

Pneumonia:

 

Other:

 

Education

 

Range of potential emotional response:

 

Grief relapse with headstone/significant dates/holidays:

 

 

 

II. 2 mo. Complete grief assessment inventory
Date: Complete Immunizations
45-] Hr. Physical/Safety

 

Educate potential grief renewal approx. 4-9 months

 

Review accomplishment/ continued need

 

Encourage life review:

 

Evaluate how remembering deceased

 

Coping/daily schedule or routine:

 

 

42
Life style changes experienced/reaction to

 

Support/family concerns

 

Assessment for depression/withdrawal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

III. 6 mo. Comfort/confidence making decisions/delayed decisions
Date: Able to visualize the future/make plans
.5 Hr. Support/family concerns
Assesses coping/significant dates or events
Assess for depression/grief renewals/withdrawal
Safety/Injury/Physical
Readiness for future relationship/Safe sex, birth control
IV. 12 Mo. Assess changes in support system/new network?
Date: Anniversary reactions/ grief renewal/coping
.5 Hr Assess need for delayed decisions/Job/Home
Explore and identify strengths/defects/strategies
Assess current outlook for the future/positive/negative
Assess depression/withdrawal
Safety/Injury/Physical
V. 18 Mo. Assess continues support/ from whom?
Date: Actions taken to follow-up on own aspirations/dreams
.5 Hr. What does their reality consist of now/need change?

43

 

Safety/Physical

 

Grief renewal/Depression/Withdrawal?

 

 

 

 

Social network/support
VI. 2yr. Grief renewal/depression/withdrawal
Date: Physical/Safety
.5 Hr. Assess evolving lifestyle/positive/negative

 

Continue grief evaluation every six months or as necessary until the
widow feels that she has successfully made the transition and feel that she
has stabilized. Assessments may be completed and discontinued at any

point that the widow no longer feels that she needs this support.

REFERENCES

References

American Psychiatic Association (1994). W
manualnfmentalfisordm (4th ed). Washington DC: American

Psychiatric Association.
Attig, T. (1991). The importance of conceiving of grief as an active

process. M 385-393.
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