Conjugal bereavement is considered a major psychosocial Stressor associated with high morbidity and mortality rates in surviving spouses.1-8 The effects of stress, poor self-care, and suicide all contribute to mortality.9 The grieving process and role changes add stress, which may result in illness.
Persons 65 years of age and older are the fastest growing group in the US population. There were 13.9 million older women in 1977 (versus 9.5 million older men); this number is expected to increase to 33.4 million women (versus 22.4 million men) by the year 2035. 9 Conjugal loss is a problem that mainly affects women because they have greater longevity, are usually younger than their husbands, and their marriage rate after bereavement is lower than that of widowers. Given the projected increase in older women and the effects of bereavement on health, conjugal loss is a significant problem for women.
Researchers interested in bereavement have often studied persons under 65 years of age2-10-12 or have mixed the aged with the young.1,4,13,14 Findings on younger widowed may not be directly applicable to aged widowed, as many elderly grievers may have lost family and friends through death and are coping with multiple age-related Stressors, leaving fewer available resources to help them cope following bereavement.
Limited numbers of studies exist on coping with bereavement, especially the coping responses of older adults in earlier bereavement time periods of one year or less,15-17 which may be the most stressful. Coping with bereavement has been addressed in theoretical discussions and in the secondary findings of research on widows. Dimond18 mentioned the following as coping methods used by widows: keeping busy, ignoring, denying, selective attention, rationalizations, obsessional review of events surrounding the death of the spouse, taking psychotropic drugs and alcohol, initiating participation in social groups, and learning new things such as driving a car. Keeping busy, developing new social roles and relations, and focusing on one's social role were strategies used by older widows to cope with loneliness associated with bereavement.19 It was suggested by Moss and Moss20 that the widowed cope by maintaining their tie with the deceased through keeping memories alive, talking to the deceased and by fulfilling expectations of the deceased spouse. Johnson et al17 found that the widowed who initially coped effectively continued to do so over the course of one year following the death of their spouse; however, presence of persistent stress was negatively associated with coping ability and self-esteem one year later.
Strategies that widows view as helpful versus not helpful have seldom been identified. Clark et al15 identified the beneficial coping behaviors used by 27 widowers as: doing things with my family (57%); reading (62%); believing in God (62%); keeping myself in shape and well-groomed (54%); and going places with friends (50%).
One of the functions of nursing is to help individuals cope with Stressors. Identification of helpful ways to cope with conjugal bereavement can provide knowledge thai may help facilitate transition to widowhood, reduce stress, and expedite the helping interventions of nurses.21 The purposes of the study were to identify helpful and unhelpful coping strategies utilized "by conjugally bereaved older women and investigate the relationship between ways of coping and health dysfunction following bereavement.
Sample and Procedure - A convenience sample of 100 widows was obtained using burial records from Catholic parishes in one Midwestern city. The criteria for inclusion in the study were a widow: a) whose spouse died between I and 12 months prior to the interview; b) who was aged 65 to 85, inclusive; c) who was not remarried; d) who was able to speak English; and e) who was not institutionalized. Widows who fit the sampling criteria were mailed a "Letter of Explanation" which invited them to participate in the study. Within one week after receipt of the letter, potential subjects were contacted by telephone to seek their participation. For the widow who consented, a home interview was scheduled. Of the 153 widows who were contacted, 53 declined participation, yielding a refusal rate of 34%. The participants were: white and primarily Catholic (n = 98); aged 65 to 81 (M = 71.3 years); and bereaved for a time period ranging from 74 days to 364 days (M = 224 days). Forty percent of the subjects had spouses who died suddenly while 60% reported a chronicillness death for their spouse. The mean number of days subjects cared for their spouse before death was 487.
Instruments - Coping was denned as the cognitive and behavioral efforts made to master, minimize, alleviate, or reduce external and internal demands. Folkman and Lazarus22 Ways of Coping Checklist was used to measure coping with bereavement. The instrument describes a range of behavioral and cognitive coping strategies that a person uses in a specific stressful situation.
Examples of strategies include: "made a plan of action and followed it," and "accepted sympathy and understanding from someone."
Items were classified into overall problem-focused and emotion-focused coping items or into seven different ways of coping: problem-focused, wishful thinking, mixed (help-seeking/ avoidance), growth, minimizes threat. seeks social support, and self-blame. In the present study, reliabilities on the Ways of Coping Checklist using Cronbach alphas were lower than those based on data from a community sample of people who coped with the stressful events of daily living.22 Cronbach alpha is one type of internal consistency reliability that refers to the degree to which the subparts of the Ways of Coping instrument are all measuring the same dimension. Lower reliabilities may reflect differences in the samples studied.23
Individual coping items were examined for frequency of use and helpfulness. Scoring involved summing the number of ways of coping answered yes for each subscale. A coping strength score was obtained by summing the total number of coping strategies used by the respondent, including both desirable and less desirable coping methods.
Health status was defined as the ability of an individual to function physically and psychosocial Iy within his or her capabilities. Sickness contributes to dysfunction in behavior or performance of daily activities. The physical and psychosocial dimension subscales of Gilson et al24 Sickness Impact Profile (SIP) were used. The SIP is a behaviorally based measure of sickness-related dsyfunction that provides a reliable and valid measure of health functioning. Items address activities involved in carrying on one's life and reflect the person's perception of his or her performance of these activities. Examples of items include: "I laugh or cry suddenly," and "I stay lying down most of the time. " Subjects respond to only those items that describe them today and relate to their health. Each item has an assigned scale value indicative of severity of dysfunction. The dimension scores are calculated by adding the scale values for each item checked within categories for the dimensions, dividing by the maximum possible dysfunction score for these categories, and then multiplying by 100. For both dimensions, the larger the percent score, the greater the impairment of health functioning. Separate reliability data do not exist for the two dimension subscales. Test-retest coefficients (r = .97) and of internal stability coefficients (r = .94) for the overall instrument support a high level of reliability.24
Helpful Coping Strategies - A variety of strategies were reported to be helpful to most of the women. These included: keeping busy, participation in social groups, learning new skills, review of the death, religion and prayers, talking with the deceased spouse, sensing the spouse's presence, and recalling happy memories.
Seventy-nine percent of the widows reported keeping busy to cope following the death. Activities included: visiting relatives and friends, doing gardening and yard work, remodeling the home, eating out, shopping, attending bingo, reading, and partaking in hobbies such as crocheting. Instead of developing new roles, most widows returned to activities they had little time to do when their spouse was ill, such as sewing, or they continued to do the things they used to do with their spouses.
Participation in social groups was used by 10% of the widows. Some joined senior citizen groups or became more active in church-related groups such as the Legion of Mary. Self-help groups, such as a bereavement group and the I Can Cope cancer support group, were used by 5% of the widows to help them manage grief, and to learn new coping mechanisms and ways to readjust to a single lifestyle.
Learning new skills was another coping strategy. Widows took driving lessons so they could be more independent and arranged to take night school courses on home repairs or financial management to help them manage their household.
Review of the death was a coping mechanism reported by 64% of the widows. These women went over the death again and again in their mind to try to understand it and accept it. Use of this coping mechanism was more characteristic of widows who were bereaved for three or more months. For widows bereaved within the first three months, denial and ignoring were frequently used. Thirty-three percent of the widows reported refusing to believe their spouse had died and 26% "went on as if nothing had happened." As one woman described, "I try to forget and live with the living . . . you could get yourself sick if you dwell on it."
The majority of the widows felt they became closer to God and to their religion following the death of their spouse. Most (89%) of the widows reported using prayer to cope with their bereavement. Comments included:
"I walk around and talk to the Lord ... I say, 'I put everything in your hands; I can't handle it."'
"Prayers are uppermost in my life ... I put my faith in God, what happens is His will."
"I say, 'Dear God, help me to go through this grief.'"
In addition to prayer, widows also practiced their religion to a fuller degree following their spouse's death. Widows reported reading the Bible, participating in novenas and renewals, saying the rosary, and increasing their attendance at mass after the death. Some widows did not pray because they felt that prayers during their spouse's illness were not answered or that they were angry at God because He permitted their spouse to suffer a terrible death. The fact that the sample was primarily Catholic likely influenced findings on coping with bereavement, given Catholics' belief in afterlife and the support they may have obtained from their faith.
Talking to the deceased spouse was a coping mechanism reported by 17% of the widows. Widows asked their spouses for help when they had difficulty or were in need of special favors. Comments included:
"I couldn't open a jar ... I said to him, 'I'm going to leave it here; when I return please help me open it'. . . He opened it."
"I talk with my husband in heaven ... I asked him to work with God and help our son find a job and our daughter get pregnant . . . She is 37 and tried for seven years to become pregnant . . . Right after the death, she became pregnant and my son found a job."
Associated with talking with the spouse was "sensing the spouse's presence." These widows reported that experiencing the spouse's presence decreased their feelings of separation and loss and instilled hope that they would see their spouse in heaven.
"His spirit is here ... I feel when he is gone and when he is present."
"The first time I went to church after he died, I said, 'It would be funny if I got two hosts (communion), one for him and one for me.'. . . The priest gave me two hosts ... I took it as a sign that he was with me in spirit."
Use of memories was a coping mechanism that presented dichotomous findings. Many widows found it helpful to recall happy memories with their spouse in order to cope with bereavement. For these widows, memories were fostered by keeping some of the spouse's belongings, maintaining the house as it was prior to the spouse's death, collecting family pictures to tell their story, or keeping a diary of how they met.
Other women (23%) found that forgetting helped them to cope. These widows got rid of the spouse's belongings shortly after the death and, in some cases, sold their homes and moved to a new apartment. Women who attempted to forget appeared to be in more psychological turmoil and, in general, had poorer physical and psychological health than widows who fostered memories.
Other helpful coping strategies that were used by 78% or more of the women were: just concentrated on what to do next - the next step (98%); just took things one step at a time (98%); accepted sympathy and understanding from someone (98%); accepted strong feelings, but didn't let them interfere with other things too much (95%); accepted it (the death) since nothing could be done (94%); . . . knew what had to be done so you doubled your efforts and tried harder to make things work (92%); tried not to act too hastily or follow the first hunch (84%); looked for the silver lining . . . tried to look on the bright side of things (83%); let feelings out somehow (83%); and told yourself things that helped you to feel better (78%).
Less Helpful Coping Strategies - Less helpful strategies reported by widows were: taking medications or alcohol (n=16), blaming oneself (n=17), bargaining or compromising (n = 22), sleeping more (n=ll), avoiding (n=12) or getting mad at people (n= 16), making promises to oneself (n= 10), and using fantasy (n = 20).
Fifteen widows were currently taking medications to cope, including antidepressants (3%), tranquilizers or nerve pills (9%), and sedatives (3%). Only one widow reported consuming alcohol in the form of beer to help her forget. Most of these women reported that medications did not help them to manage their grief on a long-term basis and a few felt them to be harmful. Blaming oneself was frequently associated with feelings of extreme guilt or that the widow should have done more for the deceased spouse.
Widows most often bargained or compromised with God. If God helped them through the difficult grieving process, they in turn would do special favors for others. Sleeping more was characteristic of widows who were depressed. Generally, widows reported having difficulty sleeping, particularly in the first few months following the death.
Pearson Product-Moment Correlation Coefficients of Ways of Coping with Dysfunction Measures
Avoiding or getting mad at people, particularly physicians, nurses, and family involved with the spouse during his illness, was reported by 28 widows. Some widows verbalized their anger about the type of health care provided by health professionals, as well as the lack of support received by immediate relatives who could have given more assistance to the widow. Making promises to oneself and fantasy were both viewed as short-term coping mechanisms which were seldom effective in reducing the long-term effects of bereavement.
Widows reported receiving unhelpful or threatening information from friends or other widows which did not help them to cope with their bereavement. Unhelpful information shared with widows included: being told widowhood is terrible ("You never get over it." "They will treat you like a leper."); being made to feel guilty about decisions made to adjust to widowhood ("I went to a wedding and a friend told me I should be ashamed of myself and be at home grieving"); being told not to cry; and receiving information that was unrelated to the widow's situation or contradictory to the widow's current perceptions ("I was told time would heal ... It doesn't heal.").
Coping and Health - Descriptive data analyses indicated that the sample was a relatively heaithy group of widows. The mean physical and psychosocial dysfunction scores for the total sample were 7.51% (SD = 9.44) and 12.18 (SD = 11.64), respectively. Maximum possible scores were 100% physical and 100% psychosocial dysfunction. The mode or most frequent score on both SIP measures was 0% dysfunction, which indicated that many of the women in the study perceived themselves to be functioning maximally at 100% both physically and psychosocially. The SIP physical and SIPpsychosocial dysfunction scores were correlated (r - .57) at the .001 level of significance. More specifically, widows with high physical dysfunction also had high psychosocial dysfunction, and widows with low physical dysfunction also reported having low psychosocial dysfunction.
Pearson correlational analyses were done to examine coping's relationship to health dysfunction. The Pearson correlations are presented in the Table. The more wishful thinking, mixed, growth, minimizes threat, self-blame, overall emotion-focused and overall problemfocused coping used by widows, the higher their psychosocial dysfunction. Higher use of "minimizes threat" coping was related to higher physical dysfunction. Use of more coping strategies (coping strength) was related to higher psychosocial dysfunction (r - .39, p < .001).
Discussion and Implications
Findings from this study have practical implications for nurses caring for the conjugally bereaved. The nursing profession is one resource that can be effective in compensating for, motivating, or enhancing the coping activities of individuals.25 Knowledge about helpful coping strategies provides a beginning base from which to provide appropriate nursing care to bereaved widows. Strategies can be shared with recently bereaved women to facilitate their adjustment. Nurses might teach widows a repertoire of helpful coping strategies to manage their bereavement, such as keeping busy, participating in social groups, learning new skills, and turning to religion and prayer. Religion, with its promise of an afterlife and its community support, may offer a comforting and strengthening base in the encounter with loneliness following bereavement. The nurse might discuss the important benefits religion or spirituality have for helping widows cope with their loss. Nurses may wish to discourage widows from employing less helpful strategies, such as taking medications, blaming oneself, and using fantasy.
There is a need for nurses to educate members of widows1 support systems regarding what is appropriate to say to a widow, and what acceptable behaviors for widows are. Educational programs to address the range of acceptable and therapeutic behaviors and communications for widows following bereavement need to be developed.
Findings suggest that widows with better health functioning (lower dysfunction) following bereavement use less coping techniques than widows with more health dysfunction. It may be that widows with less health dysfunction experience fewer bereavementrelated Stressors and, in turn, require fewer coping strategies. Bereavement is a Stressor that can be associated with many other stressful problems, such as financial losses and loneliness, which also require coping mechanisms. Each bereavement-related problem may require different types and amounts of coping, and the number of bereavement-related problems confronting the widow at one time may affect the amount of coping strategies used. Understanding the nature of coping's relationship to health functioning also appears to involve the role of appraisal of bereavement as a mediating variable . Coping is a reflection of the degree of threat appraisal; that is, the higher the threat appraisal, the more coping is used.16
A methodological problem likely influenced the findings. The low to moderate reliabilities on the coping scales and subscales suggest that findings on coping's relationship to health functioning need to be viewed as tentative until additional support is provided through future research. It may be that coping is situation-specific,22 and therefore utilizing scales developed from a factor analysis of coping responses to a different kind of siressor may not be appropriate for bereavement.
Folkman and Lazarus22 suggested that coping is a shifting process; that is, coping strategies may change as the status and appraisal of a stressful situation changes over time. It is possible that coping strategies viewed as helpful during the early grieving period, such as dental, may not be helpful during later time periods following bereavement. Longitudinal research is needed to identify strategies that are beneficial during different phases of the grieving and readjustment process. Further research designed to describe the frequency and degree of helpfulness of coping strategies following bereavement will contribute knowledge necessary for the development of reliable and therapeutic intervention protocols and programs for the bereaved.
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Pearson Product-Moment Correlation Coefficients of Ways of Coping with Dysfunction Measures