Theory of Chronic Sorrow

Theory of Chronic Sorrow

Ann M. Schreier and Nellie S. Droes


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 in 1977, she graduated Summa Cum Laude from North Carolina Agricultural and Technical State University with a baccalaureate in nursing. Eakes completed an M.S.N. at the University of North Carolina at Greensboro in 1980, and an Ed.D. from North Carolina State University in 1988. Eakes was awarded a federal traineeship for her graduate study at the master’s level and a graduate fellowship from the North Carolina League for Nursing to support her doctoral studies. She was inducted into Sigma Theta Tau International Honor Society of Nurses in 1979 and Phi Kappa Phi Honor Society in 1988.

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

Eakes’ interest in issues related to death, dying, grief, and loss dates to the 1970s, when she sustained life-threatening injuries in an automobile crash. Her near-death experience heightened her awareness of how ill prepared healthcare 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, she directed her early research efforts to the investigation of death anxiety among nursing personnel in long-term care settings and to the exploration of grief resolution among hospice nurses.

In 1983, Eakes established, as a community service, a twice-monthly support group for individuals diagnosed with cancer and their significant others, which she continues to co-facilitate. Her involvement with this group alerted her to the ongoing nature of grief reactions associated with diagnosis of potentially life-threatening, chronic illness. While presenting her dissertation research at a Sigma Theta Tau International research conference in Taipei, Taiwan, in 1989, she attended a presentation on chronic sorrow by Mary Lermann Burke and 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. Subsequent to their discussions, 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 this first meeting in the summer of 1989.

Subsequent to 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 individual 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 through 1997, Eakes received three research grant awards from East Carolina University School of Nursing and two research grants from Beta Nu Chapter of Sigma Theta Tau International to support her research endeavors.

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 has been heavily involved with the training of sudden infant death syndrome counselors for North Carolina and local and regional hospice volunteers. Eakes is also active in efforts to improve the quality of care at the end of life and, toward that end, serves as 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 in recognition of excellence in the integration of research into teaching practices. In 1999, Eakes received the Best of Image award for theory publication presented by Sigma Theta Tau International Honor Society of Nursing for the publication, “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 selection as North Carolina Nurse Educator of the Year by the North Carolina Nurses Association in 1991 and as Outstanding Researcher by Beta Nu Chapter of Sigma Theta Tau International Honor Society for Nurses in 1994 and 1998. Eakes also serves as a reviewer for Qualitative Health Research, an international, interdisciplinary journal.

Eakes is a professor in the Department of Family and Community Nursing at East Carolina University School of Nursing, where she teaches 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.” Her current research efforts are directed toward further development of the Burke/Eakes Chronic Sorrow Assessment Tool, a quantitative instrument designed to assess for evidence of chronic sorrow and to identify effective coping mechanisms (G. Eakes, personal communication, 2005).

Mary Lermann Burke

Mary Lermann Burke was born in Sandusky, Ohio, where she received her elementary and secondary education. She was awarded her initial nursing diploma from Good Samaritan Hospital School of Nursing in Cincinnati in 1962, followed later that year by a postgraduate certification, from Children’s Medical Center in District of Columbia. After several years of work experience in pediatric nursing, Burke graduated Summa Cum Laude from Rhode Island College, Providence, with a bachelor’s degree in nursing. In 1982, she received her master’s degree in parent-child nursing from Boston University. During this program, 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, Brown University, in Providence. Her doctorate of nursing science in the Family Studies Cognate from Boston University followed this in 1989.

Burke was inducted as a member of Theta Chapter, Sigma Theta Tau, during her master’s program at Boston University in 1981 and as 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 the Theta Chapter in 1988. She received the 1996 Delta Upsilon Chapter-at-Large Louisa A. White Award for Research Excellence.

During the period from 1991 through 1996, Burke received four Rhode Island College Faculty Research Grants for studies in the area 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. Burke was principal investigator on the Transition to Adult Living Project, funded by a grant from the Department of Health and Human Services, Maternal and Child Health Bureau, Genetics Services Branch, from 1992 through 1995. A New England Regional Genetics Group Special Projects Grant, The Transition to Adult Living Project—System Dissemination of Information, supplemented this in 1995. Burke was co-principal investigator.

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

Burke became interested in the concept of chronic sorrow during her master’s degree program while engaged 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 the clinical hunch that the emotions displayed by 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 conducting 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 individually a series of studies that were analyzed collaboratively. Burke’s individual 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 resulted in the development of a middle range Theory of Chronic Sorrow, 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 wrote 10 articles published in refereed journals, receiving the Best of Image Award in the Theory Category from Sigma Theta Tau International for their article, “Middle-Range Theory of Chronic Sorrow.” Most recently, 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 is a member of the St. Joseph’s Health Services of Rhode Island Board of Trustees. She has been awarded the Outstanding Alumna Award for Contributions in Nursing Education by Rhode Island College Department of Nursing and the Rhode Island College Alumni Honor Roll Award (L. Burke, personal communication, 2005).

Margaret A. Hainsworth

Margaret A. Hainsworth was born in Brockville, Ontario, Canada. She received her early elementary and secondary education in her hometown of Prescott, Ontario. Following high school graduation in 1949, she entered the diploma school of nursing at the Brockville General Hospital, Brockville, Ontario, graduating in 1953. In 1959, she immigrated to the United States to attend George Peabody College for Teachers in Nashville, Tennessee, receiving a diploma in public health nursing. In 1974, she continued her education at Salve Regina College, Newport, Rhode Island, and received a baccalaureate degree in nursing in 1973 and a master’s degree in psychiatric and mental health nursing from Boston College in 1974. She received a doctoral degree in education administration from the University of Connecticut in 1986. In 1988, she was board certified as a clinical specialist in psychiatric and mental health nursing.

She was inducted into Sigma Theta Tau, Alpha Chi Chapter in 1978 and Delta Upsilon Chapterat-Large in 1989. In 1976, she was awarded an outstanding faculty award at Rhode Island College. In 1992, she was selected to attend the Technical Assistance Workshop and Mentorship for Nurses in Implementation of the National Plan for Research in Child and Adolescent Mental Disorders that was sponsored by the National Institutes of Health. In 1991, she was selected to review manuscripts for the journal, Qualitative Health Research, an Interdisciplinary Journal, a Sage publication. In 1999, Hainsworth was accepted at the Royal Melbourne Institute of Technology in Melbourne, Australia, as a visiting fellow on a faculty exchange program.

Her practice in nursing was in the specialties of public health and psychiatric and mental health nursing. In 1974, she was accepted as a lecturer in the Department of Nursing at Rhode Island College and was promoted to full professor in 1992. Her major area of teaching was psychiatric care that consisted of both classroom lectures and clinical practice. She taught a course entitled “Death and Dying” that 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 Nursing Association. She entered into a private practice at Bay Counseling Association in 1993 and maintained this 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 practice 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. At this conference, she became familiar with the research on chronic sorrow after attending a presentation by Burke.

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


The NCRCS based the middle range Theory of Chronic Sorrow on two main sources. The work of Olshansky in 1962 was cited as the basis of the original concept of chronic sorrow (Eakes, Burke, & Hainsworth, 1998). Lazarus and Folkman’s (1984) model of stress and adaptation formed the foundation for the conceptualization of how persons cope with chronic sorrow.

The concept of chronic sorrow originated with the work of Olshansky in 1962 (Lindgren, Burke, Hainsworth, & Eakes, 1992). 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 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 a never-ending nature of grief experienced by these parents. Previous to this work, grief was conceptualized as a process that resolves over time, and if unresolved, grief is abnormal according to Bowlby and Lindemann’s work (Lindgren et al., 1992). In contrast to this time-bound conceptualization, inherent in the concept of chronic sorrow is that recurrent sadness is a normal experience, according to Wikler, Wasow, and Hatfield (Lindgren et al., 1992). Burke, in her study of children with spina bifida, defined chronic sorrow as “pervasive sadness that is permanent, periodic and progressive in nature” (Hainsworth, Eakes, & Burke, 1994, p. 59).

The NCRCS did not confine its theory to the existence of chronic sorrow but sought to examine the response to the grief. This group incorporated Lazarus and Folkman’s 1984 work on stress and adaptation as the basis for effective management methods described in its model (Eakes et al., 1998). The disparity encountered and the response to re-grief stimulate individual coping mechanisms. There are categories of coping styles or management. Internal coping strategies include action-oriented, cognitive reappraisal and interpersonal behaviors (Eakes et al., 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.


Chronic Sorrow

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

These NCRCS studies involved 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 et al., 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 et al., 1998, p. 377).


Using the empirical data from these 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 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 further 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, 1995; Eakes et al., 1993, 1999; Hainsworth, 1994, 1995; Hainsworth et al., 1995; Lindgren, 1996). The examples are like distraction methods commonly used to cope with pain. For instance, “keeping busy” and “doing something fun” are given as examples of action-oriented coping (Eakes, 1995; Lindgren et al., 1992). It was 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, 1993; Hainsworth, 1994, 1995). Emotional strategy examples included “having a good cry” and expressing emotions (Eakes et al., 1998; Hainsworth, 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 et al., 1998). Healthcare professionals assist affected populations to increase their comfort through roles of empathetic presence, teacher-expert, and caring and competent professional (Eakes, 1993, 1995; Eakes et al., 1993, 1999; Hainsworth, 1994, 1995; Hainsworth 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 bereaved persons (Burke et al., 1999; Eakes et al., 1998).

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Feb 9, 2017 | Posted by in NURSING | Comments Off on Theory of Chronic Sorrow

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