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This is to certify that the
thesis entitled
A DESCRIPTIVE CASE STUDY OF THE PATTERN
RESPONSE IN WIDOWS .
presented by

Mary Rowe Somers

has been accepted towards fulfillment
of the requirements for

Master of Science degree inNursing

 

63W Km

Major professor

Date July 20, 1989

 

0-7539 MS U is an Affirmative Action/Equal Opportunity Institution

PLACE iN RETURN BOX to remove this checkout from your record.
TO AVOID FINES return on or before date due.

 

 

PATE DUE DATE DUE DATE DUE

   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MSU Is An Affirmative Action/Equal Opportunity Institution

A DESCRIPTIVE CASE STUDY OF THE

PATTERN RESPONSE IN WIDOWS

BY

Mary Rowe Somers

A THESIS

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

MASTER OF SCIENCE

College of Nursing

1989

@0435 l3

ABSTRACT

A DESCRIPTIVE CASE STUDY OF THE
PATTERN RESPONSE IN WIDOWS

BY

Mary Rowe Somers

The purpose of this study was to discover the
pattern response for one woman who had experienced the
death of a spouse. A descriptive case research design
method was utilized for this study to uncover the
meaning of the event as it is being lived. Open-ended
interrogatory questions were asked in an intensive,
face-to-face, one time interview with the researcher.
Themes that emerged were isolated and then analyzed to
depict the pattern response of bereavement for this
woman. Themes were then synthesized with the
researcher's perspective, based on the analysis. A
hypothetical statement was generated.

Conclusions from this study indicate that
bereavement is a process in which human beings freely

choose. Bereavement encompasses a constantly evolving

Mary Rowe Somers

pattern with environment, leading to self understanding,

changed perspectives and a glimpse of the future.

ACKNOWLEDGEMENTS

It is difficult to know where to begin in
mentioning all of those without whom this research would
not have been completed. I would like to thank my
thesis committee -- Barbara Given, Joanne Pohl and
Donald Melcer -- for their thoughtful guidance through
the research process in a unique atmosphere of collegial
learning. I am especially grateful to my chairperson,
Sharon King, who was always with me as I persistently
traveled into new areas of research.

Next I wish to thank the two women who are at the
center of this research. First, to the person who has
taught me the most about bereavement in living her own.
She continues to teach me everyday -- my mother, Freda
Rowe. And thanks to the woman who is the focus of this
study. In sharing her memories of death, she taught me
about life.

I would especially like to thank Cindy Brunsman who
helped me to open my mind to the real art of nursing and
who, along with Linda Keilman, dwelled with me many

hours to search for the essence of the truth.

ii

A special thanks to my colleagues at Lansing
Community College. I was continually supported by their
strength and caring. To them and to all of the other
nurses in my life, I am very grateful.

Thanks to my brothers and sisters who loved and
supported me in the "lived experience" of thesis —-
Stretch, Jan, Mingy and Dar.

And thanks to my family —- my lovely and creative
daughter, Sarah -- my handsome and sensitive son, Keith
-- and most especially, my husband, Paul, my best
friend, who always knew that I would find my way.

And finally, to my father, Keith. I miss him every

day.

iii

TABLE OF CONTENTS

CHAPTER I - Introduction . .

Research Questions . .
Purpose. . . . . .
Phenomenon . . . .
Assumptions. . . .
Limitations. . . .
Overview of Chapters.

CHAPTER II - Conceptual Framework

Introduction . . . .
Rogers' Theory. .

Interrelationship of Concepts

Human Beings . .
Pattern and Organization
Pattern Response . .
Health . . . . . .
Nursing . . .
Implications for Nursing
Summary . . . . . .

CHAPTER III - Review of the Literature

Introduction . . .
Bereavement. . . . .

The Environment of Bereavement
Role Change Expectations
Perceived Social Support/Social

Economic Factors . .

Forewarning of Spouse's Death.
Reported Physical and Mental Symptoms

The Role of Nursing .
Personal Experience .

Summary . . . . .

Selected Nursing Research . .

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solat

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12
12

16
18
18
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25
25
27

29

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34
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39
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CHAPTER IV - Methodology . . . . . . . .

Research Design . . .
The Descriptive Method .
Identifying the Phenomenon
Structuring the Study .
Research Question. . .
Conceptual Framework. .
Objectives of the Study.
Study Sample . . .
Protection of Human Rights
Date Gathering. .
Validity and Reliability
Procedure for Data Analysi
Summary . . . . . .

CHAPTER V - Data Presentation and Analysis . .

Overview. . . . . . . . . . .
The Case. . . . . . . . . . .
Objective One . . . . . . . .
Themes in the Language of the Subject .
Themes from Opening and Closing Questions
Themes from Guided Questions . . . .
Objective Two . . . . . . . . . .
Themes from Opening and Closing Questions
Themes from Guided Questions . . . .
Objective Three . . . . . .
Themes from Opening and Closing Questions
Themes Derived From Guided Questions .
Methodology: Quality of Design . . .
Summary . . . . . . . . . . . .

CHAPTER VI - Interpretation, Conclusions and
Implications of the Study . . .

Overview. . . . . . . .
Discussion and Interpretation of Findings.
Objective One . . . .
Objective Two . . .
Objective Three . .

Nursing Implications.
summary 0 O O O I

57

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99

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106
108
116
125

Appendices

Appendix
Appendix
Appendix
Appendix
Appendix

References.

£110va

vi

128
130
133
139
156

159

LIST OF FIGURES

Objective One -Themes in Subject's

Language With

Objective Two -
Language With

Objective Three
Language With

Logical Mapping
Bereavement.

Ease
Concepts. . . . . . 91
Themes in Subject's
Concepts. . . . . . 92

- Themes in the Subject's
Concepts. . . . . . 93

of Concepts of
O O O O O O O O O 110

vii

CHAPTER I

W

We are separate people constrained by the for-

bidden and the impossible, fashioning our

highly imperfect condition. We live by losing

and living and letting go. And sooner or lat-

ter, with more or less pain, we all must come

to know that loss is indeed a lifelong human

condition" (Viorst, 1986, p. 265).

Life, then, which is growing and learning and
reaching and yearning and gaining, is also losing. In
examining loss one recognizes that the word itself
arouses feelings that like pain or joy or hope are at
best illusive and most certainly subjective. In an
attempt to investigate the meaning of this most common
of human experiences a particular loss will be examined
in order to gain added insight. The loss to be examined
will be the death of a male spouse and, in particular,
the accompanying bereavement surrounding the widow's
experience.

Widowhood will be an inescapable reality for three
out of four married women (Olson & Hanover, 1985). In

1975, there were twelve million widowed persons in this

country. Of this number, eleven million were women. In

other words, widowhood is the likely consequence of mar-
riage. Holmes and Rahe (1967) have deve10ped a life
events scale based on forty-three events or crises that
the average person may expect to encounter and have
given them stress ratings termed "life change units".
The death of a spouse, by far one of the most stressful,
is rated at one hundred life change units, the highest
number possible. Shanas et a1. (1968) also found that
the death of a spouse is considered the major life
stressor among survivors of varying ages and diverse
cultural backgrounds.

It is important to look at the commonly identified
areas of potential concern that most newly widowed women
must face. These areas include economic difficulties,
the occurrence of untoward physical and mental symptoms
and feelings of loneliness (Berardo, 1968; Philblad,
Adams & Rosencrans, 1972; Lopata 1979; Moustakas, 1977;
Engel, 1971; Carey, 1979; O'Bryant & Morgan 1989: Strobe
& Strobe, 1987; and Gass, 1987). It is also helpful to
look at the predictors of successful adaptation to wid-
owhood. These predictors include age, gender, forewarn-
ing of spouse's death and, perhaps most important, per-
ceived social support (Caine, 1974; Vinick, 1978; Wal-
ters, 1980; Lopata, 1978; Ball, 1977; Glick, Weiss &

Parkes, 1974; Madison, 1968, Kirshling & Austin, 1988.

Bereavement refers to all of the physiological,
psychological, behavioral and social response patterns
displayed by an individual following the loss of a sig-
nificant person (Augspuger, 1978; Averill, 1968; Silver-
man & Cooperband, 1975; Vachon, 1976). Bereavement
then, is manifested by individual pattern responses to
environmental change. This individual response also
suggests an interrelationship with others in the envi-
ronment. To a great extent, human beings come to define
themselves and thus give meaning to their lives by
interaction with others. It is through this interrela-
tionship with others, in situation, that the individual
not only lives the experience, but also comes to know
the experience (Parce et al., 1981). Hopson and Adams
(1977) agree that events which cause an individual to
experience a personal discontinuity in his or her life
must result in development of new assumptions or behav-
ior responses because the situation is new and/or the
required behavioral adjustments are novel.

This then is the paradox. Bereavement, the evolu-
tionary process that each and every widow must travel
alone, has lately been given much attention in the
literature. Though the process must be traversed in a
very individual way by every woman, the preponderance of
bereavement literature has focused on the stages of

grief and commonalities of the event rather than the

specific responses experienced by the survivors
(Berardo, 1970). Schneider (1987) reports common situa-
tions that are faced by widows. He clearly feels that
in confronting these commonalities in order to repattern
the loss, "there is an integration of energies from
within the individual and an openness to energies out-
side " (p. 235). It is the uniqueness of the voyage
that is most helpful to observe.

Nurses' role in this discovery of the lived experi-
ence is most appropriate. The Social Policy Statement
of the American Nurses' Association (1980) specifies
that the phenomena of concern to nurses are those human
responses to actual or potential problems. The ques-
tion, "What's happening here?", is most appropriately
answered within the nurse-client interactive process.
The ongoing challenge to develop nurses' domain through
development of theory must begin from "the thorough
description and analysis of nursing phenomena derived
from the original source, that is, nurses' and clients'
lived experiences in client situations (Munhall & Oiler,
1986, pp. 16-17).

The death and loss of a loved one is a common event
in many people's lives. It is, however, a mistake to
confuse the universality of the experience with unique-
ness of how the event is experienced and lived by the

bereaved individual. The bereaved person brings with

her a history of patterning and repatterning both inter-
nal and external resources developed over a life time
which has given her a sense of her own self definition.
These resources include her personal, social and emo-
tional ties with others forming her network of relation-
ships that is her very unique environment. In her pro-
cess of bereavement, the widow will bring all of these
resources to bear in her ongoing patterning of the new
life she must face. This patterning, referred to in
this study as pattern response, will be a series of
choices that lead to further choices in the continuing
process in which the widow redefines a way of being in
her new and changed environment.

Rogers (1970, 1983) states that in patterning,
human beings are involved in an active creative-forma-
tive process directed toward self-regulation that
includes increasing complexity of organization. Inher-
ent in self-regulation is choice. This choosing is mul-
tifaceted in that, "the process (of choosing) may go on
even though the individual may not be consciously delib-
erating. At the same time, human beings have the capac-
ity to knowingly rearrange their environment to exercise
choices in fulfilling their potentialities" (Rogers,
1970, p. 65). Choice is an active process, conscious or
unconscious, whereby available alternatives are

selected.

With this in mind, the focus of this case study
will be the individual and unique pattern response of

one women as she faces life as a new widow.

es es
This present study was undertaken to answer the
following question: What is the individual pattern

response associated with widowhood?

ose

The purpose of this case study is to examine the
individual pattern response of one women as she faces
life as a new widow. The pattern response will be used
to synthesize the essence of the qualitative reality of
bereavement for one particular woman. A case study,
descriptive qualitative approach was selected for this
study not only because there is a noticeable lack of
such research in the literature but more importantly
because, "Relation with the world is a living impulse,
nonirreducible, and understandable only as a unified
experience. Coherence in the world is lived. The world
as perceived is the first reality" (Merleau-Ponty, 1962,
p. 42). It is this perception of the lived reality of
bereavement that will give meaning in the context of the
experience. The subject will be asked to describe her

patterns of experience of bereavement as she is living

it. These patterns will then be analyzed to illuminate

the meaning of her bereavement experience.

BDQDQEQEQE

Bereavement has been described as being set adrift,
deprived of hope in a suddenly alien world (Caine,
1974). A picture is formed of a person without iden-
tity, out of touch with the familiar, who has lost the
way of life's possibles. "Widows discover all too
quickly what being a survivor is all about. Without
choosing to do so - and perhaps that is the worst part -
widows learn the dreadful lessons of aloneness" (Schiff,
1986, p. 5). This feeling of a lack of control over
events is the pivotal aspect of the experience. The
fabric of life is torn, made useless and without mean-
ing. Life can no longer be lived according to a long
established pattern, one that has worked over time. All
of this happens without permission or the possibility of
regaining what used to be.

Bereavement has been universally described as a
process. It is normal, sequential and incredibly
painful but must be undertaken to gain entry back to
life. Weizman and Kamm (1985) agree, stating that:

The death of a loved one is a profound experi-

ence, disorienting and disturbing to the phys-

ical and emotional balance. You may feel con-

fused, dazed and suspended. The loss is felt

as if it were an assault, a blow to the self.
The onslaught is especially burdensome because

you are called upon to cope with the impact of

the death, attend to overwhelming feelings,

and somehow continue the tasks of everyday

life (p. 37).

The process then, must be an active one: unwelcome,
unwanted and without direction. It is a new and foreign
land with new language and new rules unknown to the
traveler. Most researchers agree that the process
begins immediately upon the death of the spouse with an
overwhelming sense of shock (Kubler-Ross, 1968: Engel,
1971: Moustakas, 1972: Ramsay, 1977: Bowlby, 1980).
These findings, well documented and helpful for study
tend to view the experience in a retrospective, quanti-
tative manner. Lindemann (1944) however, seems to take
a more experiential view by describing the beginning of
the journey as a loss of a pattern of conduct. Though
the aim of his research was concerned with the biologi-
cal manifestations of grief, he seems to have inadver-
tently uncovered a more lived meaning. Marris (1974) in
an attempt to more clearly understand loss as experi-
enced by widows discovered that the predominant theme
was a feeling of unreality. Finally, Schlossberg (1981)
discovered an awareness of change as the most identifi-
able manifestation. Dempsy (1981) concurs by saying

that the "surviving partner feels diminished as a per-

son, emotionally uprooted and uncertain of the future"

(p. 63).

 

In summary, bereavement is a process that is thrust

upon the widow and must be lived in a unique way chosen

and known only to the survivor. It is characterized by

a disruption of long established patterns formed over

time with a partner, leaving the person adrift in a

world that is suddenly alien and full of change.

Assumptions

This study is based on the following assumptions:

1.

A human being is a unified whole manifesting
characteristics that are that are more than an
different than the sum of his parts.

Human beings and environment are an open sys-
tem continuously exchanging matter and energy
with one another.

The innovative wholeness of a human being is
reflected in pattern and organization.

The experience of bereavement is a common
human experience.

Human beings give meaning to experience in
interrelation with others.

Human beings are capable of change and choice.
There are like elements in common human expe-

riences.

10.

The

1.

10

The experience of bereavement results in dis-
ruption of familiar patterns and establishment
of new patterns.

Nursing's central concern is with human beings
in their entirety.

In client-nurse interaction, the nurse is part

of the human being's environment.

Limitations

limitations of this study are as follows:

The sample consists of one woman, widowed for
6 months. The individual pattern response to
bereavement will be analyzed from transcrip-
tion. Thus the themes generated are only gen-
eralizable to the one woman.

The purpose of a qualitative case study is to
generate data that supports theory. These
findings will then have to be further examined
using other subjects.

The quality of the data depends on the sub-
jects verbal skills, degree of articulation
and ability to recall and make choices.

Due to the emotional significance of the sub-
ject matter to be investigated, a trusting
interactive relationship between researcher

and client is necessary.

11

5. Participation in the study is voluntary and as
such required a preliminary choice to be made

by the subject.

Ovezyiew of Chapters

This study is presented in six chapters. In Chap-
ter II, a conceptual framework consisting of the inter-
relationships of the previously identified patterns of
organization related to bereavement and nursing theory
will be described. In Chapter III, the pertinent liter-
ature relating to the phenomenon of bereavement will be
reviewed. The methodology of qualitative case study and
research design as well as the rationale for data analy-
sis will be explained in Chapter IV. In Chapter V, the
data and the results of the data analysis will be pre-
sented. Study findings, conclusions, recommendations,

and nursing implications will be included in Chapter VI.

CHAPTER II

Conceptual Framework

mystics:

In this chapter the conceptual framework for this
study will be described and discussed. Martha Roger's
theoretical basis of nursing was utilized as the funda-
mental underpinning for this framework. The rationale
for looking at the loss of a spouse and in particular,
bereavement, in light of Roger's theoretical perspective
will be explored. The nurse's unique place in being
with women as they find their individual pattern

response to widowhood will be examined.

Rogers' Theory

Roger's worldview of nursing includes a simultane-
ity, humanistic paradigm. This paradigm which explains
from Roger's perspective, what is important, legitimate
and reasonable to the discipline of nursing, holds at
its core the basic assumption of unitary human beings.
All other assumptions spring from this basic belief.
"Man is a unified whole possessing his own integrity and
manifesting characteristics that are more than and dif-

ferent from the sum of his parts" (Rogers, 1970, p. 47).

12

13

With this as the foundation, Roger's theory proceeds to
explore more fully how human beings interact with their
world, how they determine and invent their lifes and the
role of nursing in this evolutionary process. Other
concepts fundamental to Roger's theory are: energy
field, unidirectional life process, four-dimensionality,
continuous man-environment interaction, complementarity,
helicy and the particular focus of this study - pattern
and organization.

Energy fields are the fundamental units of the uni-
verse and therefore of living systems. In a continual
state of flux, the energy field varies in intensity,
density, and extent. It is this state of continuous
motion or change that is the dynamic nature of the
energy field. The energy field is four-dimensional,
identified by its pattern.

The continuous human being-environment interaction
is a major concept of Roger's theory. Roger's (1970)
sees each person's environmental field as unique. Envi-
ronment is all that is external to human beings and
includes the personal, social and emotional ties with
others forming her unique network of relationships and
patterning her individual sense of self-definition. The
relationship between the human energy field (the inter-
nal environment) and the environmental field (the exter-

nal environment) is one of mutual exchange and

14

interaction. The universe is an open system that is
inherently negentropic and characterized by continual
change. "Human beings and environment, then, are open
systems, are infinite, and are integral with each other:
that is, they are complimentary, and their boundaries
are imaginary and arbitrary" (Sarter, 1988, p. 61).

Fundamental to Roger's theory is the unidirection-
ality of life. "The life process evolves irreversibly
and unidirectionally along the space-time continuum"
(Rogers, 1970, p. 59). The space-time concept is under—
stood in relation to the process of change. Becoming
takes place in space along the time axis. "The process
of life evolves through time and is concomitantly bound
in space-time. At any given point in time, a human
being is the expression of the totality of events pre-
sent at that point in time" (Rogers, 1970, p. 57).

Human beings are new and different with the passage of
time, never to be the same person again.

The principle of hemodynamics including resonance,
helicy and complementarity describes a way of perceiving
human beings. "Changes in the life process in human
beings are predicted to be inseparable from environmen-
tal changes and to reflect the mutual and simultaneous
interaction between the two at any given point in space-
time" (Rogers, 1970, p. 102). Changes are assumed to be

irreversible and nonrepeatable and proceed by the

15

continuous repatterning of both human beings and their

environment.

nterrelat'ons of Con e s

These concepts are fundamental to the understanding
of how unitary human beings (widow) face the loss of a
spouse (environmental energy exchange) and actively
repattern and reorganize (bereavement). Rogers (1970)
feels that change is a unidirectional, continuous repat-
terning of both human and environmental fields that is
innovative and, further, depends on the "infinite now"
of the individual. Others are in agreement with this
activist, life/reality forming concept of man. Hav-
ighurst (1969) shares this view by pointing out that
"man is a self-propelling individual who manipulates the
environment to attain his goals." Further, he invents
his future self, just as he recreates or 'reinvents' his
past self (p. 123). It is clear that inherent in these
ideas is the belief that human beings have the potential
for growth through choice and change. Rogers' conceptu-
alization of man, health, and nursing as well as the
postulate of pattern and organization in relation to the
widow facing the event of the loss of a spouse and the
pattern response will be explored in the following sec-

tion.

16

W

As stated earlier, Rogers (1977), has defined human
beings as a unified whole possessing their own integrity
and manifesting characteristics that are more and dif-
ferent from the sum of the parts. Key assumptions
related to this concept identified by Rogers (1977) are:

1. Human beings and the environment are constantly
exchanging energy.

2. The life process evolves irreversibly and uni-
directionally along the space-time continuum.

3. Pattern and organization identify a human being
and reflect his innovative wholeness.

4. Human beings are characterized by the capacity
for abstraction and imagery, language and
thought, sensation and emotion and the ability
to choose.

5. Change is irreversible and nonrepeatable and

‘ proceeds by the continuous repatterning of both

human beings and their environment.

Women who face the loss of a spouse (the environ-
mental energy exchange of bereavement) must be capable
of change. Parkes (1971) speaks to this element of
being human by saying, "the way in which the bereaved
individual copes with the process of change and restores

a state of balance and predictability will depend on the

17

environmental and personal resources that can be brought
to bear on the problem" (p. 217). It is this ongoing,
flowing, dynamic interchange of energy with the environ-
ment during bereavement that allows the widow to main-
tain her personal integrity. The implication of this
statement is that due to this open interaction, human
beings are active interactionists with the ability to
learn and predict outcomes. Antonovosky (1979) states
that the two characteristics that are the strongest
indicators of effective bereavement are flexibility and
farsightedness.

The component of human beings that points to the
life process as being unidirectional and irreversible
holds special meaning for the bereaved. Life, for the
widow, because of its unidirectional flow will never be
the same. Carey (1979) found that the two prominent
problems anticipated by persons facing the death of a
spouse were the difficulty in accepting the reality of
the situation and fear of what life would be like after
the death. Rogers, however, views human beings as opti-
mistic and forward looking. ”The life process is a
becoming" (Rogers, 1970, p. 55). Widows, even though
faced with one of life's most difficult challenges, for
the most part, continue to search for the future path of
life (Parkes, 1971: Hauser, 1983: Martuccio, 1985: Olson

& Hanover, 1985).

18

Human beings are sentient: They think, feel and
imagine. These are the special qualities that speak to
the humanity of our being. As discussed earlier, a
large part of the process of bereavement includes won-
dering about the future of unknowns. Because widows are
sentient, they are capable of experiencing great pain,
both physical and emotional. Breckenridge et a1. (1986)
found that bereaved individuals were significantly more
likely to report heightened dysphoria, dissatisfaction,
and somatic disturbances typical of depression. Loneli—
ness, the need to be needed by someone, was identified
as the main problem experienced by over half of the wid-

ows surveyed by Carey (1979).

Pattern and Organizagion

Pattern Response

Human beings seek to organize the world of their
experience and to make sense of it (Rogers, 1970). This
organizing then, is the culmination of the essence of
being. The assumptions about human beings that have
been previously discussed: unidirecitonal/irreversible
life process, human being/environment energy exchange,
and sentience must be present all at once, all the time,
for human beings to reach this pinnacle of experience;
the ability to make change through active choice. "The

patterning of the human field is more than as assembling

19

and reassembling of parts directed toward automatic
self-regulatory acts. Man knowingly makes choices"
(Rogers, 1970, p. 71). Barrett and Schneweis (1980)
support this with findings of their study showing that
rather than adjustment to widowhood (bereavement) tran-
spiring through successive and predictable stages, each
widow chose her own pnppgzn of coping with the demands
that bereavement has placed upon her.

In this study the individual pattern response of
one woman who is experiencing bereavement will be exam-
ined. Rogers (1970, 1980) feels that the potential for
conscious involvement in the self-regulatory process (of
choice) is little understood. And further, "even less
understood is the evolutionary creativity that is going
on continuously and that is postulated to express itself
in identifiable, growing complexity of organization and
patterning in man and environment" (p. 71).

In examining this process, it is important to look
at the commonly identified changes in the environment
that most newly widowed women must face. The first of
these are the economic difficulties associated with
being suddenly alone. Berardo (1968), Philblad, Adams &
Rosencrans (1972), Lopata (1979), Morgan (1986), and
O'Bryant and Morgan (1989) among others have examined
this aspect of widowhood. Earlier studies found that

the median income for older widows was less than half of

20

that for older marrieds. In addition, fully one-half of
all widows lived at or below the income adequacy level
determined by the Social Security Administration.
O'Bryant and Morgan (1989) conducted a study concerned
with the lack of financial experience on the part of the
new widow and the effect of this on well being. These
researchers sought information from 300 recently widowed
women concerning their perceppipn of their financial
situation rather than actual income. The respondents
were asked to choose among describing their financial
situation as being, the same, a little worse, and much
worse. The response of 44% was "the same", 31% reported
"a little worse", and 14% saw their situation as "much
worse". These results are certainly valuable in helping
to understand the perception of the financial situation
on the part of the widowed.

Another glaring change accompanying widowhood,
again well documented in the literature, is the physical
symptoms which surround the period following the death
of a spouse. Berardo (1968), Parkes, Benjamin and
Fitzgerald (1970), Gove (1973), Strobe and Strobe
(1987), Gass (1987), and Goldberg, Comstock and Harlow
(1988) as well as others, have found that death rates,
chronic, physical and mental illnesses are higher among

the widowed than their married counterparts.

21

Arling (1976), Kivett (1978), Lopata (1979), Weiz-
man and Kamm (1985), and Whelan (1985) as well as others
mention loneliness as a universal response to widowhood.
Copel (1988) describes loneliness as, "an emotional
state in which an individual is aware of the feeling of
being apart from another or others, along with a vague
need for individuals" (p. 15). Moustakas (1977) sees
this loneliness aspect of bereavement as existential
encounters with the self.

The predictors of successful adaptation to widow-
hood, identified through quantitative studies, should
now be examined in light of Roger's assumptions. These
include gender (role change expectations), age, fore-
warning of spouse's death and perceived social support.
Caine (1974) feels that the impact of widowhood
increases when there is a rigidity in proscribed soci-
etal spousal roles that involve gender. Lopata (1969),
Olson and Hanover (1985), Rigdon, Clayton and Dimond
(1987), and Morgan (1989) view role change expectations
from the perspective of both the widow and the surround-
ing environment. Widows continue to see themselves as
married people while society sees them as single. This
plays a large part in the individual pattern responses
of the widow including, among others, work roles, family

roles and roles involving personal identity.

22

With regard to age, Lopata (1978) and Ball (1977),
found that young widows had a much more difficult time
with adjustment to their new circumstances. Another
predictor of successful assimilation of the event, fore-
warning of the spouse's death, produced different find-
ings also based on age. Glick, Weiss, and Parkes (1974)
found that for women under the age of 45 years, the sud-
den death of a spouse (defined as an illness of less
than two weeks duration with a terminal decline of less
than three days) was associated with a longer time to
complete grief work. Schlossberg (1984) agrees by not-
ing that most adults have built-in social clocks by
which they judge whether they are "on time" or "off
time" with respect to life events. It can be postulated
that the living of life which brings more complexity and
diversity enables the older widow to have had the expe-
rience of previous repatterning therefore enabling her
to be more able to act on her environment with increas-
ing ease. Gass (1988) found that women whose husband's
had died from a chronic illness rather than suddenly,
felt that they had more opportunity for anticipatory
grieving which they found helpful and reduced stress.

Finally, social support, perceived by the widow as
having someone with whom to share feelings as a means of

overcoming loneliness, is the most important predictor

23

of successful bereavement (Lopata, 1979; Madison, 1968,
Capal, 1988).

These findings should be viewed in light of the
continuous and active patterning and repatterning on the
part of all human beings. This patterning is based most
assuredly on the experience of living life itself. "All
characteristics and behaviors of any field are manifes-
tations of pattern, and it is these manifestations that
are changing in the process of evolution" (Sarter, 1988,
p. 61). It is the ongoing choosing and changing that
occurs over the span of life (age) together with the
constant exchange of energy with the environment (role
expectations and social support) in light of the search
for meaning of life (forewarning of death) that better
explains successful bereavement.

Roger's theory is one of great optimism. In the
face of sorrow, human beings can imagine a time of
future joy. Widows can find hope in hopelessness as
well as peace in time of turmoil. "Man's consciousness
and creativity are integral dimensions of man's whole-
ness" (Sarter, 1988, p. 60). The ability of human
beings to have a future view is found in the continuing
emergence of new patterns and ways of being. These

unique pattern responses in one widow will be examined.

24

Health
Health is not specifically defined by Rogers. This

is consistent with her theory in that she feels that
human beings are the authors of their lives and, as
such, are the only ones qualified to define their per-
sonal sense of health. Further, health patternings are
influenced by human values and choices. Health and ill-
ness are not at opposite ends of a continuum but exist
on the same unidirectional, irreversible space-time
axis. Fitzpatrick (1988) proposes that the
"meaningfulness that one attaches to life is directly
related to health" (p. 14). Health, then, is an active,
ongoing process, a process toward wellness. People are
responsible for choosing health over illness by creating
a state of wellness: synchrony with the environment.
"Maintenance and promotion of health are a nation's
first line of defense in building a healthy society"
(Rogers, 1970, p. 122). Clearly, Rogers believes that
health is an important human need. In this study,
health will be seen as the widow's active interaction
with her environment to repattern and reorganize her
life during bereavement to create a new reality and

sense of being.

25

Nursing

"The focus of nursing is human beings" (Rogers,
1970, p. 82). This statement, deceptively simple, sums
up the nurses' reason for being. The eloquence of the
statement implies much more. Nursing can not exist in a
vacuum. Nursing only happens when there is active
interaction with others, in situation, seeking to pat-
tern their lives. Rogers (1970) further elaborates that
the goal of the professional nurse is to promote sym-
phonic interaction between man and environment, to
strengthen the coherence and integrity of the human
field and to direct and redirect patterning of the human
and environmental fields for maximum health potential.

This is the art of the humanistic science of nursing.

Implicatipns to; uupsing

The study of the loss of a spouse and the resulting
bereavement has several implications for nursing prac-
tice. Losses, a consequence of living, become more
numerous as we age. Loss cannot be "fixed": it must be
lived. The nurse, whose mission is to attend to the
wholeness of man and his integrity seems most suited to
intervene at this time (Rogers, 1970). The humanistic
science of nursing seeks to describe, explain and pre-

dict phenomena central to its concern. This is the key.

26

The central phenomenon of nursing is not medicine,
or psychology, or sociology: it is nursing. It may be
helpful to look at the literature to begin to have a
better grasp of this unique phenomenon. Carey (1979)
found that when widowed persons were asked to respond to
the question, "Who helped you most?" at the time of the
illness and ensuing death of a spouse, the overwhelming
majority named - nurses. The reasons are enlightening.

The nurses were praised for showing concern for the
patient and/or relatives, including physical touch and
listening to their concerns. In addition, they were
grateful for information regarding tests and equipment.
On quick examination, these responses seem mutually
exclusive. A closer look, however, may get to the heart
of the matter. The prospective widows were constantly
exchanging energy with the environment and in turn
repatterning and reorganizing their worldview. These
seemingly diverse interventions on the part of the
nurses served to clarify, organize and illuminate the
quickly changing environment of the soon to be widow.

Rogers (1970) has said that prediction is the key
to knowledgeable intervention. This is not to be con-
fused with prediction of outcomes but prediction of ppp;
pegs: a process that is individual, unique and the spe-
cial concern and domain of nursing. It is the patterns

and rhythms of the interactive nurse-client relation, in

27

situation, that will encourage us to think anew our par-
ticular place in health care. In short, nurses do not
promise to cure pain: nurses promise to be with human
beings as they experience and try to find meaning in
their pain.

This study proposes to describe one woman's journey
through the process of bereavement by examining her par-
ticular pattern response to examine her individual sense
of health. The value of this and similar studies will
be to reinforce the understanding that human beings
remain their own individual and unique selves with the
ability to choose and change. The accompanying valida-
tion of theory will be of universal benefit to the

domain of nursing.

Summany

The nurse in synchrony with the widow, seeks to
participate in a caring, therapeutic way to traverse the
process of bereavement in order that the widow may reach
her highest individual health potential. The nurse will
accomplish this by recognizing that the widow is the
author of her own destiny, capable of change and choice.
Roger's theory provides the nurse with the theoretical
basis for understanding human beings and their ability
to determine their own future. "We don't run other peo-

ple. We have the capacity to participate knowingly in

28

the process of change, but we are just that - partici-
pants" (p. 36). Rather than directing care, the nurse
will recognize that the real focus of nursing is empow-
erment. The nurse, appropriately brings to this inter-
active relationship the ability to validate the widow's
perception of her environment of which the nurse is a
part. With this added information, the widow will
repattern her new way of being toward the goal of well-
ness. Therefore, the widow (human being) in synchrony
with the nurse, actively acts on her environment (loss
of a spouse) by repatterning and reorganizing
(bereavement) to attain and maintain maximal health.

In the next chapter, the review of the literature
relevant to this study will be presented. Included will
be a discussion of the experience of bereavement from
both a qualitative and quantitative perspective. Per-
sonal experience from autobiography will be addressed.
Additionally, literature which contributes to an under-
standing of the nurses' role in interaction with the

bereaved person will be reviewed.

CHAPTER III

Rev' w of he 'te t

Introducpipn

The focus of this chapter is the significant liter-
ature and research surrounding the phenomenon of
bereavement. Historically important literature con-
cerned with the changing attitudes toward the process as
well as conceptualization of the phenomenon from the
perspective of several authors will be presented. The
environment of bereavement, including factors affecting
bereavement, identified in the literature will be
addressed. Autobiographical writings of a widow found
in the popular culture will be included. Finally,
nurses' contribution, including interventions, will be

included.

Bereavement

For those who have studied bereavement, the concept
has been a controversial one. The controversy has been
linked to various researcher's ongoing disagreements as
to whether or not grief, the work process included in
bereavement, is a healthy one or intrinsically patholog-

ical. Historically, bereavement was seen as a

29

30

maladaptive condition in which the bereaved had few
choices and was therefore at the mercy of events. Freud
(1915) was the first significant figure to attempt to
discuss the phenomenon. Bereavement, from his perspec-
tive, was a gradual withdrawal of energy that tied the
bereaved individual to the lost object (the deceased).
Clearly, he viewed bereavement from a pathological
perspective.

In the early nineteen thirties, Eliot (1930, 1932),
proposed the next significant look at the concept. His
findings appear to be focused on the isolated event
alone, and the crisis nature of the experience of
bereavement was emphasized. The great value of his work
was that he saw the crisis experience not only involving
the bereaved individual but also the families of the
deceased. He suggested that survivors experienced a
sense of abandonment, shock and denial, sometimes anger,
and always intense and persistent longing for the one
who has died. However, his work, because of the preoc-
cupation with the event alone, continued to view
bereavement as an innately debilitating experience.

In the classic study of the Coconut Grove fire in
Boston, Lindemann (1944) attempted to describe normal
grief. In doing so, his major contribution to the field
of study was to begin to view grief as a process.

Though not specifically addressing bereavement, he pos—

31

tulated that survivors eventually "recover" from the
event, implying that the passage of time was a variable.
The other glaring implication is, of course, that the
term "recovery" continues to suggest a disease state
that only requires "getting over" in order to be well,
and live normally once again. Current researchers also
disagree with Lindemann's findings that the grief pro-
cess can be resolved in as little as several weeks.

Fulconer (1942) also viewed bereavement as a pro-
cess. His major contribution to the field was to sug-
gest that recovery occurs in stages. The individual
establishes a new and stable way of life by going
through stages beginning with shock and ending with the
stage of repatterning. His findings are most signifi-
cant in that the term "recovery" continues to suggest a
pathological state while "repatterning" introduces the
new perspective that the bereaved have control over out-
comes in the process.

Subsequent researchers agree that bereavement is a
process that includes stages in which the bereaved has
choices and control. The most significant development
has been that the process is now viewed as "normal"
rather than pathological, and that pathology appears
only when the bereaved's attempts at progression through
the stages is thwarted. Parkes (1965) described normal

grief as a stereotyped set of psychological reactions in

32

which the three stages of shock, despair, and recovery
can be delineated. Glick et al. (1974) described the
normal grief process in three phases including: the ini-
tial response phase beginning at the time of death, the
intermediate phase beginning several weeks after the
funeral and ending at approximately one year, and the
recovery phase occurring at the beginning of the second
year. Averill (1968) defined bereavement behavior as
the total response pattern, psychological and physiolog-
ical, displayed by an individual following the loss of a
significant object, usually a loved one. He, like his
fellow researchers of this era, continued to see the
process as a series of well defined, discrete, and pre-
dictable stages that had to be accomplished by all
bereaved regardless of individual differences.

Current researchers have studied bereavement from a
different and more individualistic perspective.
Kavanaugh (1972) and Kubler-Ross (1968), early propo-
nents of the grief-stage theory, have subsequently
changed their view. They have come to recognize that
the stages are not separate entities, but subsume one
another or blend dynamically. These researchers also
conclude that the stages are not necessarily successive,
that it is not necessary to experience every stage, the
intensity and duration of any one stage may vary

idiosyncratically among those who grieve, and, finally,

33

there is little empirical evidence to substantiate the
theory of stages. Bugen (1977) also postulates that the
"stage" concepts of grieving contain a number of theo-
retical weaknesses and inconsistencies. His thesis
holds that, "in the strictest sense, (stages) do not
exist in the grieving process. Instead it is proposed
that the existence of a 'variety of emotional states' is
the essential point, and 'not' the need to order them"
(p. 197). Finally, Norris and Murrell (1988) concur by
stating that, "we prefer to think of grief as
'psychological work' that is the normal process of com-
ing to terms with the meaning of the event" (p. 606).
Rigdon, Clayton and Dimond (1987) found that grief is a
very individual experience and specific to each person
who is experiencing the process. Finally, Murphy (1988)
concurs by stating that, "it (bereavement) cannot be
explained by the commonly accepted paradigm of bereave-
ment recovery-denial, anger, bargaining, depression, and
acceptance, suggesting that loss responses are distinct
and time limited". "Rather, the bereavement transition
is a lengthy process that is influenced by numerous
events and personal and social factors."

It is clear from the latest work, that the focus of
inquiry has evolved from studying the event to studying

the person experiencing the event. It is the uniqueness

34

of the repatterning choices made by the bereaved indi-
vidual that are most significant and consequently

deserve more study.

e v' o e o v

Several specific factors have been isolated in the
literature that contribute to the repatterning process
during bereavement. These include: role change expecta-
tions, financial status, social support (including lone-
liness), and forewarning of the spouse's death. In
addition, there appears to be an increase in untoward
physical and mental symptomology experiences by the
widow following the death of a spouse. In the following
section, each of these factors including pertinent

related research will be addressed.

e a e e t t' s

Brock and O'Sullivan (1985) have looked at the
older woman in relation to the traditional and often
sexist as well as ageist view of their proscribed roles
in the larger society. Their findings point out that
the strong focus on primarily ”helper" roles assumed by
women including marriage, homemaker, and parent have
left them uniquely unprepared to cope with the require-
ments of the role change brought about by widowhood.
Women have been forced by social sanction and tradition

to forestall any primary thought of their own needs.

35

Instead, over a lifetime, they shape their attitudes,
behavior, values, status, and societal integration
dependent on those of others; mainly husband and, as
necessary, children. With the event of widowhood, women
are left, as a result, singularly without direction.
They are asked, often for the first time in their lives,
to think of themselves first. ”These women have little
to look forward to, for our society's customs, values,
and mores do not sanction the role of widow" (p. 6).
Weizman and Kamm (1985) concur that women may be depen—
dent on their role as mate for their complete identity
and will experience the loss of self in addition to the
loss of their husband.

In 1985, Brock and O'Sullivan studied a population
of widows (N=92) to determine if there is a significant
relationship of between psychological well-being and
quality of lifestyle changes since widowhood, happiness
during marriage, social participation, and identity
independent of wifehood. Subjects were limited to women
one year after the death of their spouse. The
researchers found that lifestyle pre-widowhood (self
governance that was not contingent or reliant on
spouse), functional health status (subject's preparation
of her health limits or constraints on her social func-
tioning), and social readjustment (few life stressors/

changes) together significantly predict psychological

36

well-being (R=352). Brock (1984) conducted a similar
study examining 273 widows. Subjects were examined on
their degree of psychological well being after the
spouses death. A significant variable related to posi-
tive well being was found to be identity independent of
wifehood.

r 've S ‘al Su Soc 3 at

Kahn (1979) postulated that social support as per-
ceived by the widow was comprised of three key elements.
These include: expression of positive feeling, accep-
tance of another's behaviors, perceptions or expressed
views, and giving of symbolic or material aid. If wid-
ows are unable to obtain the support they feel they
need, they will come to experience the subjective phe-
nomenon of loneliness. Gubrium (1974) supports this
premise by arguing that it may be the discontinuity in
social interaction that widows experience because of
role and interpersonal losses that contribute to their
sense of relative isolation and accounts for their lone-
liness. Simply being a widow has been found to be a
significant factor in explaining loneliness (Lopata,
1969: Shanan & Sussman, 1981: Weiss, 1973). Arling
(1976) found that when widows engaged in relationships
that required reciprocal exchange (social interaction)

loneliness was mitigated. Further, the perception of

37

personal control over one's social interactions and
environment may be an important variable in staving off
loneliness (Peplau et al., 1982).

The problem of how to provide this needed support
is a complex one. It seems that bereaved widows, though
desperately needing support at this time, have diffi-
culty asking for it, and those would-be supporters are
unaware of what is needed and how to give it.

Several factors play a part in this confusion. The
emotional display as well as the response to grief is a
learned one. Averill (1968) found that grief may be
displayed in various ways that could include weeping,
stoicism, or laughter or any combination of the same.
Warner (1987) supports this finding by stating that emo-
tional display is a learned response that may not be
representative of the inherent feelings of grief. If
the widow's social network (environment) has taught her,
over a lifetime, a pattern of response that precludes an
external show of emotion, she may not display grief in
ways expected by the larger population and in turn she
may not receive the support she so desperately needs at
this time.

Glick, et a1. (1974) noted that the supporters of
the bereaved may also be, in a sense, responding to a
learned way of behaving in attempting to meet the

widow's needs. A well defined hierarchy predominates.

38

Devoted friends assist the widow but prefer to be
"asked". Family is more helpful than friends and female
kin more helpful than their male counterparts.

In a 1987 study conducted by Warner, the relation-
ship between perceived social support and the grief pro-
files of widows and widowers during the first year of
bereavement was examined. The Grief Experience Inven-
tory (representing despair, anger, guilt, social isola-
tion, locus of control, rumination, depersonalization,
somatization, and death anxiety) demonstrated a linear
relationship with the social support variables (Total
Functional, Total Network and Total Loss) as measured by
Norbeck's Social Support Questionnaire. Significant
relationships were found between the Total Functional
variable (the total score of Aid, Affect and Affirmation
scales of Norbeck's Social Support Questionnaire) and
the somatization scale (r = .21, p <.05) and with the
loss of control (r = .24, p <.05) scale from the Grief
Experience Inventory. The relationship was also found
between the Total Functional variable (a cumulative
score for the number in the support system, the length
of time known, and the frequency of contact) with the
Somatization scale (r = .21, p <.05) and the loss of
Control (r = .24, p <.05) scale of the Grief Inventory.

The importance of these findings is clear. If the

support system is numerous enough to provide variety,

39

has a sense of history with the bereaved and is in con-
tact often enough, the widow feels more comfortable
going through the work of bereavement including crying
(loss of control) and reminiscence without "wearing out"
her support system. The normal somatization response,
postulated by Parkes (1972), involving sympathetic stim-
ulation and parasympathetic inhibition, can be experi-

enced and voiced without fear of dismissal or rejection.

Epononic Factpps

Berardo (1968) and Philblad, Adams and Rosencranz
(1972) among others, have found that the median income
for widows was less than half of that of their married
counterparts. Balkwell (1981) points out that the sud-
den decrease in economic level brought about by widow-
hood may have as great an impact on the bereaved as
longstanding poverty does on others. Lewis and Berns
(1975) report an average reduction of 44% from previous
income levels was found to occur in the first two years
of widowhood. This drop in income necessitated 6 out of
10 widows to alter their former standard of living.
Poncar (1989) concurs by stating that the new widow is
often faced with the financial reality of needing to
uproot herself from her home due to financial pressures.
O'Bryant (1985) adds another interesting finding. If

the mortgage is paid on the residence that the widow

40

maintained with her spouse she may, conversely, be
trapped in her home for economic reasons since that may
be the least expensive housing available to her. In
either case, circumstances seemingly beyond the control
of the widow may be dominant at this time.

Barry and Fleming (1988) state that the financial
burden is often magnified due to a lack of marketable
skills if the need arises to enter or reenter the job
market. Though 25% of new widows experience no finan-
cial concerns, the remaining 75% are required to make
functional changes in the ways they carry out life
activities due to reduced financial and socioeconomic
status.

O'Bryant and Morgan (1989) report that the adjust-
ment to widowhood may be affected by a lack of financial
experience or knowledge. Three hundred widowed women
aged 60 years and older were studied to determine the
effects of financial experience prior to widowhood and
financial planning prior to the death of the spouse on
well being in early widowhood (12 to 22 months of the
death). It was found that preparation was positively
correlated with self perceived well being while prior
financial experience had no significant effect. In
addition, these researchers looked at the widow's self-
perception of the "ability to get along" on their income

after a spouse's death. They found that 12% reported,

41

"fairly well off": 68% reported, "comfortable": and 20%
reported, "rather short" or "really restricted". Empir-
ically, those widows reporting they were "comfortable"
had yearly incomes ranging from under $3,600 to over
$24,000. Clearly, the widow's perception of her finan-
cial situation and not necessarily the actual monies
available to contribute to her personal sense of well
being and control.

In summary, there are various outcomes in widowhood
directly related to economic factors. There may be an
actual decrease in available monies as a result of the
spouse's death. This fact of limited funds may dictate
how and where the widow must live her new life. The
role of financial manager, if formerly held by the hus-
band, may seem overwhelming or simply not acceptable to
the widow's sense of herself. Any one of these factors
or a combination thereof may increase the potential for
decreased sense of well being by seeming to limit her

choices.

0 o s s

Most of the work surrounding the effects of the
unexpectedness of the death as a factor in bereavement
have centered on the results of natural disasters. Sev-
eral interesting findings have been noted. Murphy

(1988) found that bereavement resulting from natural

42

disasters could be expected to be intense and prolonged.
Other findings include feelings of helplessness and hos-
tility on the part of the bereaved (Bugen, 1977). Weis-
man (1973) discovered that the sudden death may be
viewed by the widow as having been preventable. Murphy
(1984) and Parkes and Weiss (1983) report conflicting
findings suggesting that various factors including role
change, financial loss, and concurrent stressors are
positively correlated with lack of forewarning of death
as a predictor of a prolonging of the bereavement pro-
cess. Murphy (1988) in a subsequent study of mental
distress and recovery in a bereavement sample 3 years
after an untimely death found that self perceived mental
distress associated with an untimely death bereavement
persisted 3 years following a natural disaster. This
mental distress accounted for 42% of the unique vari-
ance: other variables (age, gender, education, social
support and self-efficacy accounted for only 4% of addi-
tional variance.

Gass (1988) studied the relationship between type
of death and appraisal, coping and resources on the part
of the widow. She found that widows reported no signif-
icant differences in appraisal, ways of coping, coping
strength or resource strength. However, she found that
women whose husbands died from a chronic illness rather

than from sudden death reported receiving more support

43

from religious beliefs, more helpful information on
grieving and widowhood from friends or others, and more
opportunity for anticipatory grieving.

Carey (1979-1980) conducted a qualitative study
that included 78 widows and 41 widowers looking at the
adjustment of the widowed during the first year. Par-
ticipants were asked to describe the main problems faced
before and after the death of their spouses. Signifi-
cant findings included the fact that widows who had
forewarning about the death of their spouse (the criti-
cal time being two weeks) reported a significantly

higher level of positive adjustment.

Reporned Enysical and Menpnl Synppgns

Several authors including Berardo (1968), Glick,
Weiss and Parkes (1974), Gass (1987), and Poncar (1989)
reported a physiological response symptoms associated
with bereavement. These response symptoms include self-
reported gastrointestinal disturbances, sleep pattern
changes, respiratory changes and loss of appetite. Psy-
chologically significant symptoms were also reported
more frequently. These include restlessness, anxiety,
forgetfulness or confusion and inability to concentrate
(Ferraro, 1985).

Clayton, Desmarais and Winokur (1968) in looking at

the symptomology surrounding the death of a spouse

44

reported three symptoms occurring in more than one-half
of the 48 subjects examined. These findings, termed
"normal bereavement symptoms", were depressed mood,
sleep disturbance, and crying. Two to four months
later, 81% reported a decrease in their symptoms.

In another study conducted by Valanis and Yeaworth
(1982), the physical and mental symptomology of 60 wid-
owed persons was examined from both a subjective and
objective perspective. Sections of the Duke University
Older Americans' Resources and Services Multidimensional
Functional Assessment Questionnaire (OARS) served as the
basic data collection instrument. Participants in the
study were asked to respond to questions concerning
feelings of overall health status. At the same time,
clinicians were asked the rate subjects on the same
criteria. Subjective ratings of physical health were
significantly higher than the objective ratings (-0.69,
p <.001). Generally, subjective and objective ratings
of mental health did not differ appreciably (-0.45, p
<.001). It can be postulated that in commenting on
their general feelings of health they were unconsciously
reporting their feelings about the more wholistic
concept of wellness.

Parkes (1975) studied the predictors of deteriora-
tion of physical and mental health (sic) in the conju-

gally bereaved. In this longitudinal study, 68 bereaved

45

persons were interviewed shortly after bereavement and,
subsequently, a year later. The findings that were sig-
nificant demonstrated that low socio-economic status
(r=.44, p. < 0.01) as well as lack of preparation for
loss (r=.29, p. < 0.05) correlated with reported
increase in untoward physical and mental symptoms.

In summary, the specific factors that have been
isolated in the literature that contribute to the repat-
terning process surrounding bereavement were discussed
in the preceding section. These factors make up the
environment of bereavement and must be faced by the

widow in her own unique way as she lives the process.

The Role of Nupsing

Death as a natural life experience, formerly wit-
nessed and attended primarily by family, has been gradu-
ally but almost entirely moved both by medical advance-
ment and passive societal sanction out of the home and
into the acute care setting. Though there is an orga-
nized effort on the part of some, through the hospice
movement, to reclaim ownership of the experience, medi-
cal management remains the dominant and directing force.
With this in mind, the role of the nurse in assisting
both patients with dying and survivors with bereavement
becomes obvious. The nurse is the one professional with

the knowledge, expertise and wholistic view that enables

46

her to better assist those involved in the experience of
death and bereavement. Being in constant attendance and
seen by the family as helper, the nurse is the most
logical person to assist in this complex process.

Freihofer and Felton (1976) examined nursing behav—
iors in bereavement. Twenty-five pairs of terminally
ill patients and their significant others were looked at
to discover the nursing actions and behaviors that
offered the greatest support, comfort, and ease of suf-
fering to the loved ones. A Q-sort methodology was used
asking loved ones to rank 88 most-desired behaviors,
pertaining to the patient and the most-desired behaviors
pertaining to the loved ones. Nursing behaviors were
ordered under a three-tier classification system. These
included: behaviors that promote the dying patient's
comfort and hygiene, behaviors that indicate understand-
ing of the emotional needs of the dying patient, and,
finally, behaviors that indicate understanding of the
impact on the bereaved of grief, grieving, and loss.

The findings are very meaningful in guiding the
interventions of the nurse. Rather than selecting
behaviors that would be principally directed towards
themselves, the loved ones chose interventions directed
toward comfort, support, and easing the suffering of the
patient. The one striking exception is the desire to

have "all of their questions answered honestly." In the

47

most clear terms, loved ones indicated that the current
work of bereavement and what would bring them the most
personal satisfaction, while the pepient remained eliye,
was the secure knowledge that all aspects of care, phys-
ical and emotional, were being attended to for their

loved ones.

W

In her book Eigen, Lynn Caine (1974) speaks elo-
quently about her experience of bereavement. She con-
firms that bereavement is a process that must be faced
on a daily basis. "There was a transition period when
every morning I had to grapple with the fact of Martin's
death all over again. Every morning it was new. A raw
wound that took a long time to heal over (p. 79)." In
addition, the process is unique to each bereaved person.
"I know what it is (bereavement), but do not know for
you, because each of us has our own way to go (p. 84)."

Throughout the telling of her story, Caine reiter-
ates her need for support from the people around her.
This began immediately after her husband's death at a
gathering following his memorial service. "I think it
was the best thing that could have happened. I needed
people around. I needed to talk. I wasn't ready to
mourn. This was a terrible moment and I needed a bridge

of people to help me cross it (p. 77)".

48

Caine experienced a sense of changing role even
before the death of her husband. ”And as Martin came
closer to death, I hated the thought that men would no
longer see me in sexual terms, but only as a widow (p.
47)". Later, after her husband's death she imagines
herself like a goose who has lost its mate and becomes
shy, reluctant to approach others and develops a ten-
dency to panic.

I was unpleasantly startled. I didn't want to

have that much in common with a goose. One

sentence struck me on a particularly raw

nerve: 'The lonely goose rapidly sinks to the

lowest step in the ranking order.‘ That was

exactly where I was. I had become a second-
class citizen, a member of the invisible

minority of widows. And like all members of

minority groups, I was deprived-sexually, emo-

tionally, socially and financially. My very
identity was shaky. At times I felt practi-

cally non-existent (p. 147-148).

Caine reports experiencing both physical and psy-
chological symptoms during her bereavement. She
describes this happening when, what she terms the pro-
tective fog of numbness, dissipated. It was then that
she was, "almost immobilized by the stomach-wrenching,
head-splitting pain of realizing that I was alone (p.
97)". Further, she experienced, "a sense of Martin, of
some quality of Martin that had filtered into me. A
very real feeling that part of me was Martin (p. 102)".

Finances were Caine's biggest worry. Before her

husband's death she became fearful. "I had no idea what

49

our situation was . . .That was the beginning of the
financial anxieties that still haunt me (p. 28)". After
her husband's death, she feels she went back to work
before she should have out of fear of losing her job.
"Nothing had been said, done or intimated that I could
have interpreted as a threat to my job security. No,
this was just part and parcel of the financial insecuri-
ties - some real, some imagined - that bedeviled me (p.
73)".

It is clear that changing perspectives was part of
the process of bereavement for Caine. Among other
things, she came to see her major concern, finances, in
more realistic terms.

Most of my craziness involved money and secu-
rity. I was terrified because Martin had left
no insurance and the money had stopped. This
was realistic enough. A widow with two chil-
dren has to be concerned with money. What was
unrealistic was that I never stopped to con-
sider the fact that I was still earning a
decent salary and that I was now getting
Social Security payments for the children. We
were certainly not going to starve. But some-
how, after Martin died I was possessed with
the idea that I was penniless (p. 100).

Finally, Caine comes through the process with a new
understanding of herself and her place in the world.

Acceptance finally comes. And with it comes
peace. Today I carry the scars of my bitter
grief. In a way I look upon them as battle

stripes, marks of a fight to attain an iden-
tity of my own. I owe the person I am today
to Martin's death. If he had not died, I am
sure I would have lived happily ever after as
a twentieth-century child wife never knowing

50

what I was missing. But today I am someone
else. I am stronger, more independent. A
different perspective. And I am a different
woman. And the next time I love, if I ever
do, it will be a different man, a different
love. Frightening. But so is life. And won-
derful (p. 222).

MW

While most of the literature surrounding bereave-
ment has focused on the general factors associated with
the process, nurse researchers are beginning to look at
the individual differences that women encounter coping
with the loss of a spouse and the necessity of repat-
terning a new life. Nurse researchers have based their
studies on the assumption that it is usually the profes-
sional nurse who will most likely encounter the bereaved
person especially if she seeks treatment from a physi-
cian for untoward physical or psychological symptoms
(Brock, 1984). The major focus of this body of research
has been to identify facilitative interventions that
assist the widow in reorganizing and reintegrating her
sense of self.

Remondet and Hansson (1987) developed a short-form
instrument that was administered to persons experiencing
extended psychological distress associated with widow-
hood, extrapolated from other tools, entitled the Grief
Resolution Index. The items focused on behaviors

indicative of short and long term grief resolution and

51

successful social transition. The four measures from
which items were secured, focusing on short-term adjust-
ment, included: the Survival Expectation Index, indi-
cating emotional and financial factors: the Fear Index,
examining fear for personal safety, health, loss of
independence and being alone: the Preparation Index,
measuring feelings of preparedness for life after the
event of death: and the Desperation Index, indicating
the widow's feelings of anger, resentment and hostility.
Long-term adjustment was measured using items secured
from four scales. TheSe included the Depression Inven-
tory, a short form of the Beck Depression Scale: the
Anxiety Index, examining the global anxiety level: the
Adjustment to Widowhood Index, looking at continued
feelings of control of life: and the Health Index, indi-
cating frequency of illness and self-estimate of overall
health.

The study consisted of seventy-five widowed, non -
remarried women, ranging in age from 60 to 90 years with
a median length of widowhood of 10.3 years. Results
indicated that persons who felt that they had success-
fully resolved their grief reported that they had
attempted to prepare for the upcoming death of their
spouse. Those widows also experienced less fear and
desperation and experienced fewer physical and psycho—

logical symptoms. In addition, controlling for the

52

varying lengths of widowhood did not substantially alter
the correlations. Most certainly the findings indicate
appropriate intervention opportunities for the nurse
that begin by viewing each widow and her experience as
unique.

Copel (1988) has examined the general phenomenon of
loneliness, described as "an emotional state in which an
individual is aware of the feeling of being apart from
another or others, along with the experience of a vague
need for individuals" (p. 14). Using a framework based
on the interaction/interpersonal relationship theories
developed by Harry Stack Sullivan and Hildegard Peplau,
Copel developed a theoretical framework from which to
study the phenomenon of loneliness. Copel viewed the
nurse, because of her strategic position, in situation,
with the client, as the most appropriate health care
provider to assist the client in repatterning and reor-
ganization. Logically, she felt that in order to assist
those experiencing loneliness, the nurse must be able to
recognize the manifestations and effects of bereavement.
To this end, Copel developed The Arc of Loneliness, a
framework to conceptualize the relational properties of
loneliness identified in Sullivan's and Peplau's inter-
personal frameworks.

Based on the premise that every person has an

innate longing for interpersonal intimacy, the framework

53

suggests that when individuals are prevented from making
human connection, tension will develop. If not over-
come, this tension will lead to loneliness. Copel fur-
ther maintains that grief, the process of responding to
a loss, can generate tension that is overwhelming to the
individual. Because of its debilitating nature, grief
must be shared and supported by others in order to over-
come the tension.

Clearly, this framework is a tool that can assist
the nurse in assessing the person's risk for loneliness,
one of the identified factors in bereavement. In addi-
tion, interventions can be directed toward facilitating
effective coping with the unique stressors identified by
the particular client.

Gass (1987) examined the coping strategies of wid-
ows. Included in the study were 100 non-remarried,
English speaking, non-institutionalized widows aged 65-
85 years whose spouse had died between 1 and 12 months
prior to the interview. Folkman and Lazarus' Ways of
Coping Checklist was used to identify the methods used
by widows in coping with bereavement. The purpose of
the study was to identify helpful coping strategies with
the goal of future intervention by health care workers
(primarily nurses) in assisting and enhancing effective

coping efforts.

54

Participants identified several helpful coping
strategies. These included: keeping busy (79%), par-
ticipation in social groups (10%), learning new skills
(no data reported), review of the death (64%), religion
and prayers (89%), talking with the diseased spouse
(17%) and recalling happy memories (no data reported).
Less helpful strategies included: taking medications or
alcohol (16%), blaming oneself (17%), bargaining or com-
promising (22%), sleeping more (11%), avoiding (12%),
getting mad at people (16%), making promises to oneself
(10%), and using fantasy (20%). The strategies were
deemed helpful versus less helpful based on correlation
of coping strategies used with physical and psychosocial
dysfunction. The use of fewer and more effective coping
strategies was positively correlated with low physical
and psychological dysfunction. Implications are clear
that increased knowledge of coping strategies which are
identified as helpful, can provide a beginning base from
which to provide appropriate nursing intervention to
bereaved widows.

Toth and Toth (1980), Silverman (1972), and Utley
and Rasie (1984) among others have clearly identified
the beneficial effects of support groups in facilitating
the coping work of the bereaved. The most significant
outcome appears to be the realization on the part of the

bereaved that she is "not alone” and that while her

 

 

55

situation is unique, she can, in a sense, gain strength
in interaction with a group of people who have the best
possible chance of understanding "what she is going
through". In addition, as the process of bereavement
progresses, the widow is given the opportunity to become
a caregiver to the more recently bereaved.

Nurses, given this knowledge, can direct the
bereaved toward appropriate support groups to facilitate
this therapeutic interaction. With special expertise,
nurses in advanced practice can organize and implement

such groups as part of their practice.

Summany

The review of the literature was divided into four
sections. Bereavement from an historical perspective
was traced. Theorists and researchers have changed
their view of the phenomenon over time. Bereavement was
first seen as a single-event pathological crisis.

Later, bereavement was viewed as a process shared by
both the survivor and her family that had discrete, pre-
dictable phases. Bereavement is presently seen as a
process in which the widow is capable of change and
choice and is the author of her own individual coping
pace and patterns.

In the second section, the environment of bereave-

ment including the factors affecting bereavement were

 

56

addressed. In both quantitative and qualitative stud-
ies, five main factors emerge. These include: role
change expectations, perceived social support/social
isolation, forewarning of death, financial factors, and
physical and mental symptoms. The bereaved person will,
based on her own individual response pattern, encounter
and cope with these areas.

In the third section, an autobiographical account
of the experience of bereavement was addressed. These
accounts replicated the findings noted in the research
literature but were distinctly unique to the person
telling them.

Finally, nursing's contribution to the study of
bereavement was included. Nurses have been identified
by widows as the health care giver who was most helpful
at the time of a spouses death and beyond. Anticipating
this, a majority of the research was directed towards
intervention strategies.

In Chapter IV, the methodology for this study will
be discussed. This will include a discussion of the
research design including the objectives for this study.
The criteria for selection of the sample subject, the
procedure for gathering data and the subsequent method
for data analysis will be addressed. Finally, proce-
dures for the protection of human subjects will be

included.

CHAPTER IV

nephedolegy

The research design which is intended to discover
the meaning of an event as it is being lived, 6 months
later, through the process of isolating themes, is the
focus of this chapter. Included in this section are:

1) a discussion of the research design and method
including the objectives for this study: 2) the criteria
for selection of the same subject: 3) the procedure for
data gathering: 4) the procedure for the protection of
human subjects: and 5) the procedures for analyzing

data.

Researc es’

A case study was undertaken to discover the lived
meaning of bereavement for a woman who has experienced
the death of a spouse. The case study examines a social
unit, to gain a complete, organized picture (Issac and
Michael, 1981). Methodologically, description was
employed in this study. The descriptive method, while
examining a moment in time, includes an elaboration of

the context of the situation. This elaboration, because

57

58

of the wholistic nature of persons includes the remem-
brance of past experiences and the anticipation of
future plans that have meaning in relation to the life
event (Parse et al., 1985). The individual provides
data through oral or written responses to open ended
questions derived from research objectives. The objec-
tives of the study flow from the conceptual framework.
For this study, oral descriptions of the bereaved woman
were obtained through the use of tape recording. After
transcription, these descriptions became the raw data
for analysis. Through the analysis/synthesis of that
data, major themes were uncovered which served to illu-
minate the nature and meaning of the lived experience of

bereavement for the subject.

The Descnippive neengg
Like other qualitative and quantitative methods,

the descriptive method encompasses five basic elements.
They are 1) identifying the phenomenon: 2) structuring
the study: 3) gathering the data: 4) analyzing the data:
and 5) describing and interpreting the findings. A dis-

cussion of these elements follows.

Identifying the Phenonenen

The phenomenon is a proposition based on a set of
cues that exist because of their experiential meaning in

the world of the observer. Evolving from a particular

59

frame of reference, the phenomenon guides the organiza-
tion of the study. Set forth in Chapters I and II of
this thesis, the frame of reference that is the basis
for the phenomenon of bereavement relates to the theory
of Unitary Human Beings (Rogers, 1983). Based on this
theoretical framework, bereavement is described as a
process that is thrust upon the widow and must be lived
in a unique way, chosen and known only to the survivor.
It is characterized by a disruption of long established
patterns, formed over time with a partner, leaving the
person adrift in a world that is suddenly alien and full

of change.

tru h
Structuring the study includes specifying a
research question, developing a conceptual framework,
identifying the objectives of the study, identifying a
study sample, and protecting the rights of the subjects

(Parse et al., 1985).

Resea uest o
This present study was undertaken to answer the
following question: What is the individual pattern

response associated with widowhood?

60

W

The conceptual framework, as discussed in Chapter
II of this thesis, that served as the rationale for this
study and explained the phenomenon was the Theory of
Unitary Human Beings (Rogers, 1970, 1983). Human beings
are wholistic, manifesting characteristics that are more
and different than the sum of their parts. Human beings
are constantly exchanging energy with the environment in
a unidirectional life process. Human beings are sen-
tient and seek to organize the world of their experience
and to make sense of it. In patterning (and repattern-
ing) the human field, human beings make choices, that
are innovative, and based on the ”infinite now". Health
is active interaction with the environment to pattern a
reality that creates a sense of well being with a future

view (Rogers, 1983).

ijeetivee e: the seedy

From this conceptual base, the objectives for this
study were developed. These objectives contain both a
content and a process component, identifying a single
activity related to one element of the phenomenon
(Parse, 1985). They are as follows:

1. To describe the pattern response related to the

significance, interpretation, and meaning of

the lived experience of bereavement.

61

This objective was developed from the concept that
human beings are sentient and seek to organize their
world and make sense of it.

2. To describe the pattern response related to
validation, overcoming obstacles, and interac-
tion with others in the lived experience of
bereavement.

This objective was developed from the concept that
human beings are constantly exchanging energy with the
environment and that in patterning and repatterning the
human field they make choices that are innovative.

3. To describe the pattern response related to
changed perspectives and a future view in the
lived experience of bereavement.

This objective was developed from the concept that

human beings come to experience the process of health by
patterning a reality that provides a sense of well being

and holds a future view.

W
In the descriptive method, the sample is found in
the population experiencing the phenomenon being stud-
ied. In this case study, the sample consisted of one
woman whose husband had died more than three months but
not more than twelve months from the time of interview.

Gass (1987) has pointed out that in the first three

62

months, widows were more inclined to use denial as their
major coping mechanism. It is therefore supposed that
participation in a descriptive study which requires the
subject to articulate the meaning of a lived experience
would be inappropriate at this time in the process of
bereavement. The one year parameter is generally con-
sidered by researchers to be the most intense period of
bereavement and therefore more rapidly lends itself to
this type of study. In addition, the subject was to be
60 years of age or older. This criterion was based
solely on the fact that gerontology is the area of
interest and expertise for the researcher. In addition,
the phenomenon is not considered age specific but rather
person specific.

Criteria for selecting the participant for this
study were based on the premise that the subject had the
capability, both intellectually and psychologically, to
participate and the ability to make choices. The area
to be addressed, bereavement, is one that has the poten-
tial for evoking feelings and responses that might be
painful to the subject. With this in mind, the criteria
are as follows:

1. The ability to understand and express one's

self in the English language.

63

2. The ability to relive the past and present
(global) experience of bereavement without
undue difficulty.

3. The ability to conceptualize, after reflection,
and describe the experience, including the
feelings surrounding it.

4. Having been a widow for more than 3 but no
longer than 12 months. .

5. An interest in participating in the study and
the ability to make choices.

0 e 0

Specific procedures were followed to assure that
the rights of the participant were not violated. In
accordance with Michigan State University College of
Nursing requirements, application was made to the Uni-
versity Committee on Research Involving Human Subjects
for permission to conduct this research. Permission was
granted and all possible efforts were made to ensure the
protection of the participants' human rights. A consent
form was signed identifying the researcher and briefly
explaining the nature of the study. Along with assuring
confidentiality and anonymity in written reports of the
study, and the right to withdraw from the study at any

time, permission was obtained to allow the researcher to

64

tape record responses to interrogatory statements
(Appendix A).

Areas covered in the consent form were initially
explained during a telephone call. At that time, an
opportunity to ask questions was also provided. The
respondent was made aware of the only possible risk
inherent in participation in the study, that is, the
possibility of becoming more aware of, and possibly dis-
turbed by, any new or old issues raised by experiencing
the thoughts surrounding the discussion of bereavement.
The participant was urged to discuss her concerns and
feelings, if engendered, with supportive persons, her
health care provider, or if desired, the researcher.

In order to carry out the promise of confidential-
ity, the participant was given a fictitious name which
was used in reporting the data. Transcriptions of the
data obtained from interviews were placed in the
researcher's private file. Tape recordings were erased
after transcription and validation of the accuracy of

the transcript.

Date Getneping

Potential participants were garnered from the gen-
eral population by referral from nurse colleagues. All
met the inclusion criteria. Four prospective partici-

pants were then contacted by telephone. One subject was

65

chosen based on willingness to participate and the abil-
ity to coordinate schedules for meeting.

An interview time convenient to the subject was
arranged by telephone. The interview took place in the
participants home where, after explanation, the consent
form was signed (Appendix B). Approximately 10 minutes
were used at the beginning of the interview to establish
rapport and collect basic demographic data. The subject
was asked, in section one, to respond into a tape
recorder to open-ended questions aimed at obtaining a
more indepth picture of the subject. In addition, in
section two, guide questions derived from the research

objectives were asked (Appendix C).

X 1.2.! l E 1i lili!

The issues of validity and reliability will be
addressed in the following section. In quantitative
research, validity and reliability are the accepted con-
cepts of measurement established through the use of cer-
tain procedures for data collection and analysis.
Because the nature and manner of the research process is
different in a qualitative methodology, the concepts of
validity and reliability are not addressed in the same
way.

Guba and Lincoln (1981) suggest that it is perhaps

inappropriate to define the scientific rigor inherent in

66

the qualitative process in terms of validity and relia-
bility. Rather, qualitative findings should be viewed
in terms of credibility, confirmability, auditability
and fittingness. Credibility is comparable to construct
validity and refers to the maintenance of the opera-
tional measures of the study. Confirmability is compa-
rable to reliability in that the procedures for data
gathering are specifically stated and followed.
Auditability refers to the maintenance of the research
process in that the segments of the study proceeded in a
logical sequence. Fittingness refers to the ability to
follow the logical flow of the process, forward and
back, from conceptual framework to hypothetical state-
ment. Further these authors maintain that the
researcher's sensitivity, conceptual ability, creativ-
ity, and insight are vital to the analytical process in
qualitative research.

Validity refers to the degree to which an instru-
ment measures what is supposed to be measuring (Polit &
Hungler, 1983). Validity can be further divided into
construct validity, internal validity and external
validity. Each of these concepts will now be addressed
with regard to this study.

Construct validity refers to establishing correct

operational measures for the concepts being studied

67

(Yin, 1989). In qualitative research this is accom—
plished by having the researcher develop a sufficiently
operational set of measures in collecting data. Specif-
ically, the researcher should include two steps:

1. Select the specific types of changes that are
to be studied in relation to the original
objectives of the study.

2. Demonstrate that the selected measures of these
changes do indeed reflect the specific types of
change that have been selected (Yin, 1989).

In this study, the first step was satisfied by very
specifically identifying the changes (pattern responses)
to be observed in bereavement based on objectives
derived from Roger's Theory of Unitary Human Beings
(1983). The second step was satisfied by employing a
tactic known as maintaining a chain of evidence (Yin,
1989). Maintaining a chain of evidence means that an
external observer can follow the derivation of findings
from the initial research question to the ultimate con-
clusions of the study. Further, the observer should be
able to follow the logic of the process in either direc-
tion. In this study this tactic was insured by the fol-
lowing means: 1) A case representation was presented as
part of the results of the study based on actual data
(Appendix D). 2) Nonverbal behaviors of the subject

were observed and recorded by the researcher during the

68

interview to note congruity of behavior and affect
(Appendix E). 3) Questions derived from objectives were
approved by a four person thesis committee and were
adhered to during the interview. 4) The subject fit the
inclusion criteria stipulated in the study.

Internal validity is concerned with establishing
causal relationships, whereby certain conditions lead to
other conditions, as distinguished from spurious rela-
tionships (Yin, 1989). It is appropriate to apply this
concept to the case study method which is not concerned
with establishing causal relationships and, for this
reason, was not done in this case study.

External validity establishes the domain to which a
study's findings can be generalized (Yin, 1989). It
must be remembered that unlike quantitative research,
which relies on statistical generalization, qualitative
research relies on analytical generalization. This
means that the aim of the researcher is to generalize a
particular set of results to some broader theory. In
this study, the results are generalizable to the Theory
of Unitary Human Beings (1983) from which the objectives
were derived and upon which the interview questions were
based.

Reliability is the degree of consistency with which

an instrument measures the attribute it is supposed to

be measuring (Polit & Hungler, 1983). In qualitative

69

research this concept is particularly concerned with
accuracy and credibility (Chenitz 8 Swanson, 1983). Yin
(1989) suggests that the most appropriate way to
approach reliability in the case study method is to make
as many steps in the process of the research, as opera-
tional as possible.

In this study, the researcher included the follow-
ing steps related to reliability: 1) Procedures for
data gathering and analysis were specifically stated in
detail before data collection and were subsequently
adhered to. 2) Two persons, in addition to the
researcher, compared the audiotaped responses of the
subject with the transcript to insure accuracy.

With regard to credibility, as discussed earlier,
findings are based on the sensitivity, conceptual abil-
ity, creativity and insight of the researcher (Guba 8
Lincoln, 1981). Qualitative findings are based on the
way the researcher connects data bits to each other and
to a body of literature (Ammon-Gaberson 8 Paintanida,
1988). Therefore, unlike quantitative studies, analyti-
cal findings from qualitative data may not be the same.

It should be noted that in this study, two sets of
questions were asked of the subject. One, an unguided
set, was aimed at gaining a better picture of the sub-

ject and the other set were guided questions based on

70

objectives and literature. It was found that the sub-
ject's responses to both the guided and unguided ques-
tions yielded data that contained the same critical ele-

ments.

e u 's

In analyzing the data from this study, utilizing
the descriptive method, the subject-researcher interac-
tion was carefully examined. The interaction was then
synthesized into a reconstructed case giving a picture
of the subject in the lived experience. Major themes
articulated by the subject about the phenomenon were
isolated through analysis-synthesis. Analysis is the
separation of the whole into constituent parts for the
purpose of study. This then was followed by synthesis
which is the recombination of the elements to form a
more coherent whole. In this case, themes (critical
elements) were separated according to the major concepts
in the objectives. These major concepts were: 1) sig-
nificance, meaning and interpretation, 2) validation,
overcoming obstacles and interaction with others, 3)
changing perspectives and future view. The themes, in
the subject's language, were examined in light of the
major concepts and formed the basis for constructing a
unified description of the phenomenon as lived by the

subject (Parse et al., 1985). A higher level of

71

discourse was reached as the themes were moved from the
subject's language to the researcher's language. In
order to verify the fittingness of the themes, the raw
data was examined by a researcher who is familiar with,
and has experience in implementing the qualitative
research methodology in research activity. In addition,
the chair of this thesis committee and one additional
member examined the data for the logic of flow.

The themes, in the language of the subject, moved
to the language of the researcher, were interrelated to
form a coherent, integrated reconstruction of the unit
of study (the bereaved widow). These findings were then
synthesized and transformed into a hypothetical state-
ment regarding the pattern response of bereavement for
this particular subject, at this point in time (Parse,

1985).

SBEEQIY
In Chapter IV, the research design as well as the

data gathering and data analysis procedures were
described. The study's sample selection, protection of
subject rights and the interview setting were also dis-
cussed. Objectives of the study derived from the con-
ceptual framework were presented. In addition, guide

questions designed to uncover the lived experience of

72

the elements of the phenomenon of bereavement were
listed.

In Chapter V, the data will be presented in the
form of the reconstructed case. Data analysis will be
carried out by identifying themes in the words of the
subject. Themes, at a higher level of discourse, in the

words of the researcher will then be presented.

CHAPTER V

Data Presentation and Analysis

Overview

A case study was undertaken to discover the lived
meaning of bereavement for a woman who had experienced
the death of a spouse. The aim of this research was to
examine the responses of the bereaved woman, in depth,
to gain a complete, organized picture of her bereave-
ment. The person studied was a 60 year old woman, mar-
ried 38 years who had been widowed 6 months previously.
The subject was asked to respond to guided questions
based on a specific theoretical framework, the Theory of
Unitary Human Beings, in order to uncover themes which
served to illuminate the nature and meaning of the lived
experience of bereavement for her.

The data will now be presented in a reconstructed
case scenario. Following this, themes in the subject's
words with supporting raw data and rationale will be
presented. A grouping of these themes by objective with
emerging concepts will follow. Themes, at a higher
level of discourse related to each objective, in the
words of the researcher will then be presented.

Finally, the tests of the quality of design including

73

74

credibility, auditability, fittingness, confirmability

and external validity will be discussed.

Tm

Mr. and Mrs. P. had been married 38 years when he
died 6 months ago. They met in college, were always
good friends, and lived their lives by planning ahead.
Their three children were a major part of both of their
lives and, as a result, Mrs. P. feels that the way the
children are now is no accident. She and Mr. P. worked
with them to help them develop into the adults they have
become.

Mrs. P. describes herself as extraverted, intelli-
gent, caring and a good friend. Though she has worked
outside the home for the last 17 years, she does not see
herself as a career person. Rather, she maintains that
she loves her home and remains, primarily, a wife and
mother.

When Mrs. P. faces new situations she thinks that
there are choices that have to be made. One of the
choices that she is facing is whether or not she will
continue to work. At this time, she has decided that
she will work until she doesn't want to anymore. She
describes this decision as being primarily because she
has a lot of energy and needs to be doing something pro-

ductive.

75

In the near future, she has planned a trip to Eng-
land to visit her son. Traveling was something she and
her husband enjoyed together, and she feels that this is
the kind of thing that she wants to continue doing now.

According to Mrs. P., making decisions isn't really
difficult for her. When her husband was alive they made
decisions together, and she feels they have always been
the kind of people who faced the world they lived in.
She has a habit of talking about problems with different
people and then making up her own mind. She does not go
to her children for advice because she is used to them
as well as other people coming to her for decision mak-
ing. When a decision is made, right or wrong, she lives
with it.

Mr. P. was diagnosed with cancer 6 years before he
died. Through his long course of treatment, Mrs. P.
feels that the couple was in control of the situation
especially due to Mr. P's. very strong will. They had
planned to build their retirement home in the future but
decided to build earlier due to Mr. P's. illness. At
different times in the course of the illness, the couple
felt that the cancer was under control. As new symptoms
appeared, they were shocked but remained hopeful.

When cancer was found in Mr. P.'s lung, they were
again shocked and dumbfounded but saw chemotherapy as

the only choice. Mrs. P. still feels that where there

76

is life, there is hope. She saw her most important job
during her husband's illness to be providing proper
nourishment for him. She wouldn't hear of Mr. P. not
eating. Mr. P. continued to eat until 2 weeks before
his death. Mrs. P. is convinced that her husband lived
2 months longer than the doctor predicted because she
provided the proper diet. Mrs. P. has since decided
that "when people don't eat is when they die".

Mrs. P. now feels that time has given her a clearer
perspective about things that happened during the course
of the illness. It is only now, when she reflects back,
that she realizes what was happening. She not only
feels Mr. P. had been ill for a long time but also that
he alone realized the seriousness of his condition.
Through sheer will, Mr. P. never gave up and in doing
so, spared her. She remembers him saying as he lay
dying, "I will maintain my dignity as long as I am
able." This so impressed her that she wrote it down.

Two weeks before he died, when she realized that
the end was near, she arranged for her children to come
home and spend time with their father for their sakes.
The couple never talked about his dying: ”we haven't to
this day".

In explaining how very strong willed and very much
in control her husband was, Mrs. P. says that the puppy

her husband loved died two weeks after he did. "I swear

77

to goodness that that dog and he are somewhere up there
together, roaming in the daisies, watching the blue
heron".

Currently, Mrs. P. has no financial worries because
she makes enough money to support herself and has
planned carefully. She has no problems talking to oth-
ers as needed but sees no problems in the future.

She sees herself in a very positive way and can
talk to people but will, in the end, do what she wants.
She hasn't thought a great deal about how she sees her-
self relative to the future. At this time she is terri-
bly lonely but positive about her life and her abili-
ties.

Family and friends are very important to Mrs. P.
She doesn't know what she'd do without them. She feels
she has a really good support system and does not see
this changing in the future.

In terms of her husband's death she thinks it's a
pretty good idea they didn't know what was ahead of them
because she doesn't know if they would have done any-
thing differently anyway. They took things one day at a
time and did what needed to be done. Mrs. P. feels free
to talk about her husband's death when she wants.

Mrs. P. is very aware of her health. She thinks

she is in relatively good physical condition and is able

 

78

to work and enjoy life. She will take the future day by
day.

Mrs. P. has identified the most difficult thing in
this situation as loneliness. She feels they were a
very close couple who shared everything. She misses
this very much.

She feels that this time has resulted in growth and
she sees herself in a new role, that of matriarch. In
that role she guides and directs her children and helps
to bind the family together. She feels very much
needed. (See Appendix F, Field Notes related to this
interview.)

In the next section, themes in the subject's words
‘with.supporting raw data and rationale will be pre-
sented. Following this, themes in the language of the
researcher, at a higher level of discourse will be
listed. The numbering sequence merely represents the
order in which themes were found in the raw data based
CH1 the identified objective and set of questions and in

no way signifies priority.

Mm
Themes 1 h La a e of he S

To describe the pattern response related to the
significance, interpretation, and meaning of the lived

experience of bereavement.

 

79
WNW:

Inene_1. She and her husband always faced the

world they live in: she continues to do so.

W.

And we always have been the kinds of people
that faced the world we lived in.

She acknowledges the need to find meaning and signifi-
cance in the world by taking it as it is.

Inene_z. Believing that nothing happens by acci-
dent, she continues to plan and take responsibility for

herself.

W.
Well we have always planned, I mean, accidents
just don't happen . . .You are responsible . .
As I say, it was no accident.
In this passage, the subject's belief that all action is
significant and meaningful with choices being made is

acknowledged.

Tnene_;. She feels that while there is life there

is hope.

W.

I mean you know, hey - where there is life,
there is hope.

The subject believes that while life continues, it is

meaningful and significant.

80

Thene_5. She believes that her husband willed him-
self to stay alive and, in doing so, avoided talking
about his death.

W-
Well, up until three weeks before he died I
was taking him to San Francisco. But he went
down hill fast. But I really and truly do
believe that he had forced himself: that he
had willed that he was going . . .We never
talked about his dying: we haven't to this
day.

In this passage, the interpretation of the force of

sheer will be explained.

Inemes from Guided Quespiene
Inene_1. Careful planning in life has given her a

sense that she can support herself and has no financial

problems.

W-

I don't have any financial problems. I make
enough money to support myself. I mean, you
know, that's why I say, careful planning in
life has been very good for me.

This passage supports the belief that planning means

fewer money worries.

Inene_z. She doesn't know what she would do with-

out her friends.

81

We.

My thoughts and feelings? I don't know what I
would do without them. So, and as I told you
before, they've been very good to me.

In this passage, the subject acknowledges that friends

are significant and of great need at this time.

Ineme 3. She feels terribly lonely but at the same
time sees herself and her abilities in a very positive

way.

Supporting Date.

I see myself in a very positive way. And I
feel basically, terribly lonely but very posi-
tive about myself and my abilities.
This passage reinforces the fact that the subject's view

of herself is meaningful and positive.

Tnene_1. She sees herself in good physical condi-
tion with the ability to work and enjoy life while mak-

ing choices.

S ort a .
And I have to think that I am in relatively
good physical condition and able to work and
enjoy life . . .Hey, I mean you know you have
choices. I'm not afraid of hard work.
For the subject, good physical condition means the abil-

ity to choose and enjoy life.

Theme . Though she thinks her husband recognized

the seriousness of the illness surrounding his death,

82

she now thinks he spared her from awareness by never

giving up.

W.
I think it is very important because he spared
me. And as I said, I think he realized how
ill he was but he never gave up.
The subject believes that her husband's never giving up

means she was spared.

Theme . She feels her husband was a person who
had a will strong enough to control his dying and

remains in control even now.

Supporting hate.

We had Sam and Sam was the dog. And actually
Sam was a year and a half old and he was just
really a puppy and he died two weeks after
J___. J___ loveg that dog, I swear to good-
ness that that dog and he are somewhere up
together roaming in the daisies, watching the
Blue Heron. That's the kind of person that .
. .He would have gilleg for that to have hap-
pened. But very strong willed, very much in
control.

This supports the subject's feelings that control means

having a will strong enough to preserve.

Objecpive Inc

To describe the pattern response related to valida-
tion, overcoming obstacles, and interaction with others

in the lived experience of bereavement.

83

WW
Thene_1. She sees herself as a person who is still

a wife and mother as well as a friend.

Where.
First of all, how would you describe yourself?
Oh, probably extraverted, and I would have to
say relatively intelligent, caring . . .I
don't know. Actually, I still love my home
and I am a wife and a mother . . .I'm a
friend, J and I were good friends.
This passage validates the person she sees herself to

be.

Thene_z. She feels she has more energy than most
people she knows and because of this, she needs to do

something fulfilling and meaningful.

W-
Because I probably have more energy than most
of the people you know. But uhm, I need to do

something. And I can't do yard work all the
time.

This theme further validates her view of herself in her

world.

Thene 3. Her habit is talking about problems with

different people and then making up her mind.

Snpponping Dane.

What I have a habit of doing is talking about
the problem with different people and then
making up my own mind . . .So on those kinds
of decision, I have had people that I could

84
talk about the problem with and then I have
made up my mind.
This passage supports the importance to the subject of

interacting with others.

Thene_e. Although he had an original prognosis of
6 months, she now feels he lived 8 months because of her

efforts.

Supporting gape.

He (doctor) said that he really didn't think
that it was necessary to put him through chemo
because he wasn't going to live beyond 6
months anyway. And actually the man was right
because from February when we found it - about
- that would be March, April, May, June, July,
August, September. Hey, we did good work: he
lived 8 months. . . (doctor) said, that the
only reason that he lived as long as he did,
was because we had taken such good care of
him.

This passage acknowledges that obstacles can be overcome

through effort.

Themes £29m guiged Quespiene
Thene_T. She does what she wants to do and says

what she wants to say.

W.

I mean, if I want to say something to some-
body, I say it. But I do what I want to do.

This acknowledges that obstacles can be met head-on and

with choice.

85

Thene_z. She feels that she has a very good sup-
port system and that people bear with her. She has the

choice to talk to people about her loneliness and is

very open.

W-

Well here again, I have a real good support
system. It was hard to go to Florida, because
we had all been there together. So, but peo-
ple will, they bear with me. . . I feel sorry
for the people who couldn't talk. . . I think
that's one of the things that you have choices
about. But people are used to me now because
I just am very open with anybody that I come
in contact with. . . And so no, I have no

problems talking about him (husband), none
whatsoever.

For the subject, interaction is a choice she can make to

alleviate loneliness.

Theme 3. She sees her changing role as that of

matriarch who will guide and direct her family and help
bind the family together.

W.

And as (son) is calling me now, I'm the matri-
arch as far as he's concerned. . . And those
are the kind of things that bind the family
together and get us through. (Daughter) needs

strength now and I am her strength and sort of
guide and direct her.

The subject validates her role through interaction in a

new way.

86

Thene 4. She continues to see herself as a needed

and valued person.

u o i .

I feel a need. And I think that's the impor-
tant thing. Are you needed?

The subject is further validated as special and needed.

W

To describe the pattern response related to changed
perspectives and future view in the lived experience of

bereavement.

Themes from O enin and C in u s 8
Theme 1. She thinks that one has choices that need
to be made. One of those choices is to work until she

doesn't want to work anymore.

W.

I think. . . you have choices that you heye to
make. And uh so, I realized that I have
choices that I have had to make. One of them
was, am I going to work?. . . So I have
decided that I am going to work. Now, am I
going to work until I'm 62? Am I going to
work until I'm 65? I'm not making any deci-
sions about that at this point in time. I
will work until I don't want to work.

This passage speaks to the subject's belief that the

future involves choices for which she is responsible.

Theme 2. She takes responsibility for her future

by being willing to live with her decisions.

87

u in a .

I'm used to people coming to me for decision
making. I'm not used to. . . And if it's
right or if it's wrong, I live with it. I
don't know whether its good or not but that's
the way it is.

Free choice as a way to face the future is acknowledged

in this passage.

Thene 3. As she went along, she gained more per-
spective and was able to see things more clearly than
when she was going through them but was glad she didn't

know what was ahead of her.

W.

Well I think, that as you go along, things
that happened. . . you begin to put into per-
spective and I think you might have been able
to pick up on things that maybe you don't pick
up on, uh. . . at the time you're going
through them. . . So, but I mean you know,
you're going through this, you don't realize
what's happening until you reflect back. . .
So I mean you know, what are you going to do?
Are you going to x-ray everybody that has a
bladder tumor? I mean, you know, that isn't
par for the course. But if we had caught it
back then, we probably could have removed the
lung, done radiation - because we did, we did
with the chemo and with the radiation - we
were able to reduce the tumor in the spinal
cord to nothing but scar tissue. . . there for
a while. . . I think now that I can reflect
back: I think he was more ill. But I think
probably it's a good thing we don't know
what's ahead of us. . . Because if we had
known, I don't know if we would have done any-
thing any differently anyway.

That perspectives change with time is acknowledged by
the subject.

Theme 5. Through living this experience, she has

come to understand that when people don't eat, they die.

W.

I have decided that when they don't eat is
when they die.

The process of changing perspectives is further acknowl-

edged by the subject.

WWW
Thene_1. She has come to realize she is taking on,

for a time, the role that once belonged to her husband.

W.

I told father (husband) this afternoon that it
used to be: he always teased me about the
rhetorical 'we'. 'We were always going to do
something. But it always ended up being 'he'
who did it. And I told him today - I laughed.
. .Anybody driving by would probably think I
was nuts. I said, 'well, it looks like the
role has reversed for a while. You're going
to watch 'me' doing instead of 'we' doing,
which was basically 'you' doing.

The perspective of a new role is recognized in this pas—

sage.

Theme 2. Having what she wants at this time, she
does not see money as being a problem now or in the

future.

89

W-

I don't see money being a problem. . . I fig-
ure that I am going to have what I want at
this point in time. . . I don't envision money
as being a problem.

In this passage, future view about finances is examined.

Thene_1. She is lonely now and hasn't thought a

great deal about the future relative to herself.

W.

I hadn't thought a great deal about the
future. Right now I'm as I say, lonely.

For the subject, the future view of herself is not clear

at this time.

Thene_1. Those people who supported her when her
husband was alive are doing the same thing now and she

doesn't see that changing.

film.

They supported us when he was alive and they
are doing the same thing now. . . I don't see
real change.

The subject sees no real change in the future relative

to social support.

Themes for each objective, in the language of the
subject with supporting data and rationale, were ana-
lyzed and then synthesized into themes in the language

of the researcher. All themes relating to each

90

objective have been grouped with the emerging concepts
(see Figures 1, 2, and 3) in accordance with the
objective. Following this are themes in the language of
the researcher, on a higher level of abstraction and
containing the central element or essence of the theme

relative to the objectives. They are as follows:

theehiye_gne. To describe the pattern response
related to the significance, interpretation, and meaning

of the lived experience of bereavement._

Resulting Theme. With careful planning and assum-
ing responsibility, the experiences of life are not
accidental. Optimism continues with choice and a sense

of control.

ijeepive Two. To describe the pattern response
related to validation, overcoming obstacles, and inter-
action with others in the lived experience of bereave-

ment.

Resulting Theme. In choosing interaction, sense of
self is validated in understanding that patterns can be

redirected through effort.

Objective Three. To describe the pattern response
related to changed perspectives and future view in the

lived experience of bereavement.

91

THEMES IN SUBJECTS LANGUAGE WITH CONCEPTS

OBJECTIVE ONE -- significance. interpretation. meaning
Human Beings seek to organize world and make sense of it

She and her husband always faced the world they lived in; she continues
to do so. [ choice ]

Believing that nothing happens by accident. she continues to plan and
take responsibility for herself. l planning; responsibility]

She feels that while there is life. there is hope. [ optimism ]

She believes that her husband willed himself to stay alive and. because
of this. the couple avoided talking about his death to this day. [control]
GUIDED QUESTIONS

Careful planning in life has given her a sense that she can support herself
and has no financial problems. [ planning ]

She doesn‘t know what she would do without her friends.
[planned support]

She feels terribly lonely but at the same time. sees herself and her abilities
in a very positive way. [optimism 1

She sees herself in good physical condition with the ability to work and
enjoy life while making choices. [choices 1

She feels her husband was a person strong enough to control his dying and
remains in control even now. [control I
THEME iN RESEARCHERS LANGUAGE

With careful planning and assuming responsibility. the experiences of life
are not accidental. Optimism continues with choice and a sense of control.

Figure 1. ec 'v e - e s cc ' n a

Wiph Qoncephe,

92

THEMES IN SUBJECTS LANGUAGE WITH CONCEPTS

OBJECT IVE TWO -- validation. overcoming obstacles. interaction with others
Human Beings constantly exchange energy with environment making
choices that are innovative.

She sees herself as a person who is still a wife and mother as well as a
friend. [ sense of self I

She feels she has more energy that most people she knows and in
addition. needs to do something fulfilling and meaningful.
[ sense of self ]

Her habit is talking about problems with other people and then
making up her own mind. [interactiom choice 1

Although her husband had an original prognosis of 6 months. she now feels
he lived 8 months because of her efforts. [ active effort 1
, GUIDED QUESTIONS

She does what she wants to do and says what she wants to say.
I active effort; choice ]

She feels that she has a very good support system and that people bear
with her. She has the choice to talk to people about her loneliness
and is very open. I interaction; choice I

She sees her changing role as that of matriarch who will guide and
direct her family and help bind the family together.
I interaction; choice I

She continues to see herself as an active and valued person.
[ sense of self 1

THEME IN RESEARCHERS LANGUAGE

In choosing interaction. sense of self is validated in understanding that
patterns can be redirected through effort.

Figure 2. Objeghiye TEE - Themee in Subjeep's Lengnege
Wihh Coneephe,

93

THEMES IN THE SUBJECTS LANGUAGE

OBJECTIVE THREE -- changed perspectives. future view
Human Beings come to experience the process of health by patterning
a reality that provides a sense of wellbeing with a future view.

She thinks that one has choices that need to be made. One of those
choices is to work until she doesn‘t want to work anymore.
I choice; responsibility 1

She takes responsibility for her future by being willing to live
with her decisions. [responsibility; future view ]

As she went along. she gained more perspective and was able to see
things more clearly than when she was going through them but was
glad that she didn't know what was ahead of her.

[clearing perspective ]
Through living this experience. she has come to understand that when
people don't eat. they die. [changing perspective ]
GUIDED QUESTIONS

She has come to realize that she is taking on. for a time. the role that
once belonged to her husband. [choicez changing perspective ]

Having what she wants at this time. she does not see money as
being a problem now or in the future. lchoice; future view ]

She is lonely now and hasn't thought a great deal about the future
relative to herself. [ future view ]

Those people who supported her when her husband was alive are doing so
now and she doesn't see that changing. [future view ]

THEME IN RESEARCHER'S LANGUAGE

In assuming responsibility for choosing. a clearer perspective emerges with
the existence of possibilities.

Figure 3. Objective Thpee - Thenes in thjeeh'e
We.

94

Resulting Theme. In assuming responsibility for
choosing, a clearer perspective emerges with the exis-

tence of possibilities.

et 0 °
Unlike quantitative research, which relies on
statistical generalization, qualitative research relies
on analytical generalization. To ensure the quality of
design with regard to this study, five areas will be
addressed. The first of these areas is confirmability.

Confirmability is comparable to construct validity

and refers to the maintenance of operational measures
used in examining the phenomenon. This is done to
ensure that the study measures what it is supposed to be
measuring. In this study, confirmability was accom-
plished by several means:

1. The subject fit the inclusion criteria in that
she was 60 years old and had been widowed 6
months previously.

2. Affect and behaviors were noted throughout the
interview and subsequently recorded. They were
found to be congruent by this researcher, who
has an expertise in communication skills.

3. The objectives were based on a conceptual
framework and subsequently examined by the the-

sis committee.

95

4. Open-ended questions were formulated that
incorporated the conceptual base and signifi-
cant factors surrounding the environment of
bereavement, derived from relevant literature.
Again, these questions were examined and
approved by the thesis committee.

Based on adherence to these steps, with consulta-
tion and agreement of the thesis committee during the
process, this researcher believes that confirmability
exists. In order to ensure construct validity, further
studies with larger populations need to be surveyed lon—
gitudinally.

The next area to be discussed is auditability.
Auditability refers to the maintenance of the process.
This aspect is especially important in qualitative
research in that the work of the study must be done in a
sequential manner in order that the researcher's think-
ing proceeds in a logical way. In this study, this was
accomplished by:

1. This researcher began with an area of interest.

2. The theoretical framework, Martha Roger's The-
ory of Unitary Human Beings was studied by the
researcher, in depth, to gain operational and

conceptual understanding.

96

3. Relevant literature surrounding bereavement was
examined and significant environmental factors
were isolated.

4. The research question was developed.

5. Objectives of the study were developed based on
the conceptual framework.

6. Interview questions were developed.

7. Data were collected.

8. Data were analyzed for themes.

9. The themes were synthesized to the

researcher's language.

10. A hypothetical statement was formulated.

Because the research process proceeded in the
sequential manner described above, this researcher
believes that auditability exists.

Fittingness, the quality of the research that
addresses the stability of response, will now be exam-
ined. This area refers to the fact that an observer can
attest to the logic of the flow of the data being pre-
sented. This logical flow should be able to be traced
forward and backward from conceptual framework to hypo-
thetical statement. In this study, this was accom-
plished by:

1. Conceptual framework and relevant bereavement

literature were examined in depth.

97

Objectives were developed from the conceptual
framework and examined by the thesis committee.
Interview questions were formulated that incor-
porated the conceptual framework and signifi-
cant factors surrounding bereavement. These
questions were examined by the thesis commit-
tee.

Data were collected and analyzed for themes
related to objectives. In addition to this
researcher, the logic of the selection of
themes was examined by the chairperson as well
as one other member of this thesis committee,
along with a nurse researcher who is familiar
with and has experience in implementing the
qualitative research methodology and a graduate
student in the College of Nursing at Michigan
State University.

Critical elements, concepts inherent in the
themes, were isolated. The logic of the selec-
tion of these critical elements was examined by
the above mentioned persons.

Themes in the language of the researcher were
developed containing the critical elements.

A hypothetical statement was developed contain-

ing the themes.

98

Because these steps in the process were adhered to,
it is the feeling of this researcher that fittingness
exists in this study.

Confirmability is comparable to reliability and
refers to the degree of consistency with which an
attribute is being measured. In qualitative studies,
this aspect is especially concerned with accuracy and
the measures taken to insure credibility, discussed in
detail above. In this study, accuracy was maintained by
having two (2) persons in addition to the researcher,
compare the audiotaped responses of the subject with the
transcript to insure accuracy. Though procedures to
insure confirmability were followed in this study, this
researcher feels that other subjects need to be surveyed
using these procedures in order that confirmability can
be said to exist.

External validity in qualitative studies refers to
the fact that findings and underlying theory are compat-
ible. In this research, it was found that compatibility
exists between the findings and Martha Roger's Theory of
Unitary Human Beings. Therefore it is the feeling of
this researcher that in this study, external validity

exists.

99

Sunnarx

Analysis of the data was undertaken by presenting a
reconstructed case scenario. Themes in the subject's
words with supporting raw data and rationale were pre-
sented. At a higher level of discourse, the themes were
analyzed then synthesized to include critical elements
and them placed in the words of the researcher.

Finally, the quality of the data was discussed with
regard to credibility, auditability, fittingness, con-
firmability and external validity.

In Chapter VI, the hypothetical statement developed
from the researcher's themes will be presented. This
hypothetical statement will be discussed in relation to
the subject. In addition, application to conceptual
framework and relevant literature will be discussed.
Finally, implications relative to research, education

and practice will be presented.

CHAPTER VI

Interpretation, Conclusions and
Implications of the Study

m

A descriptive case study was conducted to examine
the individual pattern response of one woman as she
faces life as a new widow. The purpose of this research
was to synthesize the essence of the qualitative reality
of bereavement for one particular woman. The research
question formulated for this study was: What is the
individual pattern response associated with widowhood?

In accordance with the case study methodology, the
concepts underpinning the study were derived from a the-
oretical framework. That framework is Rogers' (1970)
Theory of Unitary Human Beings. These concepts were
developed into objectives and examined with reference to
the widow's environment including role change, social
support, finances, physical/emotional symptoms and cir-
cumstances surrounding the death of the spouse.

In Chapter V, themes in the subject's language were
separated according to the major elements in the objec-
tives. Using these themes as a basis, in the language

of the researcher, at a higher level of discourse,

100

101

elements were interrelated to form a coherent, inte-
grated reconstruction of bereavement for this subject.
As stated earlier, bereavement refers to all of the
psychological, behavioral and social response patterns
displayed by an individual following the death of a
significant person and is manifested by individual pat-
tern response to environmental change. However, for
this subject, loss as such was not mentioned as a sig-
nificant factor. The hypothetical statement synthesized
from these themes, for this woman is: Bereavement is a
process in which human beings freely choose, in a con-
stantly evolving pattern with environment, leading to
self understanding, changed perspectives, and a glimpse

of the possible.

Dis ssion te at o ' s
In the next section, the findings that emerged from
this case study will be presented in relation to the
data of the subject, the conceptual framework and the

relevant literature.

Discussion Int retat of F ndi s s Re a t
gene. For the subject, bereavement is indeed a process.
In her telling of her experience of bereavement, she
repeatedly states that she has come to understand the
meaning of what has happened, and is happening, only

because of the passage of time. She expresses this

102

succinctly saying that "as you go along, you're able to
pick up on things that you don't pick up on at the time
you're going through them". The subject is thinking and
rethinking events in order to interpret, for herself,
her own bereavement.

Choice is not only an option for the subject, it is
a responsibility. She expresses this belief with the
statement, "I think you have choices that you have to
make." In line with this choice, for the subject, is
also a process, not an event. It is important, then, to
look at the previous patterns of choosing for the sub-
ject. She is convinced that the process of choice
begins with planning. Events do not happen by accident.
She gives an example of this in describing her chil-
dren's life success. She and her husband carefully
planned their approach to childrearing and this is the
reason, for her, that they are now successful. "The
kids have all done well and that's because they were
taught. . . As I say it was no accident”.

Further, this choosing is made in concert with her
environment and is an active process rather than a pas-
sive one. She feels free to seek advise, counsel and
comfort from others but the final responsibility for
decisions rests with her. "I have people that I could
talk about the problem with and then I've made up my own

mind. . . and if it's right or wrong, I live with it."

103

The subject is also rethinking her sense of her-
self. She remains very clear in her belief that she has
her own individual identity. "I still love my home and
I am a wife and mother". The subject is able to keep
her sense of self intact because of changing perspec-
tives. She recognizes that she is assuming roles that
her husband once had. "Well it looks like the role has
reversed for a while. . .". Further, she is willing to
forego discussing problems with her children because she
highly values the long established pattern of them com-
ing to her for advice. This pattern has been further
solidified in that she has now assumed the role of
"matriarch." In discussing her daughter she says, "I e_
her strength and sort of guide and direct her".

The future is not entirely clear to the subject.
What is clear is that she is not troubled because, again
she feels she has planned well. She sees herself
remaining in control of her life. She will continue to

assess and reassess as time goes on, ultimately making

decisions that she feels are right for her.

ss t s s

t mew . The findings of this study
will now be examined in light of the conceptual frame-
work on which it was based, Rogers' Theory of Unitary

Human Beings (1980). In Chapter II, Rogers' view of

104

nursing was described and discussed. In this section,
the study's findings will be examined and compared with
the objectives derived from the theoretical concepts.
From Rogers' (1983) perspective, human beings are
wholistic, manifesting characteristics that are more and
different than the sum of their parts. Human beings are
constantly exchanging energy with the environment in a
unidirectional life process. Changes in the life pro-
cess of human beings are predicted to be inseparable
from environmental changes. Human beings are sentient
and seek to organize the world of their experience and
make sense of it. In patterning (and repatterning) the
human field, human beings make choices that are innova-
tive and based on the "infinite now". Health is active
interaction with the environment to pattern a reality

that creates a sense of well being with a future view.

OhjeetTve Qne

To describe the pattern response related to signif-
icance, interpretation and meaning of the lived experi-
ence of bereavement. This objective was developed from
the concept that human beings are sentient and seek to
organize their world and make sense of it.

Clearly, the subject is thinking and rethinking her
unique experience of bereavement in order to interpret

its special meaning and significance for her. In doing

105

so she brings to the process, patterns that are deeply
embedded in her sense of self and way of being. She
sees herself as a planner and an active shaper of her
world. She firmly believes if one plans carefully and
takes responsibility, accidents don't happen. This pat-
tern has worked, over a lifetime, and the subject must
now reconcile that belief to include the death of her
husband, an event that came unplanned and seemingly by
accident.

It is interesting to follow, through her own words,
how she is doing this. She remarks often that it is in
looking back that the meaning of the event becomes
clearer to her. "I think you might have been able to
pick up on things that maybe you don't pick up on. . .
at the time you're going through them". It is postu-
lated that her lifetime pattern response of planning to
maintain choice was seriously threatened. This is fur-
ther borne out when she reflects back to the time of her
husband's illness. "But I think probably its a good
thing we don't know what's ahead of us. Don't you?
Because if we had known, I don't know if we would of
(sic) done anything any differently anyway. Because we
just sort of took one day at a time and did what was
needed to be done." There was no possible way to plan
for this event and at each progressive stage of the ill-

ness she was "shocked" and "dumbfounded". This

106

seemingly contradictory pattern of taking one day at a
time, may have been the only way for this woman to
organize and make sense of her world.

The resulting and ongoing pattern response related
to objective one includes a subtle but telling change
from her previous patterning. While seeking to organize
her world and make sense of it to interpret the special
meaning and significance for herself, the subject has
held on to her belief that planning in order to have
choices remains valid, the difference being that plan-

ning will now be on a more short term basis.

Ob ec ' e c

To describe the pattern response related to valida-
tion, overcoming obstacles, and interaction with others
in the lived experience of bereavement. This objective
was developed from the concept that human beings are
constantly exchanging energy with the environment and
that in patterning and repatterning the human field they
make choices that are innovative.

Choice is the very foundation of the subject's
lifetime of patterning. ”I think that you have choices
that you have to make. . . I mean you know you have
choices you can make". The subject also has a lifetime
pattern of interacting with her environment in order to

gather the information to make these choices. "I have

107

had people that I could talk about the problem with and
then I've made up my own mind".

In order to validate herself the subject has repat-
terned some self-imposed restrictions in interaction
with others. In handling her feelings of loneliness and
need to talk about these feelings with others she con-
tinues to believe she has, "a real good support system."
The difference is that, "I try not to put them through a
great deal. Because nobody likes to see you sit and
feel sorry for yourself.” Obviously this is a
conflicting issue with the subject because later she
says, "And people listen out of politeness or whatever."
"I really don't care what it is, they don't like it they
can move on." With regard to other interactions, the
subject remains very comfortable with continuing her
previous pattern of gathering information and solving
problems by actively accepting responsibility for her
decisions.

While the subject actively interacts with persons
in her environment to validate herself and overcome
obstacles, the resulting and ongoing pattern response
related to objective two has been a repatterning to
include a degree of self-censorship with regard to vali-
dation of the subject's very personal feelings of lone-
liness. She seems willing, at this time, to limit her

interactions with others on the subject of loneliness in

108

order to hold on to her support group and face new

obstacles.

Whites

To describe the pattern response related to changed
perspectives and future view in the lived experience of
bereavement. This objective was developed from the con-
cept that human beings come to experience the process of
health by patterning a reality that provides a sense of
well being and holds a future view.

The subject, in facing her own life, has changed
her perspectives to include enlarged roles. She veri-
fies this in her statement, "Well it looks like the role
has reversed for a while." She continues to see herself
as a wife, rather than a single woman, but is taking on
some of the roles formerly held by her husband. The
role she seems most comfortable adopting is that of
matriarch in which she guides and directs her family and
provides the touchstone that helps to bind them
together. ”I feel a need.” "I think that's the impor-
tant thing." "Are you needed?" The future is not
clear. "I hadn't thought a great deal about the
future." "I will work until I don't want to work."

The subject's pattern response related to objective
three includes a somewhat changed perspective and a lim-

ited future view. This repatterning provides her with a

109

future view that, while not completely clear to her,
remains optimistic, in her control, and provides a sense
of well being, while she clearly maintains a sense of
control.

In summary, the subject's pattern response is gen-
erally consistent with Rogers' Theory of Unitary Human
Beings. It is the subtle repatterning, unique to this
woman, that is interesting to note and truly describes

her individual, ongoing pattern response.

'c Ma i ' t ' c e ' c o
hhe Eindings in this Study. In this study, the overrid-
ing pattern response found for this particular woman
involved the element of choice. It should be noted as
discussed earlier in the limitations of the study that
because participation in the study was voluntary, inclu-
sion required a preliminary choice on the part of the
subject.

The findings of this study were incorporated into a
logical mapping (see Figure 4) that includes the con-
structs derived from Martha Rogers' Theory of Unitary
Human Beings. This mapping also includes the concepts
derived from these constructs and that were specifically
examined in the study. The common element, choice,

found in examining each objective is represented.

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111

Finally, the focal elements that were found to enable or
illuminate the ongoing choosing are also indicated.
Specifically, the logical mapping indicates that in
the process of bereavement, the subject relied on the
ongoing ability to make choices in order to pattern her
new way of being. Further, the focal elements identi-
fied were found to be inextricably involved in this
choosing. However, what is not clear from these find-
ings is whether these elements enable the making of
choice or result from the making of choice. These

elements should guide further research.

5 u 510 t a o f el e t
hhe Relevant Lihezetune pf Beneavenenn. In the litera-

ture concerning bereavement, there are several perspec-
tives from which this phenomenon has been viewed. The
findings of this research support the view that bereave-
ment is indeed a process lived in an individual way by,
the widow and not characterized by discrete stages or
proscribed behaviors. Kavanaugh (1972), Kubler-Ross
(1968), Bugen (1977), Norris and Murrell (1988), Rigdon,
4 Clayton and Dimond (1987), and Murphy (1988) concur in
this finding. All have agreed that bereavement is a
normal process of indeterminate length without discrete
stages that is influenced by many events and personal,

social factors unique to the person experiencing the

112

transition. Further, the psychological work of bereave-
ment is a self-definition of and a coming to terms with
the meaning of the event.

The environment of bereavement which contributes to
the repatterning process has been addressed in the lit-
erature. This environment includes: role change expec-
tations, financial status, social support (including
loneliness), and forewarning of (circumstances surround-
ing) the spouse's death. In addition, there is a
reported increase in physical and mental symptomology
experienced bysome widows following the death of a
spouse.

With regard to role change expectations, this study
supported the fact that there is a feeling of a shifting
of roles that includes keeping past roles and enlarging
others to repattern a new life. Brock and O'Sullivan
(1985) and Weizman and Kamm (1985) found in their
research that some women may have relied entirely on
their role of wife to give their life direction and
meaning, and when this role was removed they experienced
a profound loss of self. This finding was not true for
this subject. While continuing to identify herself as
primarily a wife and mother, she remains able to see
herself as a separate person with a separate identity

from that of her husband. This appears to be the case

113

for this subject. She is a life long planner who states
that she has the support she needs at this time.

In looking at perceived social support/social iso-
lation, this study uncovered some contradictory find-
ings. Kahn (1979) and Peplau et al. (1982) have
reported that when widows are unable to receive the sup-
port they feel they need they will come to experience
loneliness. While the subject was very positive in her
assertions that she felt she was receiving adequate sup-
jport in this process, at the same time, she described
‘the most difficult area of her life as loneliness.

A more complete understanding of these seemingly
contradictory statements may be found in light of the
results of a study conducted by Warner in 1987. Warner
(1987) found that the size of the available support sys-
tem, a sense of history with the bereaved and frequent
contact were the triad of variables that predicted the
widow's comfort with interaction with others. The sub-
ject reports a somewhat self-limited support group. She
chooses to limit discussion of her husband based on her
sense of what and to how much people are willing to lis-
ten. In addition, she does not go to her children for
some advice in order to hold on to the role of advisor
for herself. In making these choices about interaction,
she has put some individuals in her self described per—

sonal support system, perhaps those who have the

114

greatest sense of history with the deceased, out of her
reach.

Financially, the subject reports no difficulty now
or in the foreseeable future. O'Bryant and Morgan
(1989) found that adjustment to widowhood may be
adversely affected by lack of financial experience or
knowledge. These findings concur with the subject's
perception of her financial status. She handled the
family monies before her husband's death, has planned
well with regard to daily living and the future, and
feels financially secure. '

In looking at forewarning of the spouse's death,
the subject reports feeling generally contented with the
circumstances surrounding the death of her husband.
Carey (1979-1980) found that widows who had at least two
weeks forewarning of their spouse's death reported a
significantly higher level of positive adjustment.

Gass (1988) found that forewarning of death
afforded the widows more opportunity for anticipatory
grieving. The subject's forewarning included a diagno-
sis of six month's duration. The couple were life long
planners who faced the world they lived in. They
remained in control of the day to day living of their
lives during the unwanted and unexpected illness of the
subject's husband. The subject feels her husband willed

the way he lived and died and maintained his dignity.

115

Though she does not speak directly to anticipatory
grieving, the subject reports that she was able to rec-
ognize that the end was near and was able to gather her
children together to spend time with their father before
he died.

Berardo (1968), Gass (1987) and Poncar (1989)
report physical symptoms surrounding bereavement includ-
ing: gastrointestinal disturbances, sleep pattern
changes and loss of appetite. Ferraro (1985), Clayton,
Demaris and Winokur (1968) studied psychological symp-
toms associated with the phenomenon, including depressed
mood and crying.

The subject feels that she is in basically good
health and anticipates this continuing in the future.
She experienced some early morning sleeplessness and
appetite loss for about a month following her husband's
death but denies that this remains a problem. She has
been able to cry throughout her bereavement and feels
that this gives her relief. She is occasionally both-
ered that she becomes tearful without warning, but this
happens less frequently than earlier in the process.

The subject's profession is as an ancillary health
care clinician and as such, good health has always been
a value. She feels she has a more than ordinary knowl-
edge of how to remain healthy and access the health care

system.

116

Nurses played an important part in the days sur-
rounding the death of the subject's spouse. Friehofer
and Felton (1976) report that the most desired nursing
behaviors on the part of significant others were behav-
iors that supported the comfort of the dying person and
having all questions answered honestly. This was true
for the subject. She reported that during the short
time her husband was hospitalized before his death, he
received excellent care both physically and emotionally
from nurses.

In summary, the findings of this study support
findings in the literature that bereavement is an indi-
vidual and unique process determined solely by the indi-
vidual. The unique contribution provided by this
research is that the process was found to be inextrica-
bly tied to the concept of choice. The major questions
raised by the study are which elements are involved on
this choosing. These questions should be examined in

future research.

N s O
In this last section of Chapter VI, the nursing
implications and recommendations for research, practice
and education will be discussed as they relate to this

study, advanced nursing practice, and primary care.

117

ese . This study was conducted using the
descriptive, case study method. The individual pattern
response of bereavement was elicited from one woman as
she faced life as a widow, and the results are only gen-
eralizable to that woman. It is recommended that fur-
ther descriptive qualitative surveys be undertaken to
examine the patterns of bereavement in other women. In
addition, it is suggested that qualitative data be col-
lected from multiple sources including those people
identified as part of the environment of the subject to
provide a larger data base and a clearer picture of the
process. Longitudinal studies should be carried out to
further examine the qualitative process of bereavement,
over time. In addition, phenomenological studies which
look to retrospective descriptions in order to arrive at
a clearer and more indepth description of the phenomenon
should be undertaken.

One of the desired outcomes of qualitative research
includes further enhancement of underlying theory. The
findings of this examination were used to enhance and
support the Theory of Unitary Human Beings (Rogers,
1980) that formed the conceptual framework of the study.
Parse et al. (1985) notes the unique value of qualita-
tive research lies in enhancing those nursing theories,
including the Theory of Unitary Human Beings, emerging

from the simultaneity paradigm. The results were

118

consistent with that framework and bereavement was
better understood from the principle of patterning.
Additional research should be undertaken utilizing other
principles from Roger's theory to further illuminate the
lived experience of bereavement as well as enhance
theory.

The widow brings to the bereavement process unique
resources including personal, social and emotional ties
that form her very unique environment. With this in
mind, the process should be studied from a qualitative
ethnographic approach to allow researchers to understand
the bereavement process within various cultural con-
texts.

Quantitative research studies were examined in this
study to identify the specific environmental factors
that were found to be included in the process of
bereavement. These studies are important to the under-
standing of the universality of the experience related
to these identified factors and to any new factors yet
undiscovered. This research should be continued with
various populations.

Specific to this study, the pattern response for
this woman was found to include several elements, the
predominant one being choice. When studying the process
of bereavement, prospective researchers are encouraged

to examine carefully literature surrounding the concept

119

of choice. Choice should be examined quantitatively in
a similar population using a reliable and valid instru-
ment. Following this, choice should then be compared to
another element identified in the study, such as Opti-
mism, to note the presence or absence of relationship.
Intervention studies should be developed utilizing these
findings.

The results of this study support Rogers' (1980)
Theory of Unitary Human beings. Thus this theory guides
the implications for further research, practice and edu-
cation. In the next section, Nursing practice recommen-

dations will be discussed.

Epegpiee. The findings of this study support the
proposition that bereavement is a process that is thrust
upon the widow and must be lived in a unique way chosen
and known only to the survivor. In the experience of
the subject of this study, bereavement was characterized
by a disruption of long established patterns which left
the subject with a sense of uncertainty but at the same
time with the knowledge that choices were possible and
deliberate and the responsibility, alone, of the sub-
ject. As discussed earlier, the focus of the case study
method is, in addition to uncovering the experience of a
lived phenomenon for the individual being studied, also

enhancement of underlying theory that directed the

120

objectives of the study. Implications for the Clinical
Nurse Specialist (CNS) in Primary Care indicate that
intervention should be process oriented.

Bereavement was found to be a process in which
action (choices) are patterned and repatterned in the
"infinite now" of the person living the experience. As
such, the CNS should see support of that process as the
primary intervention. Ideally, the CNS would recognize
that support of the process should begin with a clear
understanding of the essence and uniqueness of the per-
son living the bereavement process. This would include
how the person sees herself, interacts with her world,
depends on others and sees her future.

In addition, a sense of the person's past interac-
tion with her environment to pattern and repattern her
ongoing well being would have to be understood from the
widow's perspective. This would include, how past deci-
sions have been made, how new situations have been
faced, what roles she has seen herself filling and how
she has coped with change in the past. This completed
picture would guide intervention of the CNS toward an
individual, client-centered facilitation of the process
rather than a generalized intervention strategy aimed at
all people experiencing the phenomenon.

As the person moves through the process, continu-

ously patterning and repatterning according to her sense

121

of her changing world and her needs, the CNS would,
reflect, support and facilitate this patterning.
Clearly, client advocacy lies in the validation of the
widow's unique and chosen way of being at any given
point in the process.

In line with this, the CNS may help the widow with
skills that better enable her to meet her needs. Though
remembering that the bereaved person is always the
first, best authority of how to live the process, the
CNS can provide helpful ways for the widow to better
express her needs and, therefore, make her choices.
These could include values clarification, assertiveness
techniques and problem solving strategies.

The widow, alone, can experience the bereavement
surrounding the death of a spouse. The CNS, recognizing
this, should also bear in mind that the widow's family
will be processing their own loss in their own way and,
in most cases, attempting to "help" the grieving widow.
The CNS should assist the family in realizing that the
bereaved person is living the process in her chosen way
and that the best help at this time will be to support
the individuality of the process rather than trying to
"fix" it by either ignoring it, trying to minimize the
pain, or hurrying the process.

In the role of Clinician, the CNS should be mindful

of the well identified environmental factors that may

122

exist during the bereavement process. Among others are
included untoward physical and mental symptoms. When a
client presents with this symptomology, assessment
should always include the discussion of recent losses
and the client's perception of how that the process of

repatterning is being lived.

Reneehien. Nursing implications for education can
be derived from this study for nurses in both learning
and teaching roles. The practice of nursing at all lev-
els can be taught based on research. Research based
interventions once learned, can, in turn, be taught and
modeled to others.

In this study, as in all case studies, the results
are only generalizable to the subject. The results are
reflected back to the theory underpinning the concepts
that guided the study. In this research, the underlying
theory is one of nursing, in this case, Rogers' Theory
of Unitary Human Beings. This theory speaks to the pro-
cess of living as it is uniquely experienced by the
individual. In order to encourage nurses to value pro-
cess as well as outcome, process based frameworks such
as the one utilized in this study should be included in
nursing curricula, most especially in advanced practice.

It is suggested that nursing education at all lev-

els be theoretically based. Theory based education is

123

not only necessary to maintain a universal frame of ref-
erence for defining the uniqueness of the discipline of
nursing but absolutely vital in order to guide practice.
With this in mind, nurses in advanced practice, should
be required to have theory content as a basic, underly-
ing component of their curriculum. Baccalaureate nurses
should be educated with the inclusion of a basic under-
standing of the theories that will guide their future
practice. Associate degree nurses should be introduced
to the idea of theory and its relationship to practice.
Nurse educators at all levels should be well grounded in
theory and its relationship to all practice levels.
Traditionally, bereavement has been taught as a
process. The problem lies in the fact that the focus of
the study of bereavement has been more exclusively
placed on the process rather than the person experienc-
ing the process. Bereavement has been viewed as a
series of discrete and separate phases that all bereaved
persons would go through in much the same manner. Each
phase was seen as having a beginning and an end with
proscribed behaviors and universally ascribed time
lengths. It was thought that to deviate from the behav-
iors or exceed the time frame was pathological. This
study's findings indicate that bereavement is indeed a
process. The difference was found to be that the pro-

cess was solely determined by the person living it.

124

This widow's perception of her ability and willingness
to make the choices involved in repatterning her life
was found to be the significant factors to assess.

Advanced practice nurses should see the role of
Educator as extending to the general public. Because
bereavement is a very universal experience, the need for
informed understanding of the process is certainly obvi-
ous. Nurse developed self-help groups for the bereaved
would be appropriate to assist this population to better
understand the process they are living. Educational
programs directed toward those persons who make up the
widow's support system could be developed to provide the
opportunity to learn about more positive ways of inter—
acting with the widow as she experiences her bereave-
ment.

Physicians in collaborative practice with Advanced
Practice Nurses should be made aware of the implications
of the process of bereavement. The nurse member of the
practice should make a home visit 3 to 6 weeks after the
death of a spouse to assess the widow's perception of
her ongoing process and intervene as directed by the
widow.

Finally, the goal of nursing research, education,
and practice is to better understand the mission of

nursing. That mission is the ongoing facilitation of

125

the person's living (patterning and repatterning) that

includes a self identified sense of well being.

EQEEQIX

In Chapter VI an overview of the study was pre-
sented. In addition, the findings were discussed and
analyzed with regard to the subject's transcriptions,
Roger's Theory of Unitary Human Beings and the signifi-
cant literature related to bereavement. Finally, the
significance of this study with regard to nursing

research, practice and education was discussed.

126

Appendices

127

Appendix A

128

MICHIGAN STATE UNIVERSITY

 

W COMMITTEE ON Imam INVOLVING EASTWSING 0 MICHIGAN 0 488244“!

mumwmmmcants)
summit

[$17) 555-9738

May 5. 1989 mm: 89-209

M Somers
113?Marigold Ave.
East Lansing, MI 48823

Dear Ms. Somers:

Re: 'BEREAVEMENT: THE INDIVIDUAL PATTERN RESPONSE IN A
RECENTLY WIDOWED WOMAN IRB# 89-209"

The above project is exempt from full UCRIHS review. I have reviewed the proposed
research (protocol and find that the rights and welfare of human subjects appear to be
'protecte . You have approval to conduct the research.

You are reminded that UCRII-IS approval is valid for one calendar ear. Ifyou plan to
continue this project beyond one year, lease make provisions for o raining appropriate
UCRIHS approval one month pnor to ay 5, 1990. .

Any changes in procedures involvin human subjects must be reviewed by the UCRIHS
prior to initiation of the chan e. U RIHS must also be notified promptly of any

problems (unexpected side e ccts, complaints, etc.) involving human subjects during the
course of the work.

Thank you for bringing this pro'ect to our attention. If we can be of any future help.
please do ‘not hesitate to let us ow.

 

”Si! is all Ill/Moe Action/Equal Opportunity Institution

129

Appendix B

130

Consent Form

The study in which I am asking you to participate is
designed to learn more about the experience of bereave-
ment. You will be interviewed in your home one time.
During the interview, you will be asked to respond to a
series of questions and verbalize your responses into a
tape recorder. The session will take approximately two
hours. If you agree to participate, please sign the
following statement.

1. I have freely consented to take part in a study of
the experience of bereavement conducted by a gradu-
ate student of the College of Nursing at Michigan
State University.

2. The study has been described and explained to me and
I understand what my participation will involve.

3. I understand that participating in this study is
voluntary and I can withdraw from participating at
any time or not answer certain questions without
recrimination.

4. I understand that no immediate benefits will result
from taking part in this study, but am aware that my
responses may add to the understanding of health
care professionals of the experience of bereavement.

5. I understand that all descriptions will be treated
with strict confidence and that I will remain anony-
mous.

6. I will be able to review my remarks before they are
used in this study.

131
I, , state that I
(print name)
understand what is required of me as a participant and
agree to take part in this study.

Signed

Date

 

132

Appendix C

133

ormat te w ues s

I would like to begin this interview by getting a

clearer picture of you with some more open kinds of

questions. You know yourself better than anyone and can

help me to understand who you are. I'm going to ask you

a series of questions, some of which may be difficult,

and I would like you to tell me all your thoughts and

feelings until you have no more to say.

W:

How would you describe yourself?

We all have various roles. For example I am a
woman and a student. What do you feel your roles
have been?

What have your interests been?

When you faced a new situation, what have been
the ways you've coped in the past?

What is it like for you when you have had to make
decisions?

Could you please describe your relationship with
your husband?

Please describe the circumstances surrounding

your husband's death.

134

- What were your thoughts? What did you do?

- Who did you call on for support?

Section Tyo
theehiye_gne. Significance, Interpretation, Mean-

ing

Now I'm going to ask you some questions about your

life now. Again, tell me all your thoughts and feelings

until you have no more to say.

How would you describe your current thoughts and
feelings about the meaning of finances? How does
this affect your life?

How would you describe your current thoughts and
feelings about the meaning of family and friends?
How does this affect your life?

How would you describe your current thoughts and
feelings about the meaning of the way you see
yourself? How does this affect your Life?

How would you describe your current thoughts and
feelings about the importance of your health?
How does this affect your life?

How would you describe your current thoughts and
feelings about the importance of the circum-
stances surrounding your husband's death? How

does this affect your life?

135

Objegtive Two. Validation, Overcoming Obstacles,

Interaction With Others.

In your life now, how would you describe people's
response to you when you want or need to talk
about finances? If you have financial worries,
how do you handle them?

In you life now, how would you describe people's
response to you when you want or need to talk
about the way you see yourself? If you are trou-
bled about the way you see yourself, how do you
handle it?

In your life now, how would you describe people's
response to you when you want or need to talk
about health? If you have concerns about your
health, how do you handle them?

In your life now, how would you describe people's
response to you when you want or need to talk
about the circumstances surrounding your hus-
band's death? If you are troubled about your
husband's death, how do you handle it?

In your life now, how would you describe people's
response to you when you want or need to talk
about any feelings of loneliness? If you are

lonely, how do you handle it?

136

Objeetive Thpee. Changed Perspective, Future View

The next set of questions will focus on how you see

your life in the future.

Since your husband's death, how have your
thoughts or feeling about finances changed, if
any? What do you see in your future related to
finances?

Since your husband's death, how have your
thoughts or feeling about the way you see your-
self changed, if any? How do you see yourself in
the future?

Since your husband's death, how have your
thoughts or feeling about the circumstances sur-
rounding your husband's death changed, if any?
Since your husband's death, how have your
thoughts or feeling about your own health
changed, if any? How do you see your health in
the future?

Since your husband's death, how have your
thoughts or feeling about the need to have the
support of friends or family changed, if any? Do
you feel you will continue to have these same

feelings in the future?

To bring the interview to termination, the follow-

ing questions will be asked.

137

- What has been most difficult for you in this sit-
uation?

- Sometimes crises and very difficult times provide
an opportunity for people to grow. Do you think
this is true for you? And if so, in what ways do

you feel you've grown?

138

Appendix D

139

scr'

SUB: I get tired.

INT: Sure. You were just saying that you're 60 years
old and you were married how many years?

SUB: 38.

INT: And (husband) has been dead how many months?

SUB: Actually 6. He died on the 13th of October. So
that would have been November, December, January,
February, March, April, May.

INT: I would like to start by getting a little clearer
picture of you with some more open kinds of questions,
ok? You know yourself better than anyone and you can
help me understand who you are. So I'm going to ask
you some questions, some of which may be difficult,
because it brings up memories. But I'd like for you
to tell me all your thoughts and feelings about what I
ask until you feel you don't want to say anything else
about it. First of all, how would you describe
yourself?

SUB: Oh, probably extroverted. And I would have to say
relatively intelligent, caring...I don't know.

INT: That sums it up, huh?
SUB: That's right, probably.

INT: Good, ok. We all have various roles. For exam-

ple, I'm a woman and a student. What do you feel your
roles have been?

SUB: Over a lifetime?

INT: Uhuh.

SUB: Well, before I'm anything else I have always been,
well, in my married life, a wife and a mother. And I
am a career person although my responsibilities would
lead you to believe - that I was a career person but
I'm not. Actually, I still love my home and I am a
wife and a mother. And uh...probably that's one of

140

the reasons that I have a very good rapport with the
women that work with me because I can understand where
they're coming from in a work setting and, they
haven't caught up with me yet, but I give a lot of
liberties that other people don't. I mean, you
know...nursing, I think really doesn't bend at all and
my people, sometimes they take advantage I
think...0verall that, not being career oriented makes
me a little bit more personal...to people. I'm a
friend, (husband) and I were good friends. That was,
uh...neat.

INT: What have your interests been?

SUB: Mostly traveling and we liked to travel and yard
work, gardening, whatever. And it's still that way.

INT: When you faced a new situation, what have been the
ways that you've coped with it?

SUB: By a new situation, what do you mean, by his
death, particularly? Uhh - I think, Maribeth, that you
have choices that you have to make. What am I going
to do? And we have always been the kinds of people
that faced the world we lived in. Ok? And uh so, I
realized that I have choices that I have had to make.
One of them was, an I going to work? Well I mean, I'm
in a nice situation, I guess, in that actually I could
quit work and I would not starve to death and I could
stay here. But the choice there, is what in the name
of goodness am I going to do with myself? Because I
probably have more energy then most of the people you
know. At least most of the people I know. And I
doubt that the people that we know are too far differ-
ent. But uhm, I need to do something. And I can't do
yard work all the time. I mean, pretty soon it's
going to look pretty good and it didn't take me too
awfully long to do it. But then I have a boy that
helps me too. So I have decided that I am going to
work. Now, am I going to work until I'm 62? Am I
going to work until I'm 65? I'm not making any deci-
sions about that at this point in time. I will work
until I don't want to work. And uh, it was - like I'm
going to England in September and (friend) didn't want
me to go for 3 weeks. Well (friend) really didn't
have any choice in the matter because I intended to go
for 3 weeks. And he went to the president of the hos-
pital and he said, "Let her go for 3 weeks". It's a
good thing they decided that, because I mean you know,
those are the kinds of opportunities you take advan-
tage of and (son) lives in England and we're going to

141

Germany during Oktoberfest and Austria and then we'll
tour Germany for 2 weeks and then we'll go back and
I'll see the places. In fact, they're in Amsterdam
this weekend. They're at the tulip festival. So
those are the kinds of things that (husband) and I
would have done together, and I feel that those are
the kinds of things that I want to do. So, we'll see.

INT: Ok. What's it been like for you when you've had
to make decisions?

SUB: It isn't really difficult. What I have a habit of
doing is talking about the problem with different peo-
ple and then making up my own mind. (Husband) and I
always made decisions together and it was no problem
for me to make decisions. I might have, I mean you
know, a few investments or something like that I might
of felt that I needed advice. But if I did, then I
would call the tax man. Or I have, (husband) and I
have another good friend who is in insurance and tax
shelters at the hospital. So on those kinds of deci-
sions, I have had people that I could talk about the
problem with and then I've made up my own mind. I
don't discuss most those things for advice with my
children because...Oh yesterday, I got a phone call
from my son in Indiana. He was having a question. He
is a very bright young man and has developed a tech-
nique of pickle fermentation without salt and he said
"Ok mom, what do I do?" I'm used to people coming to
me for decision making. I'm not used to...And if its
right or if its wrong, I live with it. I don't know
whether its good or not but that's the way it is.

INT: Can you tell me just a little bit about your rela-
tionship with your husband? You talked about the fact
that you were good friends.

SUB: We were. We always have been and we met in col-
lege and our lives we planned: our children, we worked
with. The way our children are was no accident, we
worked together. And uh, we enjoyed each others com-
pany and uh, like I was complaining about those kids
in Dewitt, I mean you know, there's no way that those
kinds of things...And our children's education, our
children - that is why (daughter) is still in school
because her father was very determined that she was
going to be prepared. And she went as far as of
course her LPN. But uh, oh I think that probably
within (daughter) was the desire to compete with her

142

brothers...So we were good friends and we enjoyed vis-
iting. We've had, had several people who have com-
mented, we were very close. Uhhuh.

INT: Tell me a little bit about the circumstances sur-
rounding your husbands death.

SUB: Well I think, Maribeth, that as you go along,
things that happened...you begin to put into perspec-
tive and I think you might have been able to pick up
on things that maybe you don't pick up on uh...at the
time you're going through them. Let's see, it must
have been about 6 years ago. We have had this land
for oh, probably, we've owned it for 10 - 12 years. I
don't know. But he had, common to men, a prostate
infection. And uh...well we didn't, I mean you know,
I've been around hospitals for years but I don't pay
attention to men's prostate problems- And he got
quite ill. It was a flu type thing and uh, he
couldn't urinate and he was sick to his stomach well,
you know what happened. The BUN level was so high
that it was causing him to vomit. So we ended up in
the hospital and uh, because he just wasn't getting
any better. I brought him into ER and they admitted
him. And the following morning he got up - well we
have always planned, I mean, the accidents just didn't
happen. We were poor as church mice when we were
first married because I didn't work. And then when
the kids were born I didn't work until (daughter) was,
what was she? She was a senior in high school when I
went back to work. So we decided to be poor but at
least have the kids taken care of and I have never
regretted that. In fact, I encourage people to do
with a little less because (daughter) didn't have a
store bought coat until she was a senior in high
school. And she bought it herself on babysitting
money because that was the way we were raised. You
are responsible. And the kids have reflected that.
(Son) probably is sitting on a salary of $45,000 a
year and he is only 29 years old. And, I mean you
know, the kids have all done well and that's because
they were taught. As I say, it was no accident. So
anyway, I remember going upstairs because I worked at
the hospital here for 20, oh, 17 years and when he was
unaware I think of how ill he was. We've never been
aware of how ill he was because he was a very strong
willed man: the one that can get blue heron and such
to come and visit him. But anyway, he said, his com-
ment was, "I only hope I live long enough", because we
hadn't built out here yet, "to be able to do some of
the things that I want to do". So I made up my mind

143

well all we were waiting for was a little more money.
And what's a little more money among friends? So we
began to find a builder. And so then he had a TUR,
there was no malignancy there but I think a lot of
times that the cells that are in those areas are just
probably not what they ought to be anyway. So he did
have a little bit of blood show up a couple of years
later in the urine, and our Director of Nursing at the
time was a good friend of mine and when she retired,
her husband had prostate problems and one of the doc-
tors had said that, "There is always a reason why
blood appears somewhere". And in a man you hit the
road. So we took him into Dr. ___ and he had the IVP
and they gave you know a thorough check and he was
going in for a scope and I'll be doggone, it was St.
Patrick's Day what, 3 or 4 years ago that they did the
scope that he found cancer, a tumor, but it was super-
ficial he thought he got it all but he did the chemo.
And of course, that process is every 3 months you go
in for a scope until the, I mean you know, the sucker
is no longer. Well he had, actually, another tumor in
that next 3 months and then they became cells in tran-
sition but he had chemo. And we, I mean you know, he,
we, were shocked but felt we had it on the run. And
then a year ago February he had gone back to work.
He'd had a lot of stress and just really wasn't
responding quite the way that he should have. In fact
we had, he had a stomach scope because he had ulcers
so badly that we were thinking, doctor was talking
about a stomach resection. Well, I just started giv-
ing him oatmeal and Tagamet and he got along real
well. And we got through that one. But later he had
some sick leave and uh really wanted to retire very
very badly: was not happy at work, wanted to be here
and was very glad that he was coming to that age. So
we did decide that it was better that he go back to
work because he was going to retire in March of this
past year of 88. And uh, so he went back to work. It
must of been the 1st of December and he hadn't worked
a tremendous amount of that year because he just was
having a lot of - wasn't really sick but he wasn't
really good and psychologically it wasn't good for him
to go back to work. And with the connections I had at
the hospital, the doctors kept putting him off on sick
leave and until he could retire. So anyway, he went
back to work in December and in February he was - what
he was doing was he was going through chemicals that
were old and throwing them out. They had given him
help to do this and there was a lot of dust and he had
had allergies and actually he'd had a couple of colds
that just didn't seem, I mean you know. He'd been in

144

for sinus and so anyway. It was about the 9th or 10th
of February and he was fighting this cold. He'd been
to the doctor a couple of times and it just wouldn't
cure. And so we decided that it was almost, I mean
you know, figured that it was pneumonia so (doctor)
put him in the hospital and we drew fluids and found
that it was just full of cancer cells. So, needless
to say, we were all shocked. The doctors were
shocked, everybody, the whole, everyone that knew him.
We were just dumfounded. So anyway, uhm, let's
see...the MSU group, (doctor) and actually, what's the
one? Oh shoot, I can't think of his name...

INT: Dr...

SUB: No. Well anyway, (doctor) ended up, (doctor) and
(doctor). But the one that took care of him, he is
the one that is called back to (hospital).

INT: Shoot, I know who you mean...

SUB: Tall, uglier then hell, but good. Uh huh.
Really, I mean you know, he was just, he was just
really something else again, what's his name?

INT: I can't remember. I know the (hospital) group
better.

SUB: Yeah well, I've been very...We also went the
(hospital) route because they did radiation on the
lungs. Now, (doctor) is the one that uh (husband)
went to and he was another...I think he's very good.
But, uh, well anyway, through tests that they found at
the hospital, when he had had, an accident several
years, well actually, it was about 30 years ago. And
uh, he had had some problems - well they found, I mean
you know that it was not a crack or anything but,
probably, when, well, what they called a hot spot,
probably arthritis over the period of years and we
just thought it was arthritis. Well it wasn't. There
was a lesion there and so it had already, in fact,
that was where the most serious cancer was at that
time...was in the neck because it had gone in, it had
totally encompassed two vertebrae, So, but I mean you
know, you're going through this, Maribeth, you don't
uh realize what's happening to you until you reflect
back -- (doctor), (doctor). Ok. He came into the
room and he laid it on the line and (husband) didn't
want to hear it because he said that he didn't really
think that it was necessary to put him through chemo

145

because he wasn't going to live beyond 6 months any-
way. And actually the man was right because from
February when we found out - about - that would be
March, April, May, June, July, August, September.

Hey, we did good work: he lived 8 months. And he said
that it would be a matter of months but he was in such
good physical condition. And (husband) opted to go
the chemo route, so and, and I would have, I mean you
know, hey - where there is life, there is hope. But
he said that there were 3 ways that we could go. I
mean we could go with the chemo or we could go with
just maintenance or what was the other one? I don't
know. But anyway, we went for the chemo and, of
course, we had to go for radiation before we could
start on the chemo because, of, I mean you know, say
on a scale of 1 to 10, already up to 8 coverage: he
was probably going to be paralyzed within weeks,
months, whatever. He couldn't even walk straight.
(Doctor) said I mean it had already affected his gait
and so on. And so, and we didn't realize that. I
mean you know...But as I look back, now, I mean there
were so many things that he procrastinated about. And
he just really didn't feel good enough and (doctor)
seemed to think that uhm, he had had the - well - okay
we came to where we were deciding what was the prime
source. Well, everybody I knew thought that the prime
source was the bladder because that was where we found
the tumors. But (doctor) insisted that is was not the
bladder, that was the source, that the lung was the
prime source. And he had two spots on the lung that
had metastasized to the spinal cord and, beyond a
doubt, had metastasized to the bladder. 80, I mean
you know, what are you going to do? Are you going to
x-ray everybody that has a bladder tumor? I mean you
know, that isn't par for the course. But if we had
caught it back then, we probably could have removed
the lung, done radiation - because we did, we did
with the chemo and with the radiation - we were able
to reduce the tumor in the spinal cord to nothing but
scar tissue...there for a while. But my own theory in
watching him, but he was a very strong, very very
strong-willed man, and he wanted no one in here to
take care of him but me. And he tolerated (daughter).
She thinks that she was the pillar of strength and it
doesn't do any harm to let her think she was but, he
didn't even want her coming in here. I got up at 4
o'clock in the morning and got his breakfast. He went
back to bed until he to got up and he was able to take
care of his lunch. But, I mean you know, it was a
situation where, her being here forced him to go with
her and I mean you know, but it wasn't what he would

146

have chosen. And then I would go to work and come
home and we'd hit the road and we'd go to the movies
when the weather was hot, because we didn't have, at
that time, central air...we do now. But anyway, we'd
go out for dinner and I took him all over hells-half-
acre. We had an ice cream cone. I'd go to the gro-
cery store 90 dollars worth of groceries and we'd
throw out 95, I mean you know, but at least his
appetite, and he lost very, very little weight.
(Doctor) said, that the only reason that he lived as
long as he did, was because we had taken such good
care of him. And I think it has a lot to do with the
diet. I have decided that when they don't eat is when
they die. And he ate up until the last 2 weeks
because I wouldn't hear of him not eating. He'd eat
whether he wanted to or not. But we fed him high fat
things, he didn't lose the weight so his body did not
go down hill the way it does. He didn't consume him-
self. He had plenty of calories to live on. And uh,
so that was the way we handled it. But I think that
he had really been very ill for a long time.

INT: But you felt like you really had, and he had con-

trol...

SUB: He had control. If you, did I ever tell you how

much control he had?

INT: NO.

SUB: Ok. He was here and he was holding up the wall.

Finally I got oxygen in here. I just, I mean you
know, you didn't do anything. I mean, we did it very
carefully but he had a hard time breathing and towards
the end he, in fact, the week before I admitted him to
the hospital, he never went to bed. He sat up and
slept at the table and at the desk. We put all those
jig saw puzzles together. We did that every night and
he worked on jig saw puzzles all day. So, anyway, the
morning that I took him into the hospital, I knew that
he was bad but I didn't have any idea he was sick
enough to die. I mean you know, I had made arrange-
ments at the hospital because we have extended care
beds and they were going to let me put him in there
because he wouldn't have anything to do with hospice.
He didn't want anybody in the home. I was doing just
fine. It was great. I mean you know, I was up all
night, up and down with him, and working all day and
that was no problem. So anyway,uh, he, at 4 o'clock
in the morning I got up in the morning and he said "I
can't go on this way", so, I said, "Ok, I'll call

147

(doctor) when he gets up". And we admitted him and he
died - 7 days he was there. But we were going to
transfer him. I had already made the arrangements to
the extended care. Because, as it was, we could no
longer, we couldn't keep him in the room because of
utilization review. And it was only because (name)
was Chief of Staff that we were able. Because when I
took him in there the week before he said,"I just
can't”. He said, "There was a man that was sicker
than (husband) is that week”. Well up until 3 weeks
before he died, I was taking him to San Francisco. We
were going out there. I mean you know, I knew that we
were going to have problems but (doctor) and (doctor)
both said that he was able to go. But he went down
hill that fast. But I really and truly do believe
that he had forced himself: that he had willed that he
was going. In fact, it was really funny. I sat in
the room. We never talked about his dying: we haven't
to this day. And we made no funeral arrangements, we
made no nothing. He, we, he was going to be alright.
And uh, anyway, where was I?

INT: You said something about going to San Francisco.

SUB: Oh, well about 3 weeks before he passed away,

there was no way I knew that I could handle him out
there. Because here, I had my own support network.
And being an employee of the hospital, and in the
position that I have been, I had a lot of support.
And I just couldn't...(TELEPHONE RANG)

INT: Ok. I'm going to ask you some questions about

your life now. So again just tell me what your
thoughts and feelings are about what I'm going to ask.
How would you describe your current thoughts and feel-
ings about the meaning of finances and how does this
effect your life?

SUB: I don't have any financial problems. I make

enough money to support myself. And investments, we
were well taken care of because we were going to, he
was retiring in March when he was ill. And uh, so we
were able to take care of ourselves and we had planned
for our retirement. So I don't have financial prob-
lems. That is good. (Son-in-law's) mother has a lot
of problems. I mean you know, that's why I say, care-
ful planning in life has been very good to me from the
stand point that, what would you do if you had only
social security? And she hasn't even worked!

148

INT: Ok. How would you describe your current thoughts
and feelings about the meaning of family and friends
and how does this effect your life?

SUB: My thoughts and feelings. I don't know what I
would do without them. So and, as I told you before,
they've been very good to me. Too good. (LAUGHS).

INT: How would you describe your current thoughts and
feelings about the way you see yourself?

SUB: I see myself in a very positive way. Actually, I
probably have been concerned subconsciously for quite
a while, and I feel basically, terribly lonely but
very positive about myself and my abilities.

INT: How would you describe you current thoughts and
feelings about the importance of your health and how
does this effect your life? '

SUB: Well, I'm very well aware of my health. I mean
you know, I think most health career oriented people
are. And I have to think that I am in relatively good
physical condition and able to work and enjoy life.
Probably have more energy then most of the people I
know.

INT: I saw you with the shovel...boy.

SUB: Hey. I mean you know, you have choices you can
make. And this is going to be my way of life and of
course I've always been pretty good with a shovel.
But I haven't been quite as good as I'm having to be
right now. Like in raking. In fact, it's strange
that we should talk about that because I told father
this afternoon that it use to be, he always teased me
about the rhetorical 'we'. 'We' were always going to
do something. But it always ended up being 'he' who
did it. And I told him today - I laughed. Anybody
driving by would probably think I was nuts. I said,
"well, it looks like the role has reversed for a
while, you're going to watch me doing instead of 'we'
doing, which was basically you doing". So, no, I
enjoy this. I've always, I'm not afraid of hard work.
I don't do much of it. In fact, I don't clean my
house. I don't do much of anything. But this, I
enjoy and will do.

INT: Ok. How would you describe your current thoughts
and feelings about the importance of the circumstances
surrounding your husbands death?

149

SUB: How do I feel what?

INT: Ah, we just talked about what led up to his death
and the fact that he sort of controlled that, how
important is that, that happened?

SUB: That he controlled it?

INT: Uhuh.

SUB: I think it is very important because he spared me.
And as I said, I think he realized how ill he was but
he never gave up.And in the hospital, it was really
kind of funny cause this was what I was going to tell
you before we went on. I'm sure that the tumor had
reappeared because his, in the spinal cord, I'm sure
of that because he was in and out of it. And he was
mentally a very strong man: very strong willed. And
(son and daughter-in-law) had come. I wanted all the
kids to have time with him and my daughter-in-law and
she dearly loved him. (VERY TEARFUL). Go on.

INT: That's ok.
SUB: It may not end.
INT: Those memories that come back, it's hard.

SUB: Well, anyway, she and (grandson) had come and
spent the week. Well, he had a fit. And that was the
week before I put him in the hospital. And he really
didn't need the commotion but I thought, I mean you
know, I figured out, that he wasn't going to go too
far. And that the kids really needed that time with
him. And I was able to get (son) here from England.
He had just gone to England. Anyway, uh, I got him
home so that he could spend the last year, the last
week that (husband) lived. He was with him all the
time. So anyway, they had gone back. (Son and
daughter-in-law) had gone back too. I'm looking for a
picture of my grandson, because you would love it.

But anyway, (son) had been here and they had gone back
to Indiana. And actually, (husband) was, he was talk-
ing to himself, (husband) was. And he was funnier
than all outdoors. And he said, ”I will maintain my
dignity as long as I am able". I wrote these things
down. And (daughter-in-law) was able to put together
the jig saw puzzle. And he said, "She is so damn,
(daughter-in-law) is so damn fast at that, that I
can't keep up with her". So that's why I think it was

150

one more time, had gone in to the spinal cord. It was
just funny. He was having all of these conversations
with himself and he didn't care for Heidi (THE DOG).
We had Sam and Sam was the dog. And actually Sam was
a year and a half old and he was just really a puppy
and he died two weeks after (husband). (Husband)
loved that dog, I swear to goodness that that dog and
he are somewhere up together roaming in the daisies,
watching the Blue Heron. That's the kind of a person
that...He would have willed for that to have happened.
But very strong willed, very much in control. As he
said the last week he died, before he died, "I will
maintain my dignity as long as I am able". And the
only thing that we spoke about at all about his dying
was that he was very glad that (VERY TEARFUL)...ok,
let go on.

INT: Take your time. We've got time.
SUB: Are you sure?
INT: Yeah.

SUB: You may end up going to Flint. That was
(daughters) husband.

INT: Ok. I'm going to ask a couple questions about,
again, this is about your life now, and how would you
describe people's response to you when you need, want
or need, to talk about money, if that's anything you
want to do?

SUB: I don't...I mean, if I want to say something to
somebody I say it. But I do what I want to do.

INT: In your life now, how would you describe people's
response when you want or need to talk about the way
you see yourself?

SUB: I don't have any problems talking with people.
How I see myself, I mean you know...

INT: We talked about things like, oh, should you work,
should you retire, should you, in case you needed to
talk about those things with someone would there be
someone?

SUB: Oh yes. There certainly would be. Uh, actually
(friend). I've got two friends at the hospital. One
of them, that drives...well, both of them are men that
I have worked with very closely. One of them is

151

(friend) and the other one's our Senior Vice President
at the hospital. And I feel, and then this, and I
mean you know, like I have some competent people. I
mean you know, we visit all the time. And of course,
(friend), as far as he's concerned, I'm not going to
retire 'til he does. So I really don't have much
choice in the matter, he thinks. But I will do what I
want. And as I say, it may be funny, that's just the
way that I feel about it. It's kind of scary for
health care. Going back as to what my needs are at
the hospital or what I can do. I do a doggone good
job with food service. However, I had to realize that
my place is not as great as the patient care, and that
I can be replaced by a food service. And uh, that's
one of the things that motivates me in my present
position. Because I feel very responsible. We have a
patient count of probably between 80 and 90 and maybe
100. And I have 60 employees in dietary. Well you
don't have to be too swift to figure out that I've
either got to keep them extremely busy and pay my way,
or...And I really question...I have a lot of thoughts
about clinical diet management and just really how
effective are we. How much would we be really missed
if we didn't exist? Ok. If you stop and think about
it. How many people would you know adhere to their
diets strictly? Be it, well now, the diabetics, they
still have choices. But anyway...

INT: Ok. In your life now, how would you describe peo-
ple's response to you when you want to or need to talk
about feelings or loneliness and if you are lonely how
do you handle it?

SUB: Well there again, I have a real good support sys-
tem. It was hard to go to Florida, because we had all
been there together. So, but people will, they bear
with me. And I try not to put them through a great
deal. Because nobody likes to see you sit and feel
sorry for yourself. Really.

INT: Are you able to talk about (your husband) with
people when you want to?

SUB: Oh yes, heavens yes, all the time. In fact, I
have this son, in Indiana, who was extremely close to
his father. And he has had a real hard time. But he
wouldn't talk about it. And so, always, when he comes
anymore, we talk very openly. And I think its proba-
bly - I hope it will help him in the long run.

Because I think you need to. I would feel sorry for
the people who couldn't talk.

152

INT: They say its painful. I've never lived through it
so I don't know, but they say as painful as it is, in
the end, it is therapeutic.

SUB: Oh, I believe that. Wouldn't you feel sorry for
the people who couldn't talk? I think that's one of
the things that you have choices about. But people
are use to me now because I just am very open with
anybody that I come in contact with. Well (husband)
would have done this. I mean, in fact, we were over
at Dewitt last night. We played a game of hearts with
him the Monday before he went in the hospital on Fri-
day. And he could hardly hold the cards in his hands.
That's what makes me, he was just unable to really
coordinate. But we were talking about that last
night. And we thought we were going to play another
game cause she beat us and usually you don't beat him.
And so no, I have no problems talking about him, none
whatsoever. And people listen whether its out of
politeness or whatever. I don't really care what it
is: they don't like it - they can move on. They waste
too much of my time anyway.

INT: The next set of questions focuses on how you see
your life in the future, ok. Since your husbands
death, have your thoughts or feelings about money
changed, if any, and how do you see your future
related to money?

SUB: It all depends, of course, on how long I work.
But, I don't see money being a problem. I spend a lot
of money and some that I don't even earn right away.
But I figure that I am going to have what I want at
this point in time. And after you grow a little older
those things really aren't important, the traveling
and so on. I don't envision money as being a problem,
If it is, I'll go on welfare. (LAUGHED).

INT: Ok. Since your husbands death, how have your
thoughts and feelings about the way you see yourself
changed, if any, and how do you see yourself in the
future?

SUB: Oh, I don't know, I hadn't thought a great deal
about the future. Right now I'm as I say, lonely.
But, I mean you know, I don't have that many problems.

INT: Since your husbands death, how have the thoughts
or feelings about the circumstances surrounding his
death changed, if any?

153

SUB: Oh, as I said earlier, I think now that I can
reflect back. I think he was more ill. But I think
probably its a good thing we don't know what's ahead
of us. Don't you? Because if we had known, I don't
know if we would of done anything any differently any-
way. Because we just sort of took one day at a time
and did what needed to be done. Actually we thought
he was going to get well up until the first part of
September, because, or not really well, but that he
was going to be able to go on with the chemo and all
of a sudden the Cysplatnin quit working.

INT: Since your husbands death, how have your thoughts
or feelings about your own health changed, if any, and
how do you see your health in the future?

SUB: Take it day by day there too.

INT: Since your husbands death, how have your thoughts
and feelings about the need to have the support of
friends or family changed, if any, and do you feel
that you will continue to have the same feelings in
the future?

SUB: Well, (friends names) were here practically every
2 or 3 days. They supported us when he was alive and
they are doing the same thing now....and I talk to
(son) every week. I don't see where the people
that...I think there were people who weren't able to
come out here when (husband) was so ill. I think
you'll find that. There are a lot of people that can
handle illness, but they aren't a close support group
anyway and I have a lot of support from the people at
work, a lot of it. So I mean, my own employees, but I
don't see any real change, the people who were with me
then are still with me.

INT: That's not always true, that's nice.

SUB: It is.

INT: Ok. I only have a couple of more questions.
SUB: Aren't you glad?

INT: I'm worried that this is...

SUB: No, that doesn't bother me.

154

INT: 0k. What has been the most difficult think for
you in this whole situation?

SUB: Loneliness. Cause we were very close, as I said,
and there wasn't anything that we didn't talk about,
visit about, whatever. And that I miss.

INT: Sometime, crises, very difficult times, in your
life, they say, provide you will an opportunity for
growth.

SUB: Oh, I'm a firm believer in that. I'm not so sure
I wanted to grow in this way. No, there is no growth
without stress. I firmly believe that. But I didn't
have that much more growth that I needed. Actually at
this point in time, probably I'm what's holding
(daughter) together. Well, no, really!

INT: You mean in terms of her...

SUB: She's had a lot to contend with. And as (son) is
calling me now, I'm the matriarch as far as he's con-
cerned. We went to Chicago 2 or 3 weeks ago when
(husband) birthday: it was over the 24th of March.

And that's what I say, I have a good relationship with
my children. Always have. And (son and daughter-in-
law) were going to Florida and then they decided that
they really couldn't afford it. So they were going to
Chicago for their vacation and they wanted me to go
along. Well, as it was, I was going to take
(grandchildren) and (daughter) decided she wanted to
go. So the 8 of us went to Chicago. We went to the
Brookfield Zoo, and we went to the Aquarium, and to
the Museum and to the Water Tower. And we just had a
ball. And those are the kind of things that bind the
family together and get us through. (Daughter) needs
strength right now and I am her strength and sort of
guide and direct her. And (son), I mean you know,
they're strong people but they - I feel a need. And I
think that's the important thing. Are you needed? Or
are you whatever...

155

Appendix E

156

.Fi_elsl__No_tc_=—_s_

The subject was working in her yard when the inter-
viewer arrived in the late afternoon. The home, which
sits on a lake, is spacious and comfortable and deco-
rated with mementos and memorabilia that hold special
meaning for the subject. After a tour of the yard, the
subject chose to proceed with the interview at her din-
ing room table where the late afternoon sun came through
the windows.

During a tour of the house which she proudly showed
the interviewer, she make a special point of pointing
out the book shelves and desk her husband had built say-
ing "(husband) was a voracious reader". She referred to
the bedroom as, "This is our bedroom". Further, she
said, "We like to look out in the morning and watch the
lake". "We planned this house for our retirement and we
almost made it".

The subject was casually dressed, wearing no
makeup. Before the interview began the subject got a
box of tissues and placed them in front of her on the

table. She seemed somewhat nervous at the beginning of

157

the interview, crossing and uncrossing her legs and
twisting her wedding rings which she continues to wear.

Throughout the interview, the subject remained warm
and open with appropriate eye contact. She was very
attentive to questions, pausing to think before respond-
ing with good detail.

The subject was quietly tearful during the inter-
view while answering questions. She became very tearful
twice during the interaction and was unable to continue
for a few minutes. At times, the subject displayed a
sense of humor which was appropriate to the situation
and discussion. At all times, the client's affect and
behavior were congruent.

At the end of the interview, the subject seemed
very reluctant to end the discussion. Taking her cues,
the interviewer stayed and conversed with the subject

for an additional 40 minutes before leaving.

158

References

References

American Nurses Association Congress for Nursing Prac-
tice: A social policy statement. (1980). Kansas
City, MO: American Nurses Association.

Ammon-Gaberson, K., 8 Piantanida, M. (1988). Generat-
ing results from qualitative data. Tpege, 20(21.
159-161.

Antonovsky. A- (1979)- Wing. San

Francisco: Jossey-Bass.

Arling, G. (1976). The elderly widow and her family,

neighbors and friends. WW
Famil , 1e, 757-768.

Atchley, R. C. (1975). Dimensions of widowhood in
later life. Qerontglogish, 15, 176-178.

Augsberger, R. (1978). Grief resolution among recent
spouse-bereaved individuals. (Doctoral Disserta-
tion. Northwestern University.) pieeeppehien

W. 18. (9-A). 5534-
Averill, J. (1968). Grief: Its nature and signifi-
cance. Psychoiogicel Builehin,,zg, 721-748.
Balkwell, C. (1981). Transition to widowhood: A

review of the literature. a t s,

January, 117-125.

Ball, J. (1977). Widow's grief: The impact of age and
mode of death. Qnege, 1, 307-333.

Barrett, C., 8 Schneweis, K. (1980). An empirical
search for stages of widowhood. Qnege, 11, 97-104.

Barry, K., 8 Fleming, M. (1988). Widowhood: A review
of the social and medical implications. zeniiy

heeigine, 29(6), 413-417.
Benoliel, J. (1985). Loss and adaptation: Circum-

stances, contingencies, and consequences. Death
Studies, 2(3-4), 217-233.

159

160

Berardo, F. (1968). Widowhood status in the United
States: Perspective on a neglected aspect of the

family life cycle. The_£anilx_£92rdinater. 11.
191-203.

Berardo, F. (1970). Survivorship and social isolation:

The case of the aged widower. The Remily goepgine-
52;: 12. 11-25-

Bowlby, J. (1980). 5s: a ess nd e s 'o . New
York: Basic Books, Inc.

Breckenridge, J., Gallagher, D., Thompson, L., 8 Peter-
son, J. (1986). Characteristic depressive symp-

toms of bereaved elders. leurnel_2f_§er2ntelesx.
ei(2), 163-168.

Brock, A. (1984). From wife to widow: A changing
lifestyle. Jou n o s'n ,
e1(2), 8-15.

Brock, A., 8 O'Sullivan, P. (1985). From wife to
widow: Role transition in the elderly. goupnai of
Ps chosocial Nurs' , 2;(12), 6-12.

Bugen, L. (1977). Human grief: A model for prediction
and intervention. J a of s '-

QEIY: $1. 195-207-
Caine, L. (1974). EiQQE- New York: William Morrow.

Carey, R. (1979-1980). Weathering widowhood: Problems
and adjustment of the widowed during the first
year. Ome a, TQ(2), 163-173.

Clayton, P. (1975). The effect of living alone on
bereavement symptoms. e Jou Ps a-

LIX. 132(2): 133‘137-

Clayton, P., Desmarais, L., 8 Winokur, G. (1968). A

study of normal bereavement. Anenieen_lennne1_efi
Esychiatny, i25(2), 168-178.

Clayton, P. J., Halikas, J. A., 8 Maurice, W. L.
(1972). The depression of widowhood. Rpihieh

lournai of Rsychiehzy, 129, 71-78.

Constantino, R. (1988). Comparison of two group inter-
ventions for the bereaved. Tnege, 2Q(2), 83-87.

161

Copel, L. (1988). Loneliness: A conceptual model.

i2urnal_of_2§xshesesiel_Nursins. 26(1). 14-19-
Dempsey, D., (1981). Surviving loss. fieyyy, May, 63-
7o.

Dimond, M. (1981). Bereavement and the elderly: A
critical review with implications for nursing prac-
tice and research. learnal_of_Adxansed_Nursing.
e(6), 461-470.

Dimond, M., Lund, D., 8 Caserta, M. (1987). The role
of social support in the first two years of
bereavement in an elderly sample. The_§e;en§eie;

915;. 21(5): 599'504-

Duffy, M. (1986). Qualitative research: An approach

whose time has come- Nursins_and_nealth_§ere.
1(5), 237-239.

Duffy, M. (1987). Methodological triangulation: A
vehicle for merging quantitative and qualitative
research methods. Tnege, 12(3), 30-33.

Eliot, T. (1930). The adjustment behavior of bereaved
families: A new field of research. Seeiei_£ezee§,
e, 543-549.

Engel, G. (1961). Is grief a disease: A challenge for

medical research. Psychosomatie_uedisine. 23. 18-
22.

Engel, G. (1971). Sudden and rapid death during psy-
chological stress: Folklore or folkwisdom? Anneie

on internal Medicine, 255, 771-782.
Ferraro, K. (1985). The effect of widowhood on the

health status of older persons. Inheznepienei
Joupnai of Aging eng Rnnan Qevelepnenh, 21(1), 9-
23.

Fitzpatrick, J. (1988). Theory based on Roger's con-

ceptual model. I2urnal_2f_§er2ntolegisal_hursing.
ig(90), 14-16.

Freihofer, P., 8 Felton, G. (1976). Nursing behaviors
in bereavement: An exploratory study. Repeing

Reseereh, 25(5), 332-337.

Freud, S. (1915). Tnstincps ene their vicissituges;
Collected papers. New York: Basic Books.

162

Fulconer. D- (1942)- The_adiustment_behaxior_of_some

peeently bereaved speusee. Unpublished doctoral
dissertation. Northwestern University.

Garrett, J. (1987). Multiple losses in older adults.
I2urnal_2;_§er2nt212sisal_hursing. 13(8). 8-12-

Gass, K. (1987a). Coping strategies of widows. Jenn;
nal of Gergnpeiggieei aneing, 11(80), 29-33.

Gass, K. (1987b). The health of conjugally bereaved
widows: The role of appraisal, coping and
resources. BesearQh_in_Nursing_and_Eealth. 10(1).
39-47.

Gass, K. (1988). Aged widows and widowers: Similari-
ties and differences in appraisal, coping,
resources, type of death, and health dysfunction.

Archives of Esyehiehxic Reneing, 2(4), 200-210.

Gass, K., 8 Chang, A. (1989). Appraisals of bereave-
ment, coping, resources, and psychosocial health
dysfunction in widows and widowers. Repeing

Researeh, 38(i), 31-36.

Glick, I., Weiss, R., 8 Parkes, C. (1974). The_;i;eh
yea; o; beneavemenh. New York: John Wiley.

Goldberg, E., Comstock, 8 Harlow, S. (1988). Emotional

problems and widowhood. The_lournals_of_§erontel:
pgy, 52(6), 206-208.

Gove, R. (1973). Sex, marital status, and morality.

Anenicen Journal pf §eeieiegy, 12, 204-213.
Guba. E., & Lincoln. Y- (1981)- Effectixe_exaluation.

San Francisco: Jossey Bass Publishers.

Gubrium, J. (1974). Marital desolation and the evalua-
tion of everyday life in old age. Qen;nei_e£_ue;;

piege and The Reniiy, 2e, 107-113.
Hauser, M. (1983). Bereavement outcome for widows.
Jou na of s chosoci u s a en h

Serxises. 21(9). 23-31.

Heyman, D. K., 8 Gianturco, D. T. (1973). Long-term
adaptation by the elderly to bereavement. Joupna;

of gerontology, 22, 359-362.

163

Hoeffer, B. (1987). A causal model of loneliness among

older single women- Archixes.2f.£sxchiatric.flurs:
ing, 1(50), 366-373.

Holmes, T., 8 Rahe, R. (1967). The social readjustment
rating scales. I2urnal_9f_£sxshosonatic_8esearch
11. 231-218.

I

Hopson, B., 8 Adams, J. (1977). Toward an understand-
ing of transition: Defining some boundaries of

transition. In R- Mose. Hunan_adastafion1__§onins
with_ezieee. Lexington, MA: Health.

Issac, S., 8 Michael, W. (1981).
eng evalnehien. San Diego: Edits Publishers.

Kahn, R. (1979). Aging and social support. In M. W.
Reiby (Ed.), n 0 eat ° -

ciplinapy pepspectivee. American Association for
Advancement of Science, Selected Symposium. Boul-
der, CO: Westview.

Kavanaugh, R. (1972). Regingyneeph. Baltimore: Pen-
guin Books.

Kirshling, J., 8 Austin, J. (1988). Assessing support:
The recently widowed. Archixee_2f_zexshiatric

Nursing. 2(2). 81-86.

Kivett, V. (1978). Loneliness and the rural widow.
The Family ceoreineeez, 21, 389-394.

Kubler-Ross, E. (1969). Qn_geenh_ene_gying. New York:

Macmillan.

Lindemann, E. (1944). Symptomology and management of

acute grief- Americanslournal_cf_2sxchiatrx. 24.
141-148.

Lofland, J., 8 Lofland, L. (1984). hneiyeing_eeeie1
set ' : ta ve bs
en iysis. Belmont, California: Wadsworth Publish-
ing.

Lopata. H- (1979). Homen_as_zid2s81__§uneort_sxstens.

New York: Elsvier.

Lund, D., Caserta, M., 8 Dimond, M. (1986). Gender
differences through two years of bereavement among

the sldsrlY- The_§ercntclegist. 26(3). 314-320-

164

Maddison, D., 8 Viola, A. (1968). The health of the
widows in the first year following bereavement.

Journai of Rsychosomatic Reseazch, i2, 297-306.
Marris, P. (1974). Leee_eng_ehenge. New York: Random

House.

Martocchio, B. (1985). Grief and bereavement: Healing

through hurt. Runsing glinice of Nerth Ameriea,
22(2), 327-341.

Merleau-Ponty. M- (1962). 2henonenolesx_ef_nercentign.

New York: Humanities Press.

Morgan, D. (1989). Adjusting to widowhood: Do social

networks really make it easier? The_§epenhpiegieh,
22(1), 101-107.
Moustakas, C. (1972). hpneiineee_eng_ieye. Englewood

Cliffs, NJ: Prentice-Hall.

Munhall, P., 8 Oiler, C. (1986). s s c ° A

gnalitative pepspecpive. Norwalk, Connecticut:
Appleton-Century-Crofts.

Murphy, S. (1988). Mental distress and recovery in
high-risk bereavement sample three years after

untimely death. nursing Researgh, 21(1), 31-35.

Norris, F., 8 Murrell, S. (1987). Older adult family
stress and adaptation before and after bereavement.

Journai of Gepontoiogy, 12(6), 606-612.

O'Bryant, S. (1985). Neighbor's support of older wid-
ows who live alone in their own homes. The genon-
tolo ist, 22(3), 305-310.

O'Bryant, S., 8 Morgan, L. (1989). Financial experi-
ence and well-being among mature widowed women.

The Gerontologiep, 22(2), 245-251.

Olson, T., 8 Hanover, J. (1985). Preparing women to be

widows. Health Vaiues: hehieving High Level Weil-
ness, 2(1), 8-11.

Parkes, C. (1970). The first year of bereavement.

Esychiahpy, 22, 444-467.

Parkes, C. (1972). hereavement: Studies of grief in
adult iif . New York: International Universities

Press.

165

Parkes, C. (1975). Determinates of outcome following
bereavement. Qnege, 2(4), 303-323.

Parkes, C., Benjamin, B., 8 Fitzgerald, R. (1969).
Broken heart: A statistical study of increased
mortality among widowers. British_Hedical_IQurnal.
1, 740-743.

ParkeS. c.. & Weiss. R- (1983)- .Beceyery_frgm_hereaye:
menh. New York: Basic Books.

Parse, R., Coyne, A., 8 Smith, M. (1985). Hereing
research2__Qualitatiye_nethods- Bowie. Maryland:

Brady Communications.

Patton. M- (1980)- Qualitatiye_eyaluatien_method§.
Beverly Hills: Sage Publications.

Peplau, L., 8 Perlman, D. (1982). Perspective on lone-
liness. In L. Peplau 8 D. Perlman (Eds.), Leneli-
ess: sou e e s a

phepepy. New York: Wiley.

Pihiblad, C., Adams, D., 8 Rosencranz, H. (1972).
Socioeconomic adjustment to widowhood. Qmege, 2,
295-305.

Polit. 0.. & Handler. D- (1983)- Nursins_research1
Brinciples_and_methed- Philadelphia: J- 8- Lip-

pincott.

Poncar, P. (1989). The elderly widow: Easing her role
transition. 8 s

Mental Health §ezyieee, 21(2), 6-11.

Quillin, S., 8 Runk, J. (1983) Martha Rogers' model.
In J. Fitzpatrick 8 A. Wall (Eds.), gonceppnel heg-

els efi Rupsing. New York: Robert J. Brady.

Ramsay, R. (1977). Behavioral approaches to bereave-
ment. Behaxioral_Besearch_Theraey. 15. 131-135-

Raphael. B- (1983)- The_anatemy_ef_hereayement. New
York: Basic Books.

Remondet, J., 8 Hansson, R. (1987). Assessing a
widow's grief: A short index. J e to-

;ogicel Nnrsing, 12(4), 31-34.

166

Richter, J. (1987). Support: A resource during crisis
of mate loss. 0 ' '
12(11), 18-22.

I

Rigdon, 1., Clayton, B., 8 Dimond, M. (1987). Toward a
theory of helpfulness for the elderly bereaved: An
invitation to a new life. v s -

enc_. 2(20). 32-43.

Rogers, M. (1970). s s o .
Philadelphia: F. A. Davis.
Sarter. B- (1988)- The_strean_2f_becgmins-
m as .

New York: Viking Penguin, Inc.

Schlossberg, N. (1981). A model for analyzing human

adaptation to transition. on se 5 o 0 st,
2, 2-18.

Schlossberg, N. (1984). unse n du s t s -
hip_. New York: Springer Publishing.

Schneider, J. (1987). St ss oss f: nde -
stand n h r 'ns .

Rockville, Maryland: Aspen.

Shanas, E., 8 Sussman, M. (1981). The family in later
life: Social structure and social policy. In R.
W. Fogel, E. Hatfield, S. B. Kiesler, 8 E. Shanas
(Eds. ), : 8
Orlando, FL: Academic.

Shanas, E., Townsend, P., Wedderburn, D., Friis Milhi,
P., 8 Stehouwer, J. (1968).

industrial_societies- New York: Atherton.

Silverman, P. (1972). Widowhood and preventive inter-

vention. The Eemiiy Qeoreinatez, 21, 95-102.

Silverman, P. 8 Cooperband, A. (1975). On widowhood:
Mutual help and the elderly widow. 29npne1_efi
Geriatric Psychiehpy, 2, 9-40.

Stroebe, W., 8 Stroebe, M. (1987). e av
ealth: The 5 ch co s -

gnences of partnep ioee. Cambridge: Cambridge

University Press.

167

TorreS. G- (1986)- Theoretical_fcgndatign§_cf_nursing-
Norwalk, Connecticut: Appleton-Century-Crofts.

Toth, S., 8 Toth, A. (1980). Empathetic intervention
with the widow. Anerican_Iournal_2f_Nur§ing.
(Sept.), 1652-1655.

Utley, Q., 8 Rasie, S. (1984). Coping with loss: A
group experience with elderly survivors. genzne1

of_§ergntglogical_uursing. 19(8). 8-14-

Valanis, B., 8 Yeaworth, R. (1982). Ratings of physi-
cal and mental health in the older bereaved.

Besearch_i__Nursing_and_Bealth. 5. 137-146.

Vashon, M. (1976). Grief and bereavement following the
death of a spouse. s as -

tion. 21. 35-44-

Vinick, B. (1978). Remarriage in old age. The_£eni1y
Qoordinetgz, 21, 359-363.

Viorst, J. (1987). Receseapy ioeeee. New York:

Fawcett.

Walters, J. (1980). Widowhood: The clapping of one
hand- In J- Montgomery (Ed ). Handbook_of_hging
Washington, D. C.: American Home Economics Associa-
tion.

Warner, S. (1987). A comparative study of widows' and
widowers' perceived social support during the first
year of bereavement Archiyes_gf_£sychiatric_8urs:

ing,1(4), 241- -250.

WeiSS. R. (1973)- LQneliness1__The_exnerience_9f_em2:
t a o 's at . Cambridge, MA: MIT
Press.

Weizman, S., 8 Kamm, P. (1985). mou : -

. New York:
Human Sciences Press, Inc.

Whelan, E. (1985). Support for the survivor. £221:
atnic nursing, 2(1), 21-24.

Yin, R. (1989). ase t esea ° es d t -
pd . Newbury Park: Sage Publications.

168

Zisook, S., Devaul, R., 8 Click, M. (1982). Measuring
symptoms of grief and bereavement. W

he], Qt Esychiagfl, 122(12), 1590-1593.

IGQN STATE UNIV

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