31. Theory of chronic sorrow



Theory of chronic sorrow



Ann M. Schreier and Nellie S. Droes



Credentials and background of the theorists


Georgene gaskill eakes


Georgene Gaskill Eakes was born in New Bern, North Carolina. She received a Diploma in Nursing from Watts Hospital School of Nursing in Durham, North Carolina, in 1966, and she graduated Summa Cum Laude from North Carolina Agricultural and Technical State University with a baccalaureate in nursing in 1977. Eakes completed her M.S.N. in 1980 at the University of North Carolina at Greensboro and her Ed.D. in 1988 at North Carolina State University. Eakes received a federal traineeship for graduate study at the master’s level and a graduate fellowship from the North Carolina League for Nursing for her doctoral studies. She was inducted into Sigma Theta Tau International in 1979 and Phi Kappa Phi in 1988.


Photo credit: Center for Health Sciences Communication, Brody School of Medicine, East Carolina University, Greenville, NC.


Photo credit: Olan Mills Portrait Studio, Centerdale, RI.


Photo credit: Shawn Hainsworth, New York, NY.


Early in her professional career Eakes worked in acute and community-based psychiatric and mental health settings. In 1980, she joined the faculty at the East Carolina University School of Nursing in Greenville, North Carolina.


Eakes’s interest in issues related to death, dying, grief, and loss relates to the 1970s, when she sustained life-threatening injuries in an automobile crash. This near-death experience heightened her awareness of how ill-prepared health care professionals and lay people are to deal with individuals facing their mortality and the general lack of understanding of grief reactions experienced in response to loss situations. Motivated by this insight, her research investigated death anxiety among nursing personnel in long-term care settings and the exploration of grief resolution among hospice nurses.


In 1983, Eakes established a community-service support group for individuals diagnosed with cancer and their significant others that she continues to co-facilitate. Leadership of this group alerted her to the ongoing nature of grief reactions associated with potentially life-threatening and chronic illness. While presenting her research at a Sigma Theta Tau International conference in Taipei, Taiwan, in 1989, she attended a presentation on chronic sorrow by Mary Lermann Burke. She immediately made the connection between Burke’s description of chronic sorrow in mothers of children with a myelomeningocele disability and her observations of grief reactions among the cancer support group members.


After the conference, Eakes contacted Burke to explore the possibility of collaborative research endeavors. They scheduled a meeting that included Burke and her colleague, Margaret A. Hainsworth, and Carolyn Lindgren, a colleague of Hainsworth. The Nursing Consortium for Research on Chronic Sorrow (NCRCS) was an outcome of the first meeting in the summer of 1989.


Subsequent to the NCRCS’s establishment, members conducted numerous collaborative qualitative research studies on populations of individuals affected with chronic or life-threatening conditions, on family caregivers, and on bereaved individuals. Eakes focused her studies on those diagnosed with cancer, family caregivers of adult mentally ill children, and individuals who have experienced the death of a significant other. From 1992 to 1997, Eakes received three research grant awards from the East Carolina University School of Nursing and two research grants from the Beta Nu Chapter of Sigma Theta Tau International to support her research projects.


In addition to her professional publications, Eakes has conducted numerous presentations on issues related to grief-loss and death and dying to professionals and lay groups at the local, state, national, and international levels. She was heavily involved with the training of sudden infant death syndrome counselors for North Carolina and local and regional hospice volunteers. Eakes is active in efforts to improve the quality of care at the end of life and is a member of the Board of Directors of the End of Life Care Coalition of Eastern North Carolina.


In 2002, Eakes received the East Carolina University Scholar Teacher Award, which recognizes excellence in integration of research into teaching practices. In 1999, Eakes received the Best of Image award for theory publication presented by the Sigma Theta Tau International Honor Society of Nursing for her article, “Middle-Range Theory of Chronic Sorrow.” She was a finalist in the Oncology Nursing Forum Excellence in Writing Award in 1994. Other honors and awards include the North Carolina Nurse Educator of the Year by North Carolina Nurses Association in 1991 and Outstanding Researcher by the Beta Nu Chapter of Sigma Theta Tau International Honor Society for Nurses in 1994 and 1998. Eakes has served as a reviewer for Qualitative Health Research, an international interdisciplinary journal.


Eakes is Professor Emeritus at East Carolina University College of Nursing. Prior to her retirement, she taught undergraduate courses in psychiatric and mental health nursing and nursing research, a master’s-level course in nursing education, and an interdisciplinary graduate course titled “Perspectives on Death/Dying.” Currently, she is Director of Clinical Education at Vidant Medical Center in Greenville, NC (G. Eakes, personal communication, 2012).


Mary lermann burke


Mary Lermann Burke was born in Sandusky, Ohio. She was awarded her initial nursing diploma from the Good Samaritan Hospital School of Nursing in Cincinnati in 1962, and a postgraduate certification from Children’s Medical Center in the District of Columbia. After several years of experience in pediatric nursing, Burke graduated Summa Cum Laude with a bachelor’s degree in nursing from Rhode Island College in Providence. In 1982, she received her master’s degree in parent-child nursing from Boston University, where she was also awarded a Certificate in Parent-Child Nursing and Interdisciplinary Training in Developmental Disabilities from the Child Development Center of Rhode Island Hospital and the Section on Reproductive and Developmental Medicine at Brown University in Providence. In 1989, she received her nursing science doctorate in Family Studies from Boston University.


Burke was inducted into Theta Chapter, Sigma Theta Tau, during her master’s program at Boston University in 1981 and became a charter member of Delta Upsilon Chapter-at-Large of Sigma Theta Tau at Rhode Island College in 1988. She received a Doctoral Student Scholarship Award from Theta Chapter in 1988 and the Delta Upsilon Chapter-at-Large Louisa A. White Award for Research Excellence in 1996.


During the period from 1991 to 1996, Burke received four Rhode Island College Faculty Research Grants for studies of chronic sorrow. In 1998, she was awarded a grant from the Delta Upsilon Chapter-at-Large for initial quantitative instrument development for the study of chronic sorrow. From 1992 to 1995, Burke was principal investigator on the Transition to Adult Living Project, funded by the Department of Health and Human Services, Maternal and Child Health Bureau, Genetics Services Branch. In 1995, she was co-principal investigator on a New England Regional Genetics Group Special Projects Grant, The Transition to Adult Living Project—System Dissemination of Information.


Burke’s early practice was in pediatric nursing specialty in both acute and primary settings. She joined the faculty of the Rhode Island College Department of Nursing as clinical instructor in 1980, and she became full-time in 1982, assistant professor in 1987, associate professor in 1991, and professor in 1996. During this period, she taught pediatric nursing in didactic and clinical courses. She also developed and taught a nursing course encompassing nutrition, pharmacology, and pathophysiology. Burke retired from Rhode Island College faculty in December 2002.


Burke had become interested in the concept of chronic sorrow during her master’s program while in a clinical practicum at the Child Development Center of Rhode Island Hospital. While working there with children with spina bifida and their parents, she developed a clinical notion that the emotions she observed in the parents were consistent with chronic sorrow as first described by Olshansky (1962). Her master’s thesis, The Concerns of Mothers of Preschool Children with Myelomeningocele, identified emotions similar to chronic sorrow. She then developed the Burke Chronic Sorrow Questionnaire for her doctoral dissertation research, Chronic Sorrow in Mothers of School-Age Children with Myelomeningocele.


In June 1989, Burke presented her dissertation research at the Sigma Theta Tau International Research Congress in Taipei, Taiwan, where she interacted with Dr. Eakes of East Carolina University and Dr. Hainsworth of Rhode Island College. Subsequently, this group became the NCRCS, joined briefly by Dr. Carolyn Lindgren of Wayne State University. Together they developed a modified Burke/NCRCS Chronic Sorrow Questionnaire and conducted a series of individual studies that were then analyzed collaboratively. Burke’s studies in this series focused on chronic sorrow in infertile couples, adult children of parents with chronic conditions, and bereaved parents. The collaboratively analyzed studies led to the development of a middle-range Theory of Chronic Sorrow, which was published in 1998. Members of the Consortium, both individually and collaboratively, presented numerous papers on chronic sorrow at local, state, national, and international conferences and published 10 articles in refereed journals. Their article, “Middle-Range Theory of Chronic Sorrow” received the Best of Image Award in 1999 in the Theory Category from Sigma Theta Tau International. Burke has collaborated with Dr. Eakes in the development of the Burke/Eakes Chronic Sorrow Assessment Tool.


Burke is active in numerous professional and community organizations. She serves on the St. Joseph’s Health Services of Rhode Island Board of Trustees. She received the Outstanding Alumna Award for Contributions in Nursing Education from the Rhode Island College Department of Nursing and the Alumni Honor Roll Award from Rhode Island College (L. Burke, personal communication, 2005).


Margaret A. hainsworth


Margaret A. Hainsworth was born in Brockville, Ontario, Canada. She received her diploma in nursing in 1953 at Brockville General Hospital in Brockville, Ontario. In 1959, she immigrated to the United States to attend the George Peabody College for Teachers in Nashville, Tennessee, where she received a diploma in public health nursing. Hainsworth continued her education at Salve Regina College in Newport, Rhode Island, and received a baccalaureate degree in nursing in 1973. She then received a master’s degree in psychiatric and mental health nursing from Boston College in 1974 and a doctoral degree in education administration from the University of Connecticut in 1986. In 1988, she became board certified as a clinical specialist in psychiatric and mental health nursing.


Hainsworth was inducted into Sigma Theta Tau, Alpha Chi Chapter in 1978 and Delta Upsilon Chapter-at-Large in 1989. In 1976, she received the outstanding faculty award at Rhode Island College. In 1992, she was selected and attended the Technical Assistance Workshop and Mentorship for Nurses in Implementation of the National Plan for Research in Child and Adolescent Mental Disorders,sponsored by the National Institutes of Health. Hainsworth reviewed manuscripts for Qualitative Health Research, an Inter-disciplinary Journal, a Sage publication. In 1999, she was a visiting fellow on a faculty exchange program at the Royal Melbourne Institute of Technology in Melbourne, Australia.


Hainsworth’s nursing practice was in public health and psychiatric and mental health nursing. She became a lecturer in the Department of Nursing at Rhode Island College in 1974 and full professor in 1992. Her major area of teaching was psychiatric care in the classroom and clinical. A course entitled “Death and Dying” that she taught became an elective in the college’s general studies program. Hainsworth always maintained her practice and was employed for 13 years as a consultant at the Visiting Nurse Association. She entered private practice at Bay Counseling Association in 1993 and maintained that practice for 5 years.


Her interest in chronic illness and its relationship to sorrow began in her practice as a facilitator for a support group for women with multiple sclerosis. This interest led to her dissertation work, An Ethnographic Study of Women with Multiple Sclerosis Using a Symbolic Interaction Approach. This research was accepted for a presentation at the Sigma Theta Tau Research Congress in Taipei, Taiwan, in 1989, where she learned about Burke’s research on chronic sorrow after attending her presentation.


Building on Burke’s work, the NCRCS was established in 1989 to expand the understanding of chronic sorrow. Hainsworth was one of the four cofounders and remained an active member until 1996. The NCRCS research began with four studies focused on chronic sorrow in individuals in chronic life situations, and members of the consortium analyzed data collaboratively. During the 7 years she was a member, the consortium presented their findings at international, state, and regional conferences and published 13 manuscripts. In 1999, they were awarded the Best of Image Award in Theory from Sigma Theta Tau International (M. Hainsworth, personal communication, 2005).


Theoretical sources


The concept of chronic sorrow originated with the work of Olshansky in 1962 (Lindgren, Burke, Hainsworth, et al., 1992). The NCRCS (Eakes, Burke, & Hainsworth,1998) based their middle-range Theory of Chronic Sorrow on the work of Olshansky (1962). Lazarus and Folkman’s (1984) model of stress and adaptation formed the foundation for their conceptualization of how persons cope with chronic sorrow.


The NCRCS theorists cite Olshansky’s observations of parents with mentally retarded children that indicated these parents experienced recurrent sadness and his coining the term chronic sorrow. This original concept was described as “a broad, simple description of psychological reaction to a tragic situation” (Lindgren, Burke, Hainsworth, et al., 1992, p. 30)


During the 1980s, other researchers began to examine the experience of parents of children who were either physically or mentally disabled. This work validated a recurrent sadness and never-ending grief the parents experienced. Grief was previously conceptualized as a process that resolved over time, and if unresolved, was abnormal according to Bowlby and Lindemann’s work (Lindgren, Burke, Hainsworth, et al., 1992). In contrast to this time-bound conceptualization, chronic sorrow researchers later described recurrent sadness as a normal experience (Lindgren, Burke, Hainsworth, et al., 1992). Burke, in her study of children with spina bifida, had defined chronic sorrow as “pervasive sadness that is permanent, periodic and progressive in nature” (as cited in Hainsworth, Eakes, & Burke, 1994, p. 60).


The NCRCS group focused on the response to grief and incorporated Lazarus and Folkman’s 1984 work on stress and adaptation as a basis for management methods described in their work (Eakes, Burke, & Hainsworth, 1998). Internal coping strategies include action-oriented, cognitive reappraisal and interpersonal behaviors (Eakes, Burke, & Hainsworth, 1998). Thus, the middle-range Theory of Chronic Sorrow extended the theoretical base of chronic sorrow to not only the experience of chronic sorrow in certain situations but also the coping responses to the phenomenon.



Use of empirical evidence


Chronic sorrow


The empirical evidence supporting the NCRCS’s initial conceptual definition of chronic sorrow was derived from interviews with mothers of children with spina bifida, which were conducted in Burke’s (1989) dissertation work. Through this research, Burke defined chronic sorrow as a pervasive sadness and found that the experience was permanent, periodic, and potentially progressive (Eakes, Burke, Hainsworth, et al., 1993). This was the foundation for the subsequent series of studies, including the interview guides used in these studies.



The NCRCS studies addressed the following:



Based on these studies, the theorists postulated that chronic sorrow occurs in any situation in which the loss is unresolved. These studies did not demonstrate consistently that the associated emotions worsened over time. However, the theorists concluded that the studies did support the “potential for progressivity and intensification of chronic sorrow over time” (Eakes, Burke, & Hainsworth, 1998, p. 180).


The NCRCS theorists extended their studies to individuals experiencing a single loss (bereaved). They found that this population experienced these same feelings of chronic sorrow (Eakes, Burke, & Hainsworth, 1999).


Based on this extensive empirical evidence, the NCRCS theorists refined the definition of chronic sorrow as the “periodic recurrence of permanent, pervasive sadness or other grief-related feelings associated with ongoing disparity resulting from a loss experience” (Eakes, Burke, & Hainsworth, 1998, p. 180)


Triggers


Using the empirical data from the series of studies, the NCRCS theorists identified primary events or situations that precipitated the re-experience of initial grief feelings. These events were labeled chronic sorrow triggers (Eakes, Burke, Hainsworth, et al., 1993). The NCRCS compared and contrasted the triggers of chronic sorrow in individuals with chronic conditions, family caregivers, and bereaved persons (Burke, Eakes, & Hainsworth, 1999). For all populations, comparisons with norms and anniversaries were found to trigger chronic sorrow. Both family caregivers and persons with chronic conditions experienced triggering with management crises. One trigger unique for family caregivers was the requirement of unending caregiving. The bereaved population reported that memories and role change were unique triggers.


Management strategies


The NCRCS posited that chronic sorrow is not debilitating when individuals effectively manage feelings. The management strategies were categorized as internal or external. Self-care management strategies were designated as internal coping strategies. The NCRCS designated internal coping strategies as action, cognitive, interpersonal,and emotional.


Action coping mechanisms were used across all subjects—individuals with chronic conditions and their caregivers (Eakes, 1993; Eakes, 1995; Eakes, Burke, & Hainsworth, 1999; Eakes Burke, Hainsworth, et al., 1993; Hainsworth, 1994; Hainsworth, 1995; Hainsworth, Busch, Eakes, et al., 1995; Lindgren, 1996). The examples provided are similar to distraction methods commonly used to cope with pain. For instance, “keeping busy” and “doing something fun” are examples of action-oriented coping (Eakes, 1995; Lindgren, Burke, Hainsworth, et al., 1992). The NCRCS theorists found that cognitive coping was used frequently, and examples included “thinking positively,” “making the most of it,” and “not trying to fight it” (Eakes, 1995; Hainsworth, 1994; Lindgren, 1996). Interpersonal coping examples included “going to a psychiatrist,” “joined a support group,” and “talking to others” (Eakes et al., 1993; Hainsworth, 1994; 1995). Emotional strategy examples included “having a good cry” and expressing emotions (Eakes, Burke, & Hainsworth, 1998; Hainsworth, Busch, Eakes, et al., 1995). A management strategy was labeled effective when a subject described it as helpful in decreasing feelings of re-grief.


External management was described initially by Burke as interventions provided by health professionals (Eakes, Burke, & Hainsworth, 1998). Health care professionals assist affected populations to increase their comfort through roles of empathetic presence, teacher-expert, and caring and competent professional (Eakes, 1993; Eakes, 1995; Eakes, Burke, Hainsworth, et al., 1993; Eakes, Burke, & Hainsworth, 1999; Hainsworth, 1994; Hainsworth, 1995; Hainsworth, Busch, Eakes, et al., 1995; Lindgren, 1996).


In summary, an impressive total of 196 interviews resulted in the middle-range Theory of Chronic Sorrow. The theorists summarized a decade of research with individuals with chronic sorrow and found that this phenomenon frequently occurs in persons with chronic conditions, in family caregivers, and in the bereaved (Burke, Eakes, & Hainsworth, 1999; Eakes, Burke, & Hainsworth, 1998).


Major assumptions


Nursing


Diagnosing chronic sorrow and providing interventions are within the scope of nursing practice. Nurses can provide anticipatory guidance to individuals at risk. The primary roles of nurses include empathetic presence, teacher-expert, and caring and competent caregiver (Eakes, Burke, & Hainsworth, 1998).


Person


Humans have an idealized perception of life processes and health. People compare their experiences both with the ideal and with others around them. Although each person’s experience with loss is unique, there are common and predictable features of the human loss experience (Eakes, Burke, & Hainsworth, 1998).


Health


There is a normality of functioning. A person’s health depends upon adaptation to disparities associated with loss. Effective coping results in a normal response to life losses (Eakes, Burke, & Hainsworth, 1998).


Environment


Interactions occur within a social context, which includes family, social, work, and health care environments. Individuals respond to their assessment of themselves in relation to social norms (Eakes, Burke, & Hainsworth, 1998).


Theoretical assertions



Logical form


This theory is based on a series of qualitative studies. Through the analysis of 196 interviews, the middle-range Theory of Chronic Sorrow evolved. With the empirical evidence, the NCRCS theorists described the phenomenon of chronic sorrow, identified common triggers of re-grief, and described internal coping mechanisms and the role of nurses in the external management of chronic sorrow. Evidence of the theoretical assumptions is clear in empirical data.


Acceptance by the nursing community


Practice


NCRCS-original work


The series of NCRCS studies, which form the foundation of the middle-range Theory of Chronic Sorrow (Eakes, Burke, & Hainsworth, 1998), are replete with practice applications. Each article relates the findings to clinical nursing practice (Burke, Eakes, & Hainsworth, 1999; Eakes, 1993; Eakes, 1995; Hainsworth, 1994; Hainsworth, Burke, Lindgren, et al., 1993; Hainsworth, Busch, Eakes, et al., 1995; Hainsworth, Eakes, Burke, 1994; Lindgren, 1996; Lindgren, Burke, Hainsworth, et al., 1992). Suggestions are provided on how nurses may assist individuals and family caregivers to effectively manage the milestones or triggering events. More specifically, the work identifies nursing roles as empathetic presence, teacher-expert, and caring and competent professional (Eakes, Burke, Hainsworth, et al., 1993).


Ncrcs-derived literature


The original NCRCS work is referenced in publications in practice-focused journals. Several non-NCRCS nurse authors published articles that cite NCRCS studies directed to practicing clinicians (Gedaly-Duff, Stoger, & Shelton, 2000; Gordon, 2009; Kerr, 2010; Krafft & Krafft, 1998; Scornaienchi, 2003). Interdisciplinary practice-focused literature provided guidance useful to nurses (Doka, 2004; Harris & Gorman, 2011; Miller, 1996).


The work listed above in the practice section is also educationally related. The next section presents evidence of undergraduate, graduate, and continuing education support of the NCRCS’s work on chronic sorrow’s relevance in the educational community.


Education


Undergraduate education


Standardized Nursing Languages. Literature on standardized nursing languages reveals that chronic sorrow is a diagnostic category (NANDA, 2011) with related expected outcomes and suggested interventions (Johnson, Moorhead, Bulechek, et al., 2012). Comparison of the definitions of chronic sorrow used by the North American Nursing Diagnosis Association International (NANDA-I) and the NCRCS (Eakes, Burke, & Hainsworth, 1998) reveal essentially similar dimensions. Several widely used nursing diagnosis textbooks (Ackley & Ladwig, 2011; Carpenito-Moyet, 2010; Doenges, Moorhouse, & Murr, 2010) cite the work of the NCRCS and/or authors who used the NCRCS’s work to explicate linkages among chronic sorrow as a diagnostic category, intervention, and outcome. Linkages among diagnostic categories in the North American Diagnostic Association International (NANDA-I), the Nursing Outcomes Classification (NOC), and the Nursing Interventions Classification (NIC) (Johnson, Moorhead, Bulechek, et al., 2012) provide educational applications for undergraduate nursing students and educators—for nursing students learning clinical decision processes and for nurse educators designing curricula and teaching clinical decision processes. Moreover, the linkages focus care planning on outcomes, an essential step in teaching evidence-based practice (Pesut & Herman, 1998).


Graduate research education: Nursing


The use of the NCRCS’s theoretical work in unpublished master’s theses and doctoral dissertations and in dissertation-related articles is evidence of graduate nursing education use. Studies are listed as follows and are categorized according to graduate level and topic.


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Jan 8, 2017 | Posted by in NURSING | Comments Off on 31. Theory of chronic sorrow

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