The loss of a spouse can be one of the most devastating and challenging events in a person’s life. Experiencing a spouse’s death is at the top of the list for stressful events on the Holmes and Rahe (1967) Social Readjustment Rating Scale (SRRS), which is the most widely used instrument to measure a person’s experience of psychological distress (McGrath & Burkhart, 1983). Research has demonstrated that SRRS scores are consistently related to subsequent episodes of illness and psychological distress (McGrath & Burkhart, 1983). Since the average age of widowed women and men in North America is 75, it is important to understand the stress that widowhood can bring to older adults (Martin-Matthews, 2011).
With the increasing life span over the past years, the number of older adults who are widowed has also increased. The 2009 American Community Survey reported widowhood rates for the previous 12 months as 7.8 for women and 3.5 for men per 1,000 women or men age 15 and older (Elliott & Simmons, 2011). Approximately 50% of women ages 75 to 84 are widowed (Rusoff, 2011). When considering the number of aging Baby Boomers born between 1946 and 1961, it is easy to see that the number of widowed people is likely to increase substantially in the next decade. Given the large number of those widowed in the older adult population, along with the significant stress that comes with the loss of a spouse, it is surprising that nursing research has not focused more on the effects of bereavement on the health of the surviving spouse.
Physical and Mental Health
In one study from the Women’s Health Initiative, researchers examined whether widowhood was associated with physical and mental health problems in women ages 50 to 79 (Wilcox et al., 2003). Findings from the sample of 72,247 participants indicated that widowed women report poorer physical and mental health and generally poorer health behaviors than married women. They also reported more unintentional weight loss during the 3-year period of the study. Recent widows experienced the most significant impairments, but over time they showed increased stability and slight improvements in both physical and mental health. Researchers concluded that becoming a widow often leads to acute impairments in mental health, depressive symptoms, and decreased social functioning. After 3 years, the emotional and social functioning of widows usually improved, attesting to their resilience and capacity to reestablish connections. The researchers noted, however, the need for additional services that strengthen social support among women who have difficulty during this transition.
Psychological stress leading to depression and anxiety is a normal response to bereavement, but it is important to recognize the increased vulnerability of widowed people to psychiatric illnesses that may result in suffering and impairment of daily functioning. Onrust and Cuijpers (2006) conducted a systematic review of mood and anxiety disorders in widowhood that included 11 studies of 3,481 widowed individuals and 4,685 non-widowed individuals who served as controls. The term widowhood included both women and men who had lost a spouse. Researchers found that the prevalence of depression and anxiety disorders was considerably elevated in widowed individuals. This was especially true during the first year after loss of a spouse, when there was a prevalence rate of nearly 22% for individuals with a major depressive disorder. The authors noted that due to the small number of studies reviewed, caution should be used in generalizing their findings. However, since the problems in widowed individuals were sometimes not evident in the early stages of bereavement and appeared as long as 2 years after the loss of a spouse, it is important for health care professionals to monitor widowed individuals for potential mental health problems for extended periods of time.
It is also important to think of the effects of bereavement on partners in same-sex relationships. Although the numbers of older lesbian, gay, and bisexual (LGB) adults is increasing, very little research has focused on end-of-life or bereavement issues for this population (Almack, Seymour, & Bellamy, 2010). Boswell (2007) studied the structure of grief resulting from spousal bereavement experienced by heterosexual and homosexual men and women. She found that although many similarities existed between the heterosexual and homosexual groups, the homosexual widows and widowers experienced less social support and were more isolated in their grief. Taylor and Robertson (1994) noted that the surviving partner may be acknowledged by the family as only a “friend,” denying the depth of their loss. Almack et al. (2010) suggested the need to focus specifically on issues relevant to older LGB generations, where the experience of bereavement intersects with the experience of growing old. LGB older adults in today’s society have lived through a time when same-sex relationships were criminalized and therefore may be less open to sharing their sexual orientation than younger LGB individuals.
The study by Almack et al. (2010) included focus groups with 15 older LGB individuals. Comments from participants revealed how their reluctance to “come out” sometimes had huge implications on their experiences of bereavement. One participant described how this affected the loss of his partner:
I knew he wanted burial and he wanted to be buried next to his mother. He ended up being cremated [which] was totally against his religion.... I couldn’t stop them but it was like strangers organizing his funeral; I was his family.... But he never wanted it to be known that he was gay. And I respected that.
Almack et al. (2010) also noted that it is important to recognize that widowed older LGB people are not as likely to have children to help care for them and may also have less access to informal sources of care and support. Participants described fears of dying alone and worried about being placed in a long-term care institution with a heterosexual peer group that may view their lifestyle as a stigma. One woman described her fears: “An assumption that when you get old, everyone co-exists happily in a nursing home or whatever but…you’ve got what were called the gay bashers and now they’re the same age still as us” (Almack et al., 2010, p. 917).
Most bereaved individuals are resilient and do not require mental health treatment to help them adapt to their grief. Some individuals, however, experience chronic severe grief that is debilitating and may require clinical intervention. One of these disorders, complicated grief, is a recently recognized phenomenon that is characterized by intense distress that interferes with functioning. The condition is estimated to occur in as many as 10% to 20% of bereaved individuals (Ghesquiere, Martí Haidar, & Shear, 2011; Shear et al., 2011). Boswell (2007) found that homosexual partners who had experienced the loss of their spouse tended to have a history of prior mental health difficulties that could be predictors of complicated grief. Symptoms include sadness, crying, sleep disturbance, suicidal thinking, and intense yearning for the deceased. Complicated grief is currently being considered for inclusion in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, because of the importance of diagnosing, so appropriate treatment can be implemented (Shear et al., 2011). It is important, however, that new disorders only be created when they are clearly different from existing diagnoses (e.g., major depression, posttraumatic stress disorder [PTSD]). Continuing research has provided strong evidence that although symptoms of complicated grief overlap with symptoms of major depression and PTSD, they are different entities. Thus, the potential benefits of creating a new diagnosis of complicated grief to identify bereaved individuals who need clinical intervention outweighs potential harm that could come from a misdiagnosis (Shear et al., 2011).
As widowed individuals continue to make up an increasing percentage of our population, it is important to consider what effect living alone has on these individuals. It is known that loneliness can lead to depression and an increase in illnesses in old age. However, recent research suggests that widowed people are able to transition into meaningful existences for themselves, even while living alone, if provided with needed support from their families, friends, and the community.
Van den Hoonaard (2009) carried out qualitative studies that compared widows’ (n = 27) and widowers’ (n = 26) transitions to living alone. Findings from the studies suggest that widows and widowers transition to living alone in different ways, have different understandings of the experience, and use different strategies to make the change successful. In the research interviews, widows focused on their need to overcome the fear of living alone. They described how they initially wanted to stay with friends or family, but they worried that they might not have the courage to eventually leave. One woman, whose daughter wanted her to live with her temporarily, stated, “No, I’ve got to stay here…I’ve got to face it. If I’m going to live in my own home, I’ve got to face up to it…I’ve got to stay here. So I did from then on” (van den Hoonaard, 2009, p. 741).
The women talked about the challenge of learning to master daily tasks that their husbands had assumed. One participant, Muriel, suggested the initiative that is needed for widows to learn even simple new tasks:
The electricity had gone out and the clock was “blinking…12. 12…I had never adjusted that thing and I didn’t even know how to open the little box there.” After a week, “I put up a box so I wouldn’t see it.” Finally Muriel decided, “I’m going to fix this thing or it’s going to be unplugged.” She used the instruction book to go step-by-step until it was done. For Muriel, this represented a “big achievement.”
Women in the van den Hoonaard (2009) study described how they came to enjoy living alone and the new sense of competence they experienced from having mastered new skills. In contrast, the men described their households as “cold” places and felt the need to be out of the house for most of the day so that they would not “sit and dwell” and give in to their grief. One widower described it this way: “The house was like a big, empty cavern, canyon, cave, anything you want to express it. There was an emptiness there, and I was looking for her and I couldn’t find her” (van den Hoonaard, 2009, p. 743).
The men did not seem to enjoy taking on the skills of cooking and cleaning, typically done by their wives, tending to minimize the development of these kinds of skills; some men resorted to “buying” the housekeeping and cleaning tasks. Those who did the work themselves, even those who had helped their wives with housekeeping, expressed surprise at how much work it was, as described by two participants who discussed doing the laundry and preparing meals:
- There are some things that I got: two shelves of chemicals in there. I don’t know what the hell she used that for.... My clothes are probably not as clean as they should be, but I wash them.... I’m starting to get a little bit tired of housework and all that stuff.... You know, I don’t always do a good job of it. Sometimes I just give it a lick and a promise every few weeks.
- I never realized the amount of work to keep a house going until afterwards…just a little lunch, you know. There’s a mess. You’ve got to wash the dishes and stuff like that. It’s the planplanning that gets to me. (van den Hoonaard, 2009, pp. 747–748)
Van den Hoonaard (2009) concluded that both women and men were lonely after being widowed, but it was primarily the men who lost the sense of their house as a home. It appears that although women did not begin to live alone by choice, once they adjusted to it, they found a “comfort factor” in nurturing themselves after spending the majority of their years caring for a husband and children. Men felt mainly emptiness in the house and a strong need to get out, which was an important strategy for maintaining social connections since men do not tend to invite others to their home to socialize (van den Hoonaard, 2009).
When a widowed person becomes ill and needs treatment, living alone takes on new dimensions. Because women have a longer life expectancy—and also tend to marry older men—the majority of widowed individuals living alone are women. Robinson (2002) explored 12 older widows’ experiences of living alone after heart surgery. The women perceived the surgical experience as a personal health crisis that was closely related to their ability to live alone. The illness threatened the highly valued independence they had worked so hard to attain after losing their spouse. They exhibited a new awareness of their bodies’ symptoms and feelings of vulnerability related to knowledge of the chronicity of their cardiac disease. This sense of vulnerability seemed to lead to a contracting world during the recovery period in which they experienced a loss of spontaneity and were more cautious in engaging in physical activities. One participant explained it this way: “I was so used to doing everything myself. And then all of a sudden, you can’t do [as much]. So, that’s what concerned me. Would I be able to go back and do what I used to do” (Robinson, 2002, p. 123).
During the post-recovery period, the women especially valued their renewed ability to live alone and do things for themselves again. They saw living alone as a reflection of their self-worth through accomplishing daily activities and having personal freedom. One woman explained why she had not moved in with her daughter: “I prefer living alone. Because I do what I want. I go to bed when I want, get up when I want. If I want to go somewheres [sic], I do. If I don’t, I stay home” (Robinson, 2002, p. 124).
Nurses’ Roles in Interacting with Widowed Individuals
There are a variety of settings in which nurses may encounter individuals who are experiencing grief from loss of a spouse. Thus, nurses need to be aware of potential physical, mental, and emotional needs of widowed individuals. Even the simple act of filling out information on a patient history form may bring back sad memories as the patient finds it necessary to check the “Widowed” box. The mere act of checking a box may seem to invalidate the years of marriage that have meant so much to them. Research suggests that 9 of 10 bereaved spouses have negative reactions to the terms widow and widower, believing that the label tends to isolate them at a time when they need emotional support from others (Adelman, 2011). This feeling was described by Sue Larrison (2012) on her blog:
Isn’t it weird when you are asked your marital status and you have to indicate widow? I hate that word. It makes me think of grim looking old ladies in black dresses. I don’t know why they need to know my marital status. Do widows have marital status? Does a widow have any status in our society today? I don’t think so.... Therefore I think the W word needs to be changed. Updated, modernized, more reflective of the 21st century.
Very little research is available today that focuses on needs of older adults who have been widowed, and almost none exists on those in same-sex partnerships. For nurses to understand how to meet the complex needs of this vulnerable population, we need to know more about their experiences. How do variables such as length of the marriage or number of marriages; degree of liking or positive regard for each other, children, and grandchildren; and work history affect widowhood?
What clues for complicated grief should nurses look for in those who have been widowed? What types of social support from family, friends, and the community are especially helpful? How can the experience of living alone be made more satisfying for both widows and widowers? What social policies need to be changed to provide ways for widows and widowers in diverse situations to maintain their independence?
In her poetry, Sharon Weber (1998) expressed the ambivalence and courage experienced by a recovering widow (Figure). As much as we need to understand the overall needs of widowed adults in our society, we also need to understand the uniqueness of each person who has experienced the devastating loss of a spouse.
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