What is Anticipatory Grief?

Despite it being widespread and inevitable, grief as an emotional state is pretty misunderstood. No, not everyone goes through the same stages of grief and there’s no set timeline grief follows. It can come and go like clockwork or re-emerge seemingly out of nowhere. If something as universal as grief is misunderstood, it’s safe to say that its predecessor, anticipatory grief, isn’t even a blip on our radars.

But just because you don’t know what anticipatory grief is doesn’t mean it’s not there. It’s definitely there—and the pain that stems from the anticipation of loss can be magnified in this profession.

Not only has the pandemic made the sense of loss front and center in our collective awareness, nurses have the added pressure of experiencing this loss firsthand. The patient admitted to the ICU with COVID-19—will they leave in a wheelchair or on a gurney? The patient’s family who hasn’t given up hope—how will you help them say good-bye?

"Nurses, in fact, are particularly at risk for experiencing anticipatory grief because they are the ones who are most connected to sick and dying patients on a consistent basis, says John Burton, MD, a professor of psychiatry at Columbia University’s medical school.

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“Nurses see patients as the people that they are, not just a set of vitals, lab results and diagnoses,” he says.

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“They are also the ones who have the most contact with family members. When a patient is expected to die, the nurse will be the one who feels that most acutely. They have to manage the first wave of anticipatory grief from the patient, from family and from themselves. "

The next thing to understand about anticipatory grief is that it’s normal. “Not only is it natural, like any reaction our minds or bodies have to an injury, it is an opportunity for growth and healing. Grief allows us to recognize the meaning of something that was once present in our lives. It gives meaning to our experiences.”

Sometimes anticipatory grief can be cumulative and take a toll on the way nurses feel and how they show up at work.

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“Anticipatory grief can become problematic when it begins to interfere with our ability to show up and meet our obligations, experience well-being, or be present in the rest of our lives,” Burton says.

Along with symptoms of depression, such as sadness, guilt, loss of pleasure, loss of appetite, poor sleep, poor energy and poor concentration, complicated grief can make you want to avoid work, sap your sense of purpose and passion for this job, and ramp up your anxiety about the well-being of others.

“Of course it is normal to feel emotional pain continue when you leave a shift, for example,” he says. “But when it becomes pervasive and generalized and sustained, it is no longer the kind of pain that allows for growth, it is a pain that stops growth.”

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Addressing Anticipatory Grief

Heather Wills is an RN who has spent much of her career in hospice care. As such, she is well-versed in the concept of anticipatory grief and says the first step in addressing it is simply acknowledging that it’s there.

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“As nurses, I think we need to get better at recognizing it as the real phenomenon it is and the role it can play in burnout,” she says. “In hospice we believe that people are equal parts mind, body and spirit. And if you’re not protecting all three of those areas, then something’s going to suffer. As nurses, if we allow ourselves to grieve, then we’ll be able to function in a more holistic way.”

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Next is addressing the emotions that stem from that grief. Name what comes up for you as best you can. “Find your feeling words,” Wills says. (If you can’t, don’t be afraid to google “Feeling Words” for inspiration.)

So, how do you feel? Sad? Threatened? Anxious? Overwhelmed? Angry? If you answer yes to that last one, Wills suggests going deeper still: “Anger is always secondary to the core emotion,” she says. “If you’re angry, it could be that you’re feeling abandoned or betrayed.”

Ambivalent may be another reaction—and that’s normal, says Burton. “It is normal to feel a wish for the inevitable to come quickly.”

Also pay attention to physical symptoms. Are you tired? Are you tense in your shoulders? Is your breathing shallow? Is there a knot in your stomach? “Sitting still and settling into what you’re feeling in your body can be a really good way to prepare yourself physically for grief,” Wills says.

For a busy nurse, of course, this is easier said than done. “Just don’t push the feeling away,” advises Burton. “But it is OK to wait to reflect on the feeling, giving yourself time away from immediate clinical demands to turn inwards and observe the feelings and thoughts that you’re having.”

And then of course, there’s self-care. Remember: Self-care is not selfish; it’s necessary.

“Whenever work gets especially heavy or I notice I’m not doing well, I intentionally spruce up my self-care toolkit,” Wills says. “Prayer, journaling, exercising and sleep are huge for me. Cognitive behavioral therapy can be helpful. And community is so important—I ask my close friends to ‘check my oil levels’ all the time.”

For the nurse leaders out there, Burton has another suggestion:

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“It might be good practice to carve out times within a shift for nurses to have dedicated quiet time when they’re not available, or creating groups to provide reflection and support.”

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In other words, consider giving your nurses the time and space and tools that will allow them to grieve.

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