The crisis of mate loss in the elderly has been described as one of the most profound losses that a person can experience.1·2 In the first year following the loss of a mate, there is an increase in morbidity and mortality rates.3 This is particularly true for the aged bereaved where the spouse died of a long-term illness.4
Although previous research has identified needs of spouses of dying patients,5-6 research in the understanding of resources available to the spouse at the time of the mate's death has been limited. The critical factor in determining the outcome of a crisis, according to Narayan and Joslin,7 is the perceived importance of the problem and the availability and utilization of resources. Dimond8 described older people in their adjustment to bereavement and suggested that access to adequate and appropriate resources is important in determining successful bereavement.
If nurses were to learn about existing resources of the spouse during the dying process of his or her mate, interventions could be focused on reinforcing those resources. The spouse of a dying patient is likely to feel helpless and bewildered during the final week of the patient's life. Nursing interventions that would facilitate the spouse's use of available resources could enable the individual to be an active participant in the final phase of the marriage relationship.
Crisis theory911 has been used as the conceptual framework in most studies of loss. While this theory has some limitations in describing the total bereavement process, it provides a meaningful way of understanding the spouse's experiences during his or her mate's dying process.
There is an imbalance of needs and resources that accompanies the crisis of loss. The elderly spouse must accept the ending of a relationship that has lasted for as long as 40 to 50 years. The realization of the finality of death can create insurmountable obstacles for the surviving spouse who has limited resources.
Generally, nurses have been oriented to problem solving as a basic approach to patient care. A nursing intervention that could be further developed is the mobilization or reinforcement of resources. The notion of crisis as a turning point offers the hope that effective interventions during the disequilibrium7 of the crisis could increase the possibility of a healthy outcome.9 During a crisis, the individual, in a state of helplessness, is more likely to accept the assistance of others.
Resources that have been considered to have a significant influence on health outcome include interpersonal support,1217 religious-spiritual beliefs,18,19 and intrapersonal coping.8,20 The extent to which these resources are available and useful to the spouse can influence the crisis of loss perception and ultimately, the outcome of the crisis.
Interpersonal support involves interactions perceived as providing information, material goods and services, and emotional support.12 Support provided during the crisis can enable the spouse to feel cared about and valued as a person. The support and influence of others can have a significant impact on the extent to which the older individual makes a satisfactory adjustment to the experiences of widowhood.8
The Institute of Medicine appointed a committee to study the impact of the bereavement process on the physical and mental health of the individual. The focus of the report was primarily on reactions to the loss of a close family member.21
In the elderly, the loss of a spouse can mean not only the absence of the primary person one depended on for many years, but also the most important source of emotional and social support. Social isolation problems may become serious among the elderly who have limited financial resources or who live far away from other family members. The elderly may also experience failing health, which may make it difficult to maintain social contacts following the loss of a mate.21
The most significant primary support group for the bereaved is their family.1317 An interesting finding in Hampe's6 study was that 30% of the spouses gave as well as received support and comfort from their dying mates. Other sources of support for the grieving spouse included friends, neighbors, nurses, physicians, funeral directors and chaplains.14
Religious and spiritual beliefs involve faith in a power outside of self. These beliefs can be considered a resource if they allow the spouse to find meaning in their mate's death or enable the spouse to believe in a life after death.
Nighswonger18 suggested that, ideally, the family's hope for a cure will evolve to a concern for the meaning of the death. The ability to find meaning in the loss can enable the surviving spouse to accept the death and its finality. Stoner19 studied hope in cancer patients and found that religion was an important aspect in the lives of 87% of the people interviewed. Belief in religion was associated with higher hope.
Coping with the crisis of loss is determined by a repertoire of personality characteristics, previous experience with stressful situations, and specific cognitive and behavioral strategies.8 Dimond8 described cognitive strategies as all mental processes which reduce threat.
Their purpose is to control the meaning of a situation. Behavioral strategies on the other hand would involve direct actions. A variety of responses in the cognitive and behavioral domains would be considered more beneficial to the person than a single coping strategy.
A review of the literature revealed the importance of interpersonal support, religious-spiritual beliefs and intrapersonal coping, as resources during the grief process following a loss. There were no studies, however, which described spouse resources during the final week of the mate's life in the hospital.
The purpose of this study was to describe widows' and widowers' perceptions of resources available to them during the last week of their mates' lives in the hospital. Many families choose hospice for care at home during the dying process. However, most cancer deaths still occur in the hospital where the nurse has the opportunity to facilitate the resources of the dying patient's spouse.8
The loss of a mate who died of cancer is unique because the marriage partners have had some time to live with the diagnosis and to anticipate the loss before it occurs. All interviews for this study were conducted with subjects whose mate died of cancer.
The nursing care provided in the final week is more likely to be palliative than curative. The dying patient's spouse and the hospital staff are more likely to be aware that death is impending.22 Nursing interventions that could allow the spouse to utilize available resources could have a positive impact on the health of the spouse after the mate has died.8
Interviews were conducted after the death of the mate, in order to allow the spouse to focus more clearly on self than was possible during the dying process. Subjects for this study had been widowed for three to 12 months. Previous research has shown that prior to three months following a loss, people are still experiencing acute grief.23 Subjects interviewed by Parkes23 at 13 months following a loss were found to have good recall of events surrounding the death of a mate.
An interview guide was developed for the study. It consisted of closed questions and an open-ended question about what helped during the mate's dying process. Two experts in the area of death and dying were contacted in order to obtain content validity of the research tool. Both of the experts, a nurse who has conducted research with spouses of dying patients, and a psychologist who has taught death and dying courses, responded that the organization of the tool and the questions were appropriate to the research question.
The researcher contacted all subjects by letter to explain the project. This was followed by a telephone call to determine interest in participating in the study. The researcher interviewed subjects in their homes and asked them to recall the last week of their husbands' or wives' lives in the hospital. After subjects were asked specific questions about their experiences, such as length of mate's illness and length of last hospitalization, the open-ended question was asked.
Subjects were asked "What helped you or got you through your husband's (or wife's) dying process?" Each interview lasted for about an hour. The interviews were tape recorded and after they were completed, a data card was made for each resource given in response to the open-ended question.
In order to establish reliability of content selected for analysis, five tapes were randomly selected and two raters independently recorded resources that were named by the subjects. The investigator compared content selected for analysis with that selected by the raters. The rate of agreement in content selected was 87%.
At the conclusion of the reliability check for content selected for analysis, the researcher sorted data cards according to responses that were very similar, and then placed them into one of the categories described in the literature review. The researcher provided the raters with the definitions of each of the categories of resources: interpersonal support, religious-spiritual beliefs, and intrapersonal coping (see Table 1). The raters independently sorted the subjects' responses into the three categories. The reliability of response placement between the investigator and the raters was based on rate of agreement and was 96% to 99%. Prior to data analysis the cards were combined for each subject according to resource category named. This was done so that results would describe subjects according to resource category named rather than the frequency with which each subject identified one resource.
The names of people who met the criteria for the study were obtained from the medical records office in two hospitals. The two hospitals were similar in size and each had an oncology unit where the potential subjects' mates had died. AU spouses of patients who had died of a cancer death in the past three to 12 months and who were over 50 were contacted and invited to participate in the study.
BEHAVIORS OF NURSES WHO HELPED DURING CRISIS OF MATE LOSS
Forty-eight individuals, 19 (40%) men and 29 (60%) women agreed to participate in the study. The sample that refused to participate (34%) did not differ appreciably from the sample that agreed to participate except that the majority of all refusals were from women (77%) with few men (23%) refusing to participate in the study. Thirty-two (67%) of the subjects were between the ages of 50 and 69, and 16 (33%) of the subjects were between the ages of 70 and 89.
There was only one subject in the study who had a Spanish surname and there was no other ethnic variation in the sample. The distribution between the two hospitals was fairly equal. The majority of the sample (90%) had been married for more than 30 years. Nineteen percent of those subjects had been married for more than 50 years. Seventy-seven percent of the subjects described their marriage as very satisfactory.
Subjects who participated in the study described characteristics of their mates' dying process and death-related characteristics. The majority of mates (67%) were ill for two years or less and (69%) were in the hospital for two weeks or less on the last hospital admission. Sixty- four percent of the patients had been in the hospital four times or less.
When subjects were asked what it meant to them to have their mates on an oncology unit, 19 (40%) said that it meant to them to have their mates in an said that it bothered them to see people die, and 21 (42%) liked the oncology unit for one or more reasons.
Forty (83%) of the subjects said that they had experienced previous losses, and the majority mentioned the loss of relatives, primarily parents. Some subjects would say that the relationship between parent and child is "different" than that between spouses, or that they remained "strong" during the loss of a parent because the spouse was there to help.
Resources During Crisis of Mate Loss
Subjects most often named emotional support (77%) and support in the form of information, aid and services (60%). Religious or spiritual beliefs that reflected hope or meaningful death were named by 38% of the subjects. Fatalistic comments based on belief in the will of God were named by 35% of the subjects.
Cognitive coping strategies such as "keeping strong" for self or others were named by 46% of the sample. Behavioral actions such as "keeping busy" were described by 21% of the subjects.
Subjects were asked to name hospital staff who helped in the last week of the mate's life. Nurses were named most often for the help they provided. Seventy-five percent of the subjects named nurses as helpful and described behaviors that could be considered supportive (see Table 2).
As mentioned earlier by Dimond,8 the extent to which the bereaved person perceives the social network to be supportive is as important as the nature and accessibility of the support. The fact that support is so important during the last week of a mate's life is probably related to a number of factors. As a spouse realizes that one of the most important people in his or tier life is leaving, the support of others could help to decrease feelings of loneliness.
The support of others allows spouses to express their fears and concerns, and to feel the physical and emotional comfort of being close to others.
The recognition that interpersonal support was perceived by many spouses to be important during the crisis of loss has an impact on nursing roles and functions. A hospital environment is generally frightening and foreign to most people. When a spouse is able to turn to others for support, the environment could become less threatening. The support offered by nurses to patients and family should be legitimized as a critical component of nursing care rather than something to be offered when tasks are completed. The caring approaches used by nurses can enable spouses to perceive themselves as part of the process that the mate is experiencing rather than as an outsider.
Findings from the Institute of Medicine study on bereavement21 indicated that during the crisis of loss everyone needs support and some education about the grief process. While support and education may be provided informally by friends and family, "health professionals also have a responsibility to offer support, to inform the bereaved of additional resources in the community (such as mutual support groups), and to monitor their progress and make referrals to mental health professionals as appropriate."
The nurse is the health professional who is likely to have the closest working relationship with the family. The grief process presents a situation in which the artistic and scientific aspects of nursing can be applied in the care and support administered to the patient and spouse.
The majority of patients who were ill for less than two years had less than four admissions to the hospital and were in the hospital less than two weeks before dying. These patterns are an indication that most treatment for cancer is taking place outside the hospital.
The findings have implications for nursing in that nursing interventions could have an important impact in an outpatient setting before the crisis of loss. A relationship that could be established between the nurse and spouse of a terminally ill patient at time of diagnosis could be maintained through the treatment phase and eventual dying process. A long-term relationship between the nurse, patient and spouse is likely to enhance rapport, and facilitate the support that the nurse could provide to the patient and spouse.
An important finding in this study was that 75% of the subjects said that nurses were helpful to them. This is an indication that nursing education and practice should continue to emphasize the caring aspects of nursing. Supportive interventions should be taught and reinforced in nursing school. It is important that the environment in a hospital setting and the staffing patterns be designed to foster supportive behaviors of nurses. At times when healthcare costs are trimmed, consideration should be given to maintaining the ability of the nursing staff to offer support.
In this study, behaviors perceived as helpful included holding, hugging, crying with spouse, showing kindness, as well as providing information about the mate's condition. Subjects described relief and comfort when the nurse cried with them or held them when they cried.
The final phase of life, as well as the final phase of a marriage relationship can be a shattering experience for the husband and wife who have spent most of their lives together. The loss echoes other past grief experiences and is often accompanied by other losses associated with the aging process. Future research of the crisis of mate loss could focus on application of the findings in this study. Clinical research that would evaluate the effectiveness of supportive nursing interventions could provide a better understanding of the caring components of nursing.
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BEHAVIORS OF NURSES WHO HELPED DURING CRISIS OF MATE LOSS