http://nsq.sagepub.com/ Nursing Science Quarterly http://nsq.sagepub.com/content/18/3/233 The online version of this article can be found at: DOI: 10.1177/0894318405277525 2005 18: 233 Nurs Sci Q F. Beryl Pilkington Grieving a Loss: The Lived Experience for Elders Residing in an Institution Published by: http://www.sagepublications.com can be found at: Nursing Science Quarterly Additional services and information for http://nsq.sagepub.com/cgi/alerts Email Alerts: http://nsq.sagepub.com/subscriptions Subscriptions: http://www.sagepub.com/journalsReprints.nav Reprints: http://www.sagepub.com/journalsPermissions.nav Permissions: http://nsq.sagepub.com/content/18/3/233.refs.html Citations: What is This? - Jun 23, 2005 Version of Record >> at BROWN UNIVERSITY on October 29, 2012 nsq.sagepub.com Downloaded from
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http://nsq.sagepub.com/Nursing Science Quarterly
http://nsq.sagepub.com/content/18/3/233The online version of this article can be found at:
DOI: 10.1177/0894318405277525
2005 18: 233Nurs Sci QF. Beryl Pilkington
Grieving a Loss: The Lived Experience for Elders Residing in an Institution
Published by:
http://www.sagepublications.com
can be found at:Nursing Science QuarterlyAdditional services and information for
ARTICLEGrieving a LossNursing Science Quarterly , 18:3, July 2005
Grieving is a univerience that accompaniloss (Cowles & Rodg1993; Peretz, 1970), fmultiple theoreticalvarious stages and ppsychologists, and otand written about grithe hope that knowlstanding about this hmight better prepare tbe with those who arStill, there is room fstanding from theorethat present the grievinis lived by persons wities in histories andsearch reported here eexperience of grievelderly persons residicare facility.
A review of theotraced interest in griev(1917/1957) classic trand Melancholia, whiing as a process whewithdraw the energy tlost object, throughseminal investigationsseparation. Most authas a normative experiephases or stages (seBowlby, 1980; EngeRoss, 1969; Lindema
Grieving a Loss: The Lived Experiencefor Elders Residing in an Institution
rsal human expe-es any significanters, 1991; Jacob,or which there areviews depicting
rocesses. Nurses,hers have studiedeving a loss withedge and under-uman experiencehem to assist ande experiencing it.or further under-tical perspectivesg experience as itth some similari-contexts. The re-xplored the liveding a loss withng in a long-term
retical literatureing from Freud’seatise, Mourningch explains griev-reby individuals
hat tied them to aBowlby’s (1980)on attachment andors depicted griefnce consisting ofe, for example,l, 1964; Kubler-nn, 1944; Parkes,
1972; Werner-Beland, 1980). The en-during influence of such works isapparent in the normative view of griefthat prevails in nursing and medical lit-erature (Cowles & Rodgers, 1991),wherein the focus is on delineating nor-mal grief, distinguishing it from patho-logical grief, and managing its symp-toms (Harwood, 2001; Rosenzweig,Prigerson, Miller, & Reynolds, 1997).
Aging has been described as a pro-cess marked by multiple, gradual, andcumulative losses (Burnside, 1973;Garrett, 1987). Kastenbaum (1969)proposed that in later life, losses mayoccur so frequently that there is insuffi-cient time to really grieve each one. Ac-cording to Agee (1980), limited supportsystems, poor health, restricted mobil-ity, and inadequate coping strategiesmake grieving more difficult for elderlypersons. Miller and Oertel (1992) pos-ited that admission to an institution canrepresent a major loss for chronically illelderly persons and, combined withother losses, it may produce feelings ofpowerlessness and hopelessness. Theseauthors also suggested that residents ininstitutions may receive positive rein-forcement for not expressing grief at thedeath of fellow residents and therefore,grieving may go unrecognized.
Research on grief in old age hassought to identify, classify, and differ-entiate psychiatric syndromes and todetermine their relationship to mortal-ity, bereavement-related behaviors, and
has mainly focused on conjugal be-reavement, which is believed to be themost significant loss event affecting theelderly (Byrne & Raphael, 1994). Con-sistent with earlier theories of grieving,most researchers have presented griev-ing in later life as a normative process ofmovement along stages linked with suc-cessful coping and resolution or inte-gration of loss (Caserta & Lund, 1992;Grimby, 1993; Hegge & Fischer, 2000;Herth, 1990; Vachon et al., 1982). Incontrast, and of particular interest here,are researchers who have investigatedthe lived experience of grieving a lossfrom the perspectives of persons livingwith losses. Jacob (1996), for example,conducted a series of interviews over 16months with widows whose spouseshad received hospice care. In other stud-ies, Cody (1991) explored grieving withadults from the general population andwith families living with AIDS (Cody,1995), and Pilkington (1993) exploredgrieving with mothers who had recentlylost their infant at birth. Findings fromthese studies provide insights intogrieving as a multidimensional, evolvingprocess of choosing meaning whilemoving beyond with losses.
The review of literature uncoveredno studies that specifically examinedthe experience of grieving a loss fromthe perspective of elderly persons resid-
, Vol. 18 No. 3,
July 2005, 233-242DOI: 10.1177/0894318405277525
F. Beryl Pilkington, RN; PhDAssociate Professor & Graduate Program Director, School of Nursing, York University, Toronto, Canada
Grieving a loss is a profound and universal human experience. This phenomenological-hermeneutic study was aninquiry into the lived experience of grieving a loss. The nursing perspective was Parse’s human becoming theory.Participants were 10 elderly persons residing in a long-term care facility. The study finding specifies the structure ofthe lived experience of grieving a loss as aching solitude amid enduring cherished affiliations, as serene acquies-cence arises with sorrowful curtailments. Findings are discussed in relation to the guiding theoretical perspectiveand related literature. Recommendations for additional research and insights for practice are presented.
dementia (Harwood, 2001). Research
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Keywords: grieving, human becom-ing theory, institutionalized elders, loss,Parse
ing in an institution. The current studybegins to address this gap in knowledge.The research question was, “What is thestructure of the lived experience ofgrieving a personal loss?” Study partici-pants were 10 elderly persons residingin a long-term care facility. The studycontributes new knowledge about aphenomenon that is especially signifi-cant for health and quality of life in thispopulation. The knowledge gained pro-vides insights for enhancing the qualityof nursing practice, particularly with el-derly persons residing in an institution.Avenues for further research are alsosuggested.
Nursing Perspective
The perspective in approaching thisinquiry was Parse’s (1981, 1992, 1998)human becoming theory. Viewedthrough the lens of this theory, humansare unitary beings coexisting in dy-namic, mutual process with the uni-verse. Humans freely choose meaningin situations and live what is personallyimportant and thus, actively participatein creating their unique lives. Health, inthis view, is an ever-evolving process ofbecoming (Parse, 1992). Health is alsounderstood as quality of life as viewedfrom the perspective of the one livingthe life (Parse, 1994).
Grieving a loss is a universal experi-ence that relates to health and quality oflife. The theory’s three principles andtheir related concepts (indicated withitalics) provide a framework for con-ceptualizing this phenomenon. The firstprinciple specifies the process of “struc-turing meaning multidimensionally [as]cocreating personal reality” (Parse,1981, p. 42). In light of this principle,grieving a loss can be viewed as the pro-cess of structuring the personal mean-ing of loss. It involves the explicit-tacitpicturing (imaging) whereby onechooses the significance of the loss andpreferred ways of living with it (valu-ing), while manifesting that realitythrough speaking-being silent and mov-ing-being still (languaging) (Parse,1998). The second principle explicatesthe rhythmical patterns of relating that
humans cocreate with the universe inthe process of becoming (Parse, 1981,1998). The rhythmical patterns that hu-mans live are inherently paradoxical inthat apparent opposites are lived all-at-once, though one side of the rhythmmay be in the fore and the other, in thebackground (Parse, 1981, 1998). Thus,it was an assumption that grieving a lossis manifested in paradoxical patterns ofrelating with others and the universe. Itentails engaging and not engaging(connecting-separating) with the real-ity of one’s loss while all-at-once dis-closing and not disclosing (revealing-concealing) how one is with the loss inways that both enable and limit(enabling-limiting) possibilities forone’s becoming. The third principlestipulates how humans cotranscendwith the possibles in the process of be-coming (Parse, 1981, 1998). It suggeststhe uniqueness (originating) of individ-uals’ways of grieving and their inherentpower to keep on living when losseschallenge being-becoming (powering);moreover, viewing the familiar in a newway changes everything (transform-ing). This principle shaped the writer’sview of grieving a loss as a way of mov-ing beyond with loss while actualizingpossibilities for becoming.
Participants were elderly persons re-siding in a long-term care facility. Toparticipate, they had to be fluent in Eng-lish and able to take part in a dialogue.The facility where they resided is part ofa large university teaching hospital lo-cated in a Canadian metropolis. Partici-pants were recruited from several pa-tient care units designated for chroniccare or nursing home care. Persons whoagreed to participate were assumed tobe able to authentically describe theirexperiences in ways that would illumi-nate the meaning of the phenomenonunder study (Parse, 1987, 2001). A re-search assistant, in consultation withnursing staff, identified residents whowere eligible to participate. She thenvisited residents to explain the study
and, if they were willing to participate,obtained informed consent. If there wasany doubt about a person’s apparent un-derstanding of the study’s purpose andthe terms of participation, s/he was notentered into the study. Participantsreceived a copy of the consent form.
Nine men and 1 woman who rangedfrom 70 to 92 years in age participatedin the study. Nine participants were ofCaucasian descent while the 10th was aperson of color from a Caribbean back-ground. All were war veterans. Stan-dard measures were taken to protecttheir confidentiality and anonymity. Atall times, the research assistant and theprincipal investigator sought to be sen-sitive to residents’ comfort and wishesregarding their participation.
Methodology
Parse’s (1987, 1995, 2001) researchmethodology was chosen to answer theresearch question because it is congru-ent with the philosophical underpin-nings of the nursing perspective.Phenomenological and hermeneutic inorigin, Parse’s methodology was devel-oped to guide inquiry into universallived experiences of health. As withother phenomenological approaches, itis intended to generate descriptions ofphenomena as humanly lived. The re-search processes are dialogical engage-ment, extraction-synthesis, and heuris-tic interpretation (Parse, 2001). Thespecifics of these are described below,as they were carried out in this study.
Dialogical Engagement
Data were gathered through dialogi-cal engagement, an intersubjective pro-cess in which the researcher was trulypresent with the participants as they de-scribed the phenomenon under study(Parse, 1987, 2001). The dialogical en-gagement was not an interview, wherepredefined questions are asked. Rather,it was a free-flowing attentiveness thatinvolved focusing, without directing,on the phenomenon as described by theparticipant (Parse, 2001).
Dialogues took place in the privacyof the participants’ rooms. After re-
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viewing the purpose of the research, theresearcher initiated the dialogue by ask-ing the participants to describe as com-pletely as possible their experience ofgrieving a loss. Some asked for clarifi-cation about what kind of loss to discussand others did not. If they questionedwhat kind of loss they were to address,the researcher encouraged them tospeak about any losses that mattered tothem. Thus, participants were free tochoose the meaning of loss, which pro-vided the context for their description ofgrieving. As the participants’ lived ex-periences emerged in the telling, the re-searcher bore witness in true presence,encouraging continuation with com-ments like, “Please go on,” “Could yousay more about that?” or, “How doesthat relate to grieving a loss?” Thedialogical engagement ended when theparticipants indicated that they werefinished. The dialogues lasted any-where from 20 min to more than an hourand were audiotaped and transcribedverbatim.
Extraction-Synthesis
Extraction-synthesis is the processwhereby data are moved through pro-gressively higher levels of abstractionin order to create the structure of thelived experience. The process requirescontemplative immersion in the datawhile repeatedly reading the transcriptsand simultaneously listening to the au-diotapes (Parse, 1987, 2001). As speci-fied by Parse (2001), the researcherconstructed a story for each participantthat captured the main ideas aboutgrieving a loss contained in the dia-logue. The essences of the participants’descriptions were extracted and synthe-sized in their own language and thenreconceptualized in the researcher’slanguage. The latter essences were usedto formulate the language-art for eachparticipant. Formerly called proposi-tions, language-art is a new term used toindicate the researcher’s representationof the essential ideas in the dialogue (R.R. Parse, personal communication, July9, 2003). Lastly, the core concepts pres-ent in the language-art for every partici-pant were extracted and synthesized.
These core concepts were used to formthe structure of the lived experience ofgrieving a loss for the participants inthis study. This structure is the mainstudy finding and answers the researchquestion (Parse, 1987, 2001). Theextraction-synthesis process is presentedbelow, beginning with sample storiesfor 3 of the participants. Extraction-synthesis is shown in Tables 1, 2, and 3.
Mr. C’s Story
Mr. C, aged 84, began the dialogueon grieving a loss by speaking about adivorce from his second wife after 10years of marriage. He shared his disbe-lief that this could have happened, be-cause his relationship with his first wife(now deceased) had been so good. Hesaid that his grief related to the fact thathis wife had a reason to leave him. He“felt it very badly,” he said, because hewas “always accustomed to being afamily man.” The divorce had meantgiving up his home and car to his ex-wife and coming here to live, which hefound to be “lonely.” For one thing, hecould no longer go to Mass every morn-ing, as was his custom. Moreover, hischildren, whom he loved, had their ownchildren and grandchildren, so hecouldn’t expect them to “come andspend most of their time” with him. Mr.C also spoke of suffering from the lossof his leg at age 70, and with “a badheart, arthritis, diabetes, ears, eyes, andeverything.” And, he could no longerplay the piano, having lost the use of hisfingers, nor could he read, because hewas almost blind. Still, Mr. C said, “I amsatisfied with what I can do—what Ihave, presently.” He shared that it“eased it up quite a bit” when he said tothe Lord “Thy will be done.” Also, hesaid he enjoyed music and that it helped“to watch the television, or to go out andmeet people and chat,” because “you’renot by yourself. You don’t have to thinkabout what’s happened. You talk aboutdifferent experiences in life—and minehas been many.” He added that he felt“pretty fortunate” to have “good chil-dren and grandchildren and great-grandchildren,” and friends who were“very faithful” and visited him. Mr. C
said he was still enjoying life and that hewas “thankful to God” for keeping himalive. But, he was prepared to die: “I’vehad a good life. I can go at any timewithout any regrets, whatsoever.”
Mr. B’s Story
Mr. B, a 92-year-old gentleman, be-gan the dialogue by noting, “Everybodyhas all kinds of grief in life.” He notedthat he had lost “some very dear friendsat times;” and yet, “you muddle throughit.” Then he described his recent loss ofa very good friend, whom he had knownfor the past 30 years. He said that now,he had to “carry on” by himself and hemissed her “very, very much.” He spokeof having faith in “the powers that con-trol our destinies,” and about having to“face up to a disastrous fact. There co-mes a feeling of quiet and great calmwhen you look at death in the face andrealize there’s nothing you can do aboutit; whatever will be will be.” He also de-scribed grieving a marriage break up,which was like “a death in the family,”and too, the “heartbreak,” years ago, ofending a wonderful relationship with awoman whose death notice he had re-cently seen in the paper. Also, there wasa recent “episode” at the residents’council, where he had felt ridiculed andhurt: “[It was] nothing like a death in thefamily, but nonetheless, there was griefabout not being accepted.” Mr. B talked,as well, about grieving “the calamity ofgetting old,” which you don’t thinkabout “until it’s on you.” For him “thehardest part of all was giving up thewheels,” which he did at the age of 80.He said he dreaded the time when he“would be dependent on other people,altogether.” He shared that he wanted touse his legs and his “thinking appara-tus” as long as he could, although heknew the day would come that hewouldn’t be able to. Mr. B stated “griev-ing is something we have to accept, andto accept it means accepting your ownideas, your own way of life.” He saidthat it no longer bothered him, when hewent to sleep at night, to know that hemight not wake up: “Life has been won-derful, [but] when it’s finished, it’s fin-ished.” He noted the wonderful way we
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have of “remembering the good thingsand forgetting the bad things,” adding,“I’m glad it’s like everything; if youwait, time is a wonderful healer.”
Mr. D’s Story
Mr. D, who was 81 years old, beganto speak about grieving in relation to theloss of his wife a year before. Also, justbefore his wife’s death, he had lost hisbrother and sister-in-law. “We were twobrothers married to two sisters, so it wasa big loss there,” he explained. Mr. Dshared that “it’s very lonely,” and that hemissed his wife very much: “It’s very,very—I don’t know, I can’t really ex-plain it,” he said. For awhile, he would“kind of forget,” but “now and again,”all the memories would come back andthen, he “really felt it.” He said he’dbeen “tempted a couple of times to dosomething,” but then, he would thinkabout his son and about having gonethrough the war. Mr. D said that hethought of his wife a lot, especially justbefore going to bed. “I’ve had her herebeside me in bed,” he confided. “Couldsee her arms wrapped around me. It waspretty clear.” Mr. D said he believed inGod and that every day, he saw and feltthings all around. He shared that he was
“looking forward to meeting her” anddoing things together again. Mr. D wenton to tell about spending summers at thecottage with his family and about hislove for fishing, boating, and camping.“How beautiful it was!” But now, hewas “not in too good a shape,” whatwith diabetes and “a bad foot,” and so hecouldn’t do such things any more. Still,he said he felt “very fortunate” to have“a good bunch of kids,” with whom hehad fun on days like Thanksgiving.While his brothers had all passed awaynow, he fondly remembered having “apretty good family. Christmas time, es-pecially. You don’t forget those thingsyou know—never forget them.”
The extracted-synthesized essencesfor Mr. C, Mr. B, and Mr. D are shownin Tables 1, 2, and 3, respectively.Language-art was formed from theextracted-synthesized essences for eachof the 10 participants and is presented inTable 4.
From the language-art, two coreconcepts representing ideas that werepresent in each and every participant’sdescription were extracted and synthe-sized: aching solitude amid enduringcherished affiliations and serene acqui-escence with sorrowful curtailments.
The core concepts, when joined, formthe structure of the lived experience,which answers the research questionand is the main study finding (Parse,1987, 2001). Thus, for the participantsin this study, the structure of the livedexperience is as follows: Grieving a lossis an aching solitude amid enduringcherished affiliations, as serene acqui-escence arises with sorrowful curtail-ments.
Discussion of Findings
Heuristic interpretation is Parse’s(1987, 1995, 2001) unique expansion ofphenomenology, which she created sothat the study finding can be woven withthe concepts and principles of the hu-man becoming theory, thus expandingthe theory and adding to the knowledgebase of nursing. Heuristic interpretationinvolves moving the generated structureup two steps on the ladder of abstrac-tion: The first step, structural trans-position, provides a bridge between theresearch finding and the human becom-ing theory, while the final step, concep-tual integration, connects the findingwith the theoretical concepts and princi-ples. A new process, added after the
236 Nursing Science Quarterly, 18:3, July 2005
Table 1Extracted-Synthesized Essences for Mr. C
Mr. C’s Language Researcher’s Language
Grieving a loss is a very lonely feeling that happened after a divorce and yet, also, Aching solitude with absent intimacy emerges witha feeling of acceptance and satisfaction with good children, grandchildren, contented gratitude for enduring cherished affiliations.great-grandchildren, friends who are faithful, and God.
Grieving a loss is suffering the loss of a leg and the use of fingers and, no longer Sorrowful curtailment surfaces with serene acquiescence.being able to walk, play the piano, or read, ready to die anytime without regrets;and yet, still enjoying life.
Table 2Table 2. Extracted-Synthesized Essences for Mr. B
Mr. B’s Language Researcher’s Language
Grieving a loss is the heartbreak of having to carry on alone after the deaths of dear Devastating solitude emerges with resolute enduring amidfriends and broken relationships, and of not being accepted; but also, knowing that the balm of cherished recollections.time is a wonderful healer when remembering the good and forgetting the bad.
Grieving a loss is having to accept things like the calamity of getting old, having to Serene acquiescence arises with abhorrent curtailmentsgive things up, and being dependent on others. But, facing up to the truth with faith while anticipating the inevitable.in the powers that be brings a feeling of great calm and, while life has beenwonderful, it’s time to die.
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completion of this study, is the re-searcher’s artistic expression of the heu-ristic interpretation (R. R. Parse, per-sonal communication, July 9, 2003).However, the researcher had completedthis study before this process was intro-duced and so, an artistic expression hasnot been included here.
The heuristic interpretation is sum-marized in Table 5. At the level of struc-tural transposition, the finding was rep-resented as follows: Grieving a loss isdesolation amid the treasured as reso-lute tranquility emerges with constric-tions. At the theoretical level, this find-ing was conceptually integrated withthe human becoming theory as thestructure: Grieving a loss is valuingconnecting-separating while poweringenabling-limiting.
In the discussion that follows, the re-searcher elaborates on the core concepts
in light of the human becoming theoryas well as relevant literature, with the in-tent of expanding the theory and addingto the knowledge base of nursing and togeneral knowledge concerning the ex-perience of grieving a loss.
This core concept represents two in-terwoven ideas present in all of the par-ticipants’ descriptions of grieving aloss: The first is the participants’painfulawareness of being alone, and the sec-ond, their ongoing prized connectionswith persons (living and deceased),memories, and personal projects. Thephrase aching solitude reflects the poi-gnant expressions: “very alone,”“lonely,” “lost,” “blue,” “at odds,” and“heartbroken” that participants used indescribing their sense of missing those
who were absent from their lives. Sevenof 10 participants spoke about grievingin the context of the loss of a spouse, ei-ther through death or divorce. In addi-tion, all but one of the participantsspoke about missing family members orfriends who had died or were no longeraround. Mingled with aching solitudewere enduring cherished affiliations,which included relationships with de-parted loved ones, living family mem-bers and friends, and God; favorite pur-suits (alone and with others); andmemories of the good and beautifulthings in life.
Through heuristic interpretation, thecore concept aching solitude amid en-during cherished affiliations was struc-turally transposed to desolation amidthe treasured. This representation high-lights the coexistence in participants’descriptions of painful loneliness along
Grieving a Loss 237
Table 3Extracted-Synthesized Essences for Mr. D
Mr. B’s Language Researcher’s Language
Grieving a loss is an unexplainable feeling of loneliness and feeling still very present Unutterable solitary sorrow emerges with the ebbing-with a close other, the memories of whom return now and again, while looking surging endurance of cherished affiliations.forward to meeting in another life and feeling fortunate to have wonderful kids.
Grieving a loss is remembering the beautiful, like fishing and things that are no longer Exquisite recollections arise with grateful acquiescencepossible, and being thankful for that. amid curtailments.
Table 4Language-Art for all Participants
Participant Language-Art
Mr. C. Grieving a loss is aching solitude with absent intimacy emerging with contented gratitude for enduring cherished affiliations, whilesorrowful curtailment surfaces with serene acquiescence.
Mr. B. Grieving a loss is devastating solitude emerging with resolute enduring amid the balm of cherished recollections, as serene acquiescencearises with abhorrent curtailment while anticipating the inevitable.
Mr. W. Grieving a loss is aching solitude emerging with cherished intimacy, as listless endurance arises with serene acquiescence with theinevitable.
Mr. D. Grieving a loss is ebbing-surging sorrow amid unutterable solitude emerging with enduring cherished affiliations, as exquisiterecollections arise with grateful acquiescence with curtailments.
Mr. E. Grieving a loss is unuttered sorrowing with devastating curtailment while resignedly persevering with aspirations, as aching solitudeamid the absence of intimate others emerges with gratitude for benevolent affiliations.
Mr. H. Grieving a loss is aching solitude with curtailed possibilities emerging with enduring cherished engagements, as contemplating theinevitable surfaces with acquiescence amid desire for serenity.
Mrs. S. Grieving a loss is a disquieting solitude arising with ebbing-surging recollections amid enduring cherished affiliations, as contemplatingdismaying ambiguity emerges with grateful acquiescence.
Mr. J. Grieving a loss is forlorn solitude amid gratitude for cherished affiliations, as contemplating inevitable confinement emerges withcontented acquiescence.
Mr. Y. Grieving a loss is poignant solitude amid the absence of intimate others emerging with serene acquiescence, as bitter despondency withcurtailed possibilities surfaces with appreciation of amiable engagements.
Mr. G. Grieving a loss is devastating solitude amid absent intimacy emerging with appreciation for enlivening engagements, as constrictingpossibilities arise with acquiescent contemplation of desired serenity.
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with treasured relationships with otherpersons (living and deceased) and thingsthat made life meaningful. At the theo-retical level, this core concept was con-ceptually integrated with the human be-coming theory as valuing connecting-separating, an interpretation that lendsnew meaning to these two theoreticalconcepts. The concept of valuing comesfrom the first principle of the human be-coming theory, which specifies how hu-mans structure meaning multidimen-sionally in the process of “cocreatingreality” (Parse, 1998, p. 35). Valuing isthe process of cocreating realitythrough choosing and living what ispersonally important. It involves theparadoxical process of “confirming-notconfirming cherished beliefs in light ofa personal worldview” (Parse, 1998, pp.37-38). The second theoretical concept,connecting-separating, comes from thesecond principle of the theory, whichspecifies the paradoxical unity of hu-man rhythms of relating with theuniverse. In particular, connecting-separating signifies “being with and apartfrom others, ideas, objects, and situa-tions all-at-once” (Parse, 1998, p. 45).
For the participants, the personal re-ality of grieving a loss entailed all-at-once connecting and separating withthat which was lost and that which re-mained. The aching solitude that partic-ipants described reflects their valuing ofrelationships with absent loved onesand the enduring importance of these
loved ones in their lives. While theywere separated from loved ones throughdeath or physical distance, participantsalso connected with them through re-membering and imagining being withthem. Valuing is also manifested inother enduring affiliations that partici-pants treasured; for example, relation-ships with children, grandchildren,friends, and God; memories of goodand beautiful things in life; and enjoy-able pastimes. In connecting-separatingwith such cherished affiliations, partici-pants were, for the moment, separating-connecting from the desolation whichtheir losses brought them. Throughconnecting-separating, then, partici-pants manifested valuing of that whichwas lost and of that which remained, aprocess that structured their personalreality of grieving.
In three previous studies on the livedexperience of grieving a loss that wereguided by Parse’s human becomingtheory (Cody, 1991, 1995; Pilkington,1993), the concepts of valuing andconnecting-separating also emerged inthe heuristic interpretation of the studyfinding. The emergent pattern of griev-ing a loss then, is one of confirming-notconfirming what is important, whileconnecting-separating all-at-once withwhat is lost and what endures. The theo-retical linkage with the concept of valu-ing in the human becoming theory isconsistent with existing theoreticalknowledge, inasmuch as the process of
assigning meaning to a loss is thought tobe fundamental to the process of griev-ing (Bowlby, 1980; Peretz, 1970).
The core concept aching solitudeamid enduring cherished affiliations isconsistent with the finding in other re-search studies that showed that loneli-ness is very common among widowedolder adults (Grimby, 1993; Hegge &Fischer, 2000; Jacob, 1996). Partici-pants in this study resided in a long-term care facility where they were sur-rounded by people and yet, they de-scribed feeling very alone. This phe-nomenon has elsewhere been namedfeeling alone while with others (Gouty,1996). While aching solitude amid en-during cherished affiliations reflectsthe idea of loneliness, it differs in itsparadoxical nature; that is, for the par-ticipants, aching solitude coexistedwith enduring cherished affiliationswith persons, objects, and favorite pur-suits. Enduring cherished affiliationsincluded a comforting sense of the pres-ence of one’s deceased spouse (see Mr.D’s story), an experience that is report-edly common among widowed elderlypersons (Byrne & Raphael, 1994;Hegge & Fischer, 2000; Grimby, 1993).
The first core concept enhances anunderstanding of grieving as a multidi-mensional process of structuring mean-ing while living the was, is, and will beall-at-once. It suggests that aching soli-tude and enduring cherished affiliationsare paradoxical, coexisting realities
238 Nursing Science Quarterly, 18:3, July 2005
Table 5Progressive Abstraction of the Core Concepts
within the multidimensional lived expe-rience of grieving. In contrast, in twoqualitative studies that explored the ex-perience of grieving for older widows(Hegge & Fischer, 2000; Jacob, 1996),the findings were interpreted as beingconsistent with phases similar to thosein the classic grief literature, althoughthe researchers went on to seeminglycontradict this characterization. For in-stance, Jacob’s (1996) model of griev-ing depicts a dynamic process fluctuat-ing between being aware, facing newrealities, coping, and experiencing dis-tress. And Hegge and Fisher (2000) ob-served that “the work of grieving wasfound to follow an erratic cycle withpeaks and valleys, spurts, and relapsesthrough four major phases of grief reso-lution” (p. 37). Thus, the fluctuatingdistress and the spurts and relapses inthese studies, like the finding in thecurrent study, call into question thenotion of distinct, linear phases ofgrieving.
The phrases aching solitude and sor-rowful curtailments (from the secondcore concept, discussed next) are indic-ative of the suffering that participantsexpressed in describing their experi-ence of grieving—indeed, several per-sons actually used that word suffering.The notion of suffering is also evident inthe findings of three other Parse methodstudies on grieving, although the word-ing of these studies’ core concepts sug-gests a greater intensity in participants’descriptions. For example, in Pilkington’s(1993) study with mothers who had re-cently lost their infant at birth, the firstcore concept was anguished suffering indevastating void. And, in Cody’s(1991) study with adults from the gen-eral population, the first core conceptwas intense suffering in the flux ofchange. Lastly, in Cody’s (1995) studywith families living with AIDS, the firstcore concept was easing-intensifyingwith the flux of change. Thus, each ofthese studies emphasizes the intensityof suffering within the experience ofgrieving a loss.
The relatively tempered descriptionsof grieving offered by participants inthis study are consistent with those in astudy with elderly widows conducted
by Hegge and Fischer (2000). These re-searchers suggested that the “peaks andvalleys of grief were less intense in theeldest widows [aged 75-90 years] be-cause they were more at peace with theirown mortality” (p. 42). Interestingly,some participants in the current studypointed out how they had been throughWorld War II and others commented onhaving lost many family members andfriends, suggesting that they had “got-ten used to” loss and grieving. Alongthese lines, other researchers have ques-tions concerning the prevailing wisdomthat multiple and concurrent losses rep-resent a risk factor in older adults(Caserta & Lund, 1992; Jacob, 1996).Jacob (1996), for instance, wrote thatfor the older women in her study “suf-fering past and concurrent lossesseemed to strengthen their ability toface loss rather that increase their riskfor complicated grief” (p. 285). Simi-larly, participants in the current studyexpressed a philosophical sense ofserene acquiescence with the manylosses with which they lived.
Serene Acquiescence withSorrowful Curtailments
The second core concept representsthe tempered attitude that all partici-pants expressed concerning the sorrow-ful curtailments connected with variouslosses, including the loss of things thatthey valued like abilities, mobility, fa-miliar patterns, and independence. Inaddition, almost all participants indi-cated an awareness of their own im-pending death, suggesting the antici-pated loss of life itself, and someexpressed realization that they wouldremain institutionalized until they died.Several participants aptly described thissense of curtailed possibilities as livingin a “closed-in world.” As Mr. H said,“Your world is closing in a bit on you.And, I think the older you get, the moreso.” The participants variously de-scribed these sorrowful curtailmentswith expressions of anger, sadness, cha-grin, and resignation. And yet, in de-scribing past and impending losses, par-ticipants also expressed a sense ofsatisfaction with, and thankfulness for,the lives they had lived. Several partici-
pants explicitly stated that they wereready to die, and some expressed thehope that death and the hereafter wouldbe “peaceful.”
Through heuristic interpretation, thecore concept serene acquiescence withsorrowful curtailments was conceptu-ally transposed to resolute tranquilitywith constrictions. This expression ac-centuates the chosen attitude withwhich participants faced the constric-tions inherent in living with multiplelosses. It was as though their awarenessof dwindling time and possibilitiesmade it important to appreciate whatthey had had, and still enjoy, in life. Atthe highest level of abstraction, thisconcept was interpreted as poweringenabling-limiting. The first concept,powering, comes from the third princi-ple of human becoming, which stipu-lates ways of cotranscending with thepossibles. Powering is “the pushing-resisting process of affirming-not af-firming being in light of nonbeing”(Parse, 1998, p. 47). It is the force thatpropels humans beyond the momentwith hopes, dreams, and concerns. Thesecond theoretical concept, enabling-limiting, comes from the second princi-ple, which stipulates the paradoxicalunity of the rhythmical patterns thathumans live. In particular, “enabling-limiting specifies the opportunities-restrictions present in all choosings all-at-once” (Parse, 1998, p. 44).
Serene acquiescence with sorrowfulcurtailments corresponds with the con-cept of powering in that, in choosing anattitude of serene acquiescence, partici-pants were affirming their being and be-coming in face of the possibility ofnonbeing. As Parse (1998) wrote“nonbeing arises in everyday life as hu-mans all-at-once live what is with theunknown not-yet. The nonbeing is thenot-yet known and the potential risk oflosing something of value” (p. 47). Thesorrowful curtailments were actual andpotential losses that represented thepossibility of nonbeing. Serene acqui-escence was a way of pushing-resistingwith such curtailments, thereby affirming-not affirming being. Moreover, partici-pants’ chosen way of being with thesecurtailments reflects enabling-limiting,
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inasmuch as their choices presented op-portunities and limitations for ways ofbecoming. For instance, while partici-pants spoke of suffering in a “closed-inworld,” they also talked about “still en-joying life,” by keeping busy and hav-ing fun with others. Thus, amid the limi-tations of sorrowful curtailments, theparticipants found opportunities foraffirming-not affirming being in the pro-cess of becoming.
The theoretical concept of poweringthat emerged in heuristic interpretationof the second core concept was alsoidentified in two of the previous Parsemethod studies on grieving; thus, pow-ering seems to be integral to this livedexperience. The core concepts in thesestudies were expressed as “intensestruggling in the flux of change” (Cody,1991, p. 65), and “easing-intensifyingwith the flux of change” (Cody, 1995, p.221). At any rate, the concept serene ac-quiescence with sorrowful curtailmentsin the current study expands the notionof powering within the lived experienceof grieving. That is, besides being an in-tense struggle of moving beyond withthe changes that losses entail, poweringcan also be a serene acquiescence withsuch change.
Enabling-limiting emerged in theheuristic interpretation in the currentstudy, but not in the three previous Parsemethod studies on grieving (Cody,1991, 1995; Pilkington, 1993). This dif-ference could reflect the context of theexperience of grieving for participantsin the various studies. Naturally, all par-ticipants spoke about grieving in thecontext in which they experienced it.These contexts included bereavement(Cody, 1991; Pilkington, 1993), the lossof a friendship (Cody, 1991), and livingwith AIDS (Cody, 1995). In the presentstudy, participants’accounts of grievingencompassed a lifetime of losses of allsorts, including bereavement, divorce,the loss of a home and familiar routines,separation from family members andfriends, and the loss of abilities, mobil-ity, and independence due to aging andchronic illnesses. In addition, partici-pants spoke about their impendingdeath. The essence of grieving these
multiple, varied losses was captured bythe core concept, serene acquiescencewith sorrowful curtailments, which wasconceptually interpreted as poweringenabling-limiting. Thus, the linkagewith enabling-limiting here may reflecta difference in the context of grieving asdescribed by these participants or maybe just further illumination of themeaning of grieving.
While the gerontology literature hasamply documented that aging is at-tended by multiple and cumulativelosses (Agee, 1980; Burnside, 1973;Garrett, 1987; Kastenbaum, 1969), fewstudies have explored elderly persons’lived experiences of grieving suchlosses. However, in a study relevant tothe discussion, Mitchell (1995) used theParse research method to study the livedexperience of restriction-freedom with12 seniors aged 75-92 years. Three ofthe participants resided in a rehabilita-tion hospital while the remainder livedin the community. Mitchell’s third coreconcept was yielding to change fortifiesresolve for moving beyond, which shedescribed as “a complex rhythm ofyielding or going along with changewhich fortified participants’resolve andenergies for moving beyond” (p. 173).The connection with the current study isthat, although participants here weredescribing their experience of grievinga loss (rather than the paradox ofrestriction-freedom), discussion of therestrictions of aging naturally arose inrelation to losses experienced. Theemergent core concept, serene acquies-cence with sorrowful curtailments, issimilar to the notion of yielding tochange in Mitchell’s (1995) study, andboth core concepts were linked with thetheoretical concept of enabling-limitingthrough heuristic interpretation.
Recommendations forFurther Research
As the fourth investigation on griev-ing a loss conducted from the perspec-tive of the human becoming theory, thisstudy adds to this growing body ofknowledge about this universal livedexperience. However, more studies
need to be conducted with participantsfrom different age groups and culturalbackgrounds and with other loss situa-tions, so that the similarities and differ-ences in the phenomenon as humanlylived can be more fully understood. Inaddition, the core concepts thatemerged in this study provide manyideas for further studies. For example,the first core concept, aching solitudeamid enduring cherished affiliations,suggests the need for further researchon related phenomena like feelinglonely and feeling alone while with oth-ers. In addition, the second core con-cept, serene acquiescence with sorrow-ful curtailments, provides ideas forfurther research on lived experienceslike contentment, serenity, living withchanging expectations, and suffering.Research on any of these phenomenawould contribute to the development ofknowledge about human becoming.
Insights for Practice
Findings from qualitative researchcannot be directly applied to practicebecause they are not generalizable;however, they can enhance understand-ing about the phenomenon investigated,which, in turn, can provide insights thatinform approaches to practice. Thisstudy was guided by the human becom-ing theory, a knowledge base that pro-vides direction concerning how to livethe nurse-person process. For instance,living the art of human becoming in-volves bearing witness in true presenceas persons choose and live their valuepriorities from day to day (Parse, 1994,1998). Heuristic interpretation of thestudy findings has expanded under-standing of several of the theoreticalconcepts of the theory; namely, valuing,connecting-separating, powering, andenabling-limiting. This expanded un-derstanding can help nurses to better ap-preciate what it means to grieve a lossand thus, to be better prepared to bearwitness to those who are living this ex-perience. For instance, understandingthat when grieving a loss, valuing andconnecting-separating may emerge asaching solitude amid enduring cher-
240 Nursing Science Quarterly, 18:3, July 2005
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ished affiliations may prompt nurses toinvite persons to talk about what life islike for them, thus lending opportuni-ties for illuminating the meaning ofthese coexisting realities. For personswho are grieving, telling another aboutthe aching solitude as well as the endur-ing cherished affiliations may help toclarify values and provide new opportu-nities to choose personal meaning in thesituation. Also, telling about enduringcherished affiliations may be a way ofeasing the ache of loneliness throughthe process of connecting-separating.
In this study, the enduring cherishedaffiliations included participants’ rela-tionships with nurses. As one man re-lated, “I just had the greatest attentionfrom the nurse up there and she’s almostlike family to me.” Indeed, consideringthat residents in long-term care institu-tions may be there until they die, havingmeaningful relationships with healthprofessionals seems particularly impor-tant to their health and quality of life. Inparticular, nurses’openness to bear wit-ness in true presence with persons maymake a difference in how they experi-ence grieving a loss, simply by helpingto momentarily ease a sense ofaloneness.
The second core concept was sereneacquiescence with sorrowful curtail-ments. As suggested in the above dis-cussion, serene acquiescence can be away of moving beyond the momentthrough pushing-resisting with sorrow-ful curtailments that threaten being andbecoming; hence, the linkage with thetheoretical concepts of powering andenabling-limiting. If nurses living theart of human becoming understand thatserene acquiescence can coexist withthe sorrowful curtailments embedded inmultiple losses, then they can be open tothis possibility and thus, recognize itwhen it emerges in the nurse-personprocess. This recognition could promptnurses to explore with persons whatbrings enjoyment, satisfaction, andcontentment, even amidst “living in aclosed in world” and the nonbeing of“the not-yet known and the potentialrisk of losing something of value”(Parse, 1998, p. 47). Through disclos-
ing the opportunities and limitationswithin such situations, individuals canchoose how to move with these, as didthe participants in this study, therebycotranscending with the possibles.
Conclusions
In this study, the researcher exploredthe lived experience of grieving a losswith 10 elderly persons living in a long-term care facility, using Parse’s researchmethod. The extraction-synthesis pro-cess emerged with creation of the fol-lowing structure of the lived experi-ence: Grieving a loss is aching solitudeamid enduring cherished affiliations, asserene acquiescence arises with sor-rowful curtailments. This structure en-hances understanding of grieving a lossas a multidimensional process of be-coming by highlighting the notion ofaching solitude and enduring cherishedaffiliations as paradoxical, coexistingrealities within the lived experience. Italso sheds light on serene acquiescenceas a chosen way of pushing-resistingwith the sorrowful curtailments thatarise in living with various losses. Heu-ristic interpretation of the study findinghas expanded the meaning of thetheoretical concepts of valuing,connecting-separating, powering, andenabling-limiting.
This study contributes to the grow-ing knowledge base about the lived ex-perience of grieving from the humanbecoming perspective. As well, it addsto the general knowledge about this uni-versal lived experience. As suggested,such knowledge is important in that itexpands health professionals’ under-standing about what life is like for per-sons who are grieving a loss, whichmakes it possible to approach them withan openness to bear witness and to re-spond in sensitive and meaningfulways. In this regard, I have offeredinsights for enhancing practice withgrieving persons and also, recommen-dations for additional research.
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