There is no doubt that the attacks on September 11, 2001 have profoundly changed the United States. Although we know this in our hearts, a recent report in the New England Journal of Medicine1 provides empirical evidence that the attacks have directly and dramatically affected people throughout the country. Using random-digit dialing 3 to 5 days after September 11, researchers interviewed 560 US adults about their reactions to the terrorist attacks and their perceptions of their children's reactions. They found that 44% of the adults reported one or more substantial symptoms of stress; 90% had one or more symptoms to at least some degree. These reactions were not confined to those living in geographic proximity to New York City but were, in fact, nationwide.

The symptoms reported by the adults included feeling very upset; experiencing repeated disturbing memories, thoughts, or dreams; difficulty concentrating; disrupted sleep patterns; and feeling irritable or having angry outbursts. Parents reported similar reactions in their children. The authors concluded that the psychological effects are unlikely to disappear soon. They reminded clinicians to be prepared to assist people who are experiencing trauma-related symptoms of stress; unfortunately, they provided little guidance as to what form this assistance should take.

Reading this from the perspective of the specialty hospice and palliative nursing, I was struck that the report, albeit informative, was incomplete. What was missing was the recognition that as a nation we have embarked on the process of bereavement, with its attendant components of loss, mourning, and grief. Clearly, the destruction of two national icons, in the form of the World Trade Center Towers, and the murder of thousands of innocent people, is a loss that each and every one of us is experiencing. We are having emotional responses to the loss (grief) and are working to incorporate the experience of loss in our ongoing lives (mourning).2 For us, as a bereaved nation, we are adjusting to a new world, one without the physical, psychological, and social presence of what we have lost. This is further complicated by the suddenness of the loss. "The overwhelming nature of the event dislodges the sense of all being well with the world[horizontal ellipsis]the emotional response may not become evident until many years later."3

The latter is an important point to keep in mind. As Americans, we have been exhorted to get on with our daily lives. Although that advice is a sound coping strategy, we also must be mindful of the ripple effects of grief. We must expect to experience and re-experience the physical, cognitive, emotional, and behavioral manifestations of grief. We also should be attentive to those around us, especially children, as they take the time necessary to work through this process.

The good news is that, as hospice and palliative nurses, we have special expertise and knowledge of bereavement. We understand that it is a process that involves growth, which can be painful but often results in positive change. We are patient and willing to allow time to take its healing course. This knowledge is a gift. Use it to its fullest advantage in the coming months.

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