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Meaning of bereavement among older African American widows
Meaning of Bereavement Among Older African American Widows
Laura S. Rodgers, RN, PhD
In spite of the increase in research on spousal bereavement, researchers have not specifically addressed the impact that ethnicity may have on the bereavement experience. The results of this descriptive phenomenological study increase the understanding of spousal bereavement among older African American widows. Storytelling was at the heart of every participant’s description of her bereavement experience. Six themes were identified: awareness of death, care giving, getting through, moving on, changing feelings, and financial security. For nurses to effectively intervene in the lives of bereaved older African American widows, they must consider each widow’s culture, heritage, and lived experiences, which can be ascertained through eliciting and listening to the widow’s life stories. (Geriatr Nurs 2004;25:10-16)
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n the past 20 years, there has been an increase in bereavement research, especially regarding widowhood among the older population. Despite this accumulating knowledge, researchers have either failed to include elderly members of minority ethnic groups in their study samples or neglected to address the impact that ethnicity may have on the bereavement process or outcome. The trend in spousal bereavement research, unfortunately, has been to assume all elderly populations have bereavement experiences similar to those of the mainstream population, thus ignoring the unique historical and cultural heritage of elderly members of minority ethnic groups.1,2 Spousal bereavement is both a life stressor and life event associated with considerable physical and mental health problems,3,4 which can negatively affect the health behaviors and daily activities of older persons.5,6 The bereavement experience, as a dynamic process,7 is a unique and personal phenomenon influenced by culture, social context, one’s perception of death, personal history, environment, and the nature of the relationship between the spouses.8-10 Yet, there are virtually no empirical studies that examine the meaning of bereavement among older African American widows. The older population in ethnic minority groups is expected to triple by the year 2025, constituting more than 15% of the entire older population.11 More specifically, older black Americans are the fastest growing segment of the older population, with the population of black women aged 80 years and older growing the most rapidly.12 The majority of black women aged 65 and older are widowed (57.7% as compared with 51.1% of older white women),13 and there is an increasing tendency for black women to be widowed earlier than white women.14 Recently, Stroebe and Schut15 have proposed a new bereavement model, which would take into account both cultural and gender differences while questioning the current grief work hypothesis as being limited in its explanation of bereavement among different cultures. Yet in spite of the increase in the number of older black American widows, the process and meaning of bereavement among these women has not been adequately studied. Application and generalization of the current knowledge of bereavement through nursing interventions to this population may be premature. There are three distinct ethnic groups in the black community: American-born, Caribbean-born, and Africanborn.16 Because of this ethnic diversity, which is the result of a disparate historic past, these three groups should not be considered a single ethnic group.17 Both the Americanborn and Caribbean-born groups were part of the African diaspora; even so, these groups have had very different experiences since then.16 In addition, African-born blacks do not have the history of North American slavery, segregation, and racism as do Caribbean-born and American-born blacks. Rather, African-born blacks have experiences of apartheid, colonialism, and political instability. In spite of the differences among the three black ethnic groups, there is a worldview that links the groups with African history January/February 2004
and culture. This paradigm has been called Afrocentricity. Afrocentric scholars describe Afrocentricity as a philosophy, a lifestyle, a perspective, an analytical approach, and a cultural orientation.18,19 Asante18 believes that Afrocentricity includes every element of human orientation such as perception, religion, interpersonal relationships, philosophy, communication, language, and fashion. For instance, the African American oratory, used by pioneers of the Civil Rights movement, illustrated the power of the spoken word through sermons, lectures, gospel songs, and poetry and is a carryover of the ancestral practice of oral expression from Africa, which included storytelling and praise singing. Another example is that an African-based culture emphasizes the centrality of the family and personal integrity20 as compared with a European-based culture, which emphasizes the idea of survival of the fittest and individuality. The African American family consists of an extended, communal family that includes both blood relatives and nonblood relatives (also known as fictive kin or kin network) and reflects the African heritage in which families live together in communities.14,21 In addition, there is also a great respect for age,22,23 with the elderly occupying a special place of leadership and honor in the family.14 In the African American community, the older black woman “sits on a throne of grace, emanating an aura of dignity that permeates her being. She is respected for her wisdom, admired for her strength, and honored for her contributions to the health and well-being of both the black family and community.”23 The older black grandmother uses stories to teach skills of survival and transmit values and ideals to her family.24 Participation in the church and religious activities is an extension of family life, as well as a source of social integration, for older blacks.25 Consequently, any study of the African American experience should consider the African heritage and the American experience. PURPOSE OF THE STUDY AND METHODS Even though the majority of older African American women are widows, there are virtually no empirical studies of bereavement among this particular population. The overarching goal of this phenomenological study is to use the findings to increase the knowledge base for nursing practice to enhance the nurse’s ability to provide culturally sensitive care to this population. The research question addressed was “From the perspective of older African American widows, what is the meaning of their lived experiences of bereavement after the death of their husbands?”
Description of Participants In a middle-size city in the Pacific Northwest, 11 participants were interviewed (age range, 63-94 years) in their own homes. It is believed that some ethnic groups may age physiologically sooner than others.26,27 Study participants 11
Table 1. Representative Significant Statements of Awareness of Death
“That was when I realized that he, uh, probably would [not last the day].” “I couldn’t go golfin’ (hesitates), he was too sick! I said, (very softly) ‘uhn-nhn’ (softer) I said, ‘I can’t go…with him in the condition he’s in.’” “ ‘bout ten o’clock on this particular night. I went [in] there. I just (slower) kn-ew, I just knew (takes breath), I could just tell, …he was dy-in. I kept tellin’ my children.”
met four criteria: African American/American-born, 55 years or older, widowed, and verbally able to share the bereavement experience. Participants were recruited through personal acquaintances and professional contacts with several local black ministers, which led to a “snowballing” effect. All participants maintained regular contact with family and friends. Participants identified an affiliation with a church and described the church as a place to obtain not only spiritual nurturance but also to retain important social contacts. The educational backgrounds varied from master’s preparation to less than sixth grade. All participants actively participated in a variety of social and community organizations. The length of marriages ranged from 11 to 57 years.
Data Collection Procedure Data were collected by means of tape-recorded in-depth interviews (range, 1-31⁄2 hours) and a research journal. All field notes, personal assumptions and reflections, interactions with nursing professionals, demographic data, and coding strategies were maintained in this journal. Several open-ended questions were asked of each participant to elicit her description of her bereavement experience after the death of her husband. As themes and meanings emerged, interview questions were modified. For example, after several interviews, it became apparent that a participant’s faith was an important aspect of her bereavement experience; and consequently, an open-ended faith question was included in subsequent interviews. In addition, it became evident that stories told by the participants provided some of the richest and most descriptive data about their bereavement experience. Another open-ended question was added such as “Tell me a story about…(like when he died).” Although the interview guide was developed to probe the participant’s perspective to the fullest, each participant was encouraged to share her lived experiences in her own way.
Data Analysis Data were analyzed by using Colaizzi’s28 seven-step method. Each taped interview was transcribed verbatim and verified. Trustworthiness and accuracy in the synthe-
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Table 2. Awareness of Death Formulated Meanings
“ After close observation of their husbands, the participants became cognitively aware that their husbands were going to die shortly and they were able to verbalize this awareness to others.” “ The participants became aware of their husbands’ impending deaths through past personal experiences with deaths of other close family members and/or health care workers providing information of direct personal observation of husbands’ physical condition.” “ The widows changed their daily activities when they became aware of their husbands’ imminent deaths in order to be at their husbands’ bedsides.”
sis of the transformed meanings into an essential structure of the description of bereavement were addressed according to Polkinghorne’s29 five questions, which could be used to establish validity for a phenomenological study. Thematic analysis was validated by expert consultation with two nurse researchers (an expert in bereavement care and an expert in phenomenological research). Final validation occurred when the participants were re-contacted and confirmed that the final analyses accurately described their bereavement experiences. One participant provided more stories about her bereavement experience that further corroborated the findings. However, no new information was elicited. R E S U LT S As a result of analysis of the data, seven themes emerged. Six themes were identified from the participant’s description of her bereavement experience: awareness of death, care giving, getting through, moving on, changing feelings, and financial security. One theme, storytelling, emerged as distinct from the bereavement experience in that it provided a vehicle by which the participants shared their life experiences. The names, factual places, and dates have been changed in the following examples to protect the confidentiality of the participants.
Storytelling A pervading and prevalent theme, storytelling was at the heart of every widow’s description of her lived bereavement experience after the death of her husband. These stories, which were told throughout the entire interview, provided rich, colorful, and detailed descriptions that involved the participant’s artful ability to describe a particular situation in her past. Storytelling involved more than merely relating a particular incident in chronological and narrative fashion. Rather, through storytelling, the participant took on the various roles, mannerisms, and speech patterns of the persons who were part of the story. Participants changed tones and accents to mimic the voices of the people involved in the event
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Table 3. Representative Significant Statements of Caregiving: Task-oriented
“I took him to the doctor.” “I would give him a bath, and give him his medication…” “I did everything for him…I had to do everything for him.” “…then, the next thing, I went in, my sister and I decided, well, ‘Let’s go and turn him, he’s been on that side too long.’”
and used their hands, body language, and facial expressions to share stories.
Table 4. Caregiving Formulated Meanings: Task-oriented
“The wives provided direct and indirect physical care to their husbands before their deaths.” “Caregiving involved ‘doing for’ their husbands.” “Task-oriented care meant the wives were the doers, or they arranged to have another person provide the physical care.” “Task-oriented care meant meeting the physiologic needs of the dying husbands as perceived by the wives.” “Task-oriented care included touching their husbands (such as bathing), manipulating environmental props (such as beds and medications), or transporting their husbands (such as from house to hospital or room to room).”
Awareness of Death Awareness of death was a widow’s realization that her husband’s death was imminent. This occurred when the widow actually knew and could verbalize that her husband was going to die within the next 24 to 30 hours. Table 1 provides representative examples of significant statements, and Table 2 provides the formulated meanings for the significant statements related to the theme awareness of death.
Caregiving Caregiving included formal care that was solicited by the widows and provided by health care professionals such as nurses and physicians. Informal care, such as bathing and feeding, was provided by the widow, her family, or friends. For either type of care, the widows were present whenever possible. The participants described four aspects of care giving: task-oriented, problem-solving, decision making, and learning.
Task-oriented care. Task-oriented care included direct hands-on physical care for the husband, which was preferred to be done by the wife or family, and if needed, by a professional. Examples of task-oriented care are bathing, toileting, brushing teeth, and driving their husbands to and from a physician’s appointment. Professionals provided task-oriented care such as changing dressings, doing a physical assessment, or drawing blood for lab work.
Problem solving. The widows described specific caregiving situations in which they either directly or indirectly resolved a perplexing problem. For instance, one husband adamantly refused to have a hospital bed at home. However, the wife was concerned that he would fall out of bed as a result of restlessness. She placed four large dining room chairs next to one side of his bed after having friends push the bed against a wall. The same widow, herself not well or too strong, had difficulty getting her husband from his chair in the living room to his bed at night. She resolved that probJanuary/February 2004
lem by having her husband sit on the portable commode chair, which allowed her to roll him into the bedroom.
Decision making. Another aspect of care giving entailed making decisions. One participant decided whether her husband would have a surgical procedure, be admitted to the hospital, or take his medicines. Decision making also included determining when to call the nurse or physician for advice, when to call an ambulance, or who should be involved in the formal and informal care giving tasks. At times, the widows acted as gatekeepers in that they made decisions for their husbands and protected them from others. For example, three participants monitored who could come to the house and visit their husbands.
Learning. Participants found themselves learning many new things. For example, they were learning about their husbands’ diagnoses and treatments, how to replace a nasogastric tube, how to give injections, and how to recognize the physical signs of impending death. Table 3 is a representative sample of significant statements, and Table 4 provides the formulated meanings of task-oriented care giving.
Getting Through The actual dying process was singled out as an especially difficult moment for them. Emotional support from family, friends, professionals, and the church enabled the participants to “get through” their husbands’ moments of death. For example, nurses and social workers, either by being present at the bedside or available by telephone, provided emotional reassurance, as did family and friends by being physically present, telephoning, or bringing food. Participants found that keeping busy and recalling or retelling positive memories to others present at the bedside or other willing listeners facilitated getting through those difficult moments. Church members and the minister were expected to actively participate in the widows’ grief expe13
riences both during their husbands’ actual dying and after the funeral services. The widows stated that they expected every family member to come home to pay their last respects to their husbands, no matter how far away they lived. Knowing that family was coming and would provide support was very reassuring to the participants. Finally, four participants clearly stated that knowing that everything possible had been done to help their husbands during the illness and the actual dying process provided overwhelming comfort to them and helped them “get through” their husbands’ actual deaths.
ing. Praying to God for inner strength was described by the widows as “believing in a higher source of strength” to help them deal with the pain of losing their husbands. In addition, the participants obtained strength by being remembered by others in ways such as receiving telephone calls, gifts of food, visits, and invitations to dinner. The widows actively solicited these encounters. This subtheme, strength seeking, is different from using support, even though there are similarities. Strength seeking was an intentional act by the participant to obtain emotional and spiritual strength.
Moving On
Unlike strength seeking, using support occurred when the widow received unsolicited support from others. The participants willingly and gratefully accepted support offered by others in forms such as doing yardwork or providing advice related to finances. Using support as described in this subtheme of “moving on” is different from using support in the theme “getting through.” Using support in the theme “moving on” was provided in a specific time frame and for a specific purpose—a means of helping the widows get through the final moments of their husbands’ deaths. On the other hand, using support in moving on is of an indefinite nature in that family and friends provide encouragement and assistance to the widows on an ongoing basis.
After their husbands had died, the widows described intentional activities and behaviors that allowed them to continue living meaningful lives. This theme was labeled moving on because of the vivid descriptions the widows provided reflecting their moving forward with their lives or “putting the next foot forward.” This multifaceted theme consisted of five subthemes: positive memories or recall, personal or self-growth, strength-seeking, using support, and life-oriented.
Positive memories. Positive memories or positive recollections of pleasant times with their husbands were shared through storytelling. These stories were rich, colorful descriptions about their husbands and special times in their marriages. Each participant was eager to share positive aspects about her husband such as “He was such a good man,” “Everybody liked David,” or “He had a way with the children.”
Personal or self-growth. Personal or self-growth occurred as the widows began to reformulate their identity. Many widows said that to go on with life, they had to grow from a personal inward perspective. They came to the realization that unless they gained insight into themselves, it would be more difficult to cope with daily living. Such comments as “It’s [loss of husband] something you have to learn to live with; you can’t give up” or “I knew it was something I had to handle” demonstrate personal insight into the realization of the impact their husbands’ deaths had on their daily lives. The widows had to learn new skills, as well as chose to learn new skills. For example, one widow had to learn how to balance a checkbook, and another chose to learn how to play duplicate bridge, which would also provide her the opportunity to travel. Moreover, widows assumed new roles after their husbands’ deaths. One widow said she found it difficult to identify herself as only “Mrs. _____” rather than “Rev. and Mrs. _____.”
Strength-seeking. Strength-seeking from the widow’s church (minister and members), family, friends, professionals, and God was a common means of helping her move on with her daily liv-
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Using support.
Life-oriented. All the participants expressed a desire and need to live life to the fullest in spite of the deep pain and loss they felt for their husbands. They oriented many of their daily activities and behaviors toward living life positively. Regular participation in a variety of activities, such as bowling, Bible classes, or fishing, helped the widows through their grief experiences. Telling stories about their husbands and happier times added meaning to their lives and allowed the widows to remain connected to their husbands. Moreover, the widows gained self-understanding by reflecting on the past. Doing for others (e.g., volunteering at a local school) and giving advice (e.g., offering advice to other widows) were important aspects of being life-oriented. Tables 5 and 6 provide representative significant statements of connectedness and their formulated meanings.
Changing Feelings. The widows described feelings and emotions that they experienced both during and after their husbands’ deaths, which were often very painful and poignant. The early feelings were described as shock, “I didn’t feel anything…it just can’t be happenin,’ you know, he couldn’t really be gone!” As time elapsed, they described feelings of emptiness and loneliness, “It’s a vacant spot that never really goes away.” Events or memories that reminded the participants of their husbands would bring sudden feelings of sadness and often tears. Eventually, as time passed, the participants’ feelings changed from shock and intense sadness to “learning to live with it [the pain].”
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Financial Security Having financial security provided relief to the participants and allowed them to focus on other aspects of their lives. The widows described financial security as having good insurance or monthly income and took comfort from the assurance that if their children had good incomes, they would have fewer financial worries. Family and friends often provided financial support in the form of money trees or by directly paying bills for the widow. D I S C U S S I O N A N D I M P L I C AT I O N S The pervading and overarching theme of the grief experience of the older African American widow was her ability to communicate her experience through vivid and descriptive stories. Storytelling, rooted in a historical context,24 is used by older African American women to transmit ideals and values to their families. Retelling stories about their husbands and marriages to willing listeners (family, friends, and health care professionals) allowed the widows not only to pass on these values but also to facilitate moving on with their normal life activities and going through the grieving process more efficaciously. Because older African American widows have a rich background in the oral tradition, it is important for nurses to listen to their stories. Nurses should be aware that older African American widows may share their stories using very vivid and interactive dialogue, which can be very dramatic in nature (using hands, changing voices, mimicking gestures of people about whom they are talking). Nonjudgmental and active listening on the part of the nurse can be of much benefit to the older African American widow. Nurses can use storytelling as a therapeutic intervention, as well as a means to increase their understanding of the impact that culture and life experiences have on the bereavement experience of older African American widows.30 Six themes were identified: awareness of death, care giving, getting through, moving on, changing feelings, and financial security. Each widow stated that it was extremely important for her to be at her husband’s bedside when he was dying. Consequently, it is recommended that nurses provide accurate information regarding the exact status of the husband’s impending death. In regard to care giving, it is important for nurses to recognize that having family and extended family provide assistance with daily tasks is a unique pattern in the care system of older African Americans31 in that whites typically only request help from immediate family members.32 The participants consistently stated that their family and friends provided invaluable support in helping them get through their grief and move on with their lives. Findings from this study were consistent with observations in other studies33,34 that family and church members were prominent in the support of grieving older widows, enabling them to get through their grief and move on with their lives. Hegge and Fischer35 identified several effective coping strategies used by older widows such as visiting with othJanuary/February 2004
Table 5. Representative Significant Statements of MovingOn: Connectedness “We had a very unique relationship. There wasn’t a bit of
jealousy in our life. He was a wonderful husband.” “[my husband] influenced a lot of people; he was a really good person.” “Those boys [nephews] thought more of him [husband] than they did their own father. There was nothing in the world he couldn’t do.” “He an’ I had a very good relationship and he sure could dance, too.”
Table 6. Moving-On Formulated Meanings: Connectedness
“The widows remained connected to their husbands by recalling and retelling stories of happier times with their husbands.” “The widows stayed emotionally linked with their husbands by sharing attributes of their husbands and their marriages.”
ers, keeping busy, reflecting on positive memories, developing new skills, and relying on others including God and the church. These same coping strategies were used by the participants in this study. Nurses can encourage older African American widows to use these strategies when providing bereavement care to this population. All of the participants described changing feelings throughout their bereavement experience. With time, the widows stated that they learned to live with the pain of their loss. Rosenbaum’s study of Greek widows36 revealed that the widows never fully accepted their husbands’ death but rather became resigned to it. Indeed, the participants in this study expressed this sentiment in 26 significant statements such as “It’s a vacant spot that will never go away.” The death of a spouse can have a negative impact on the surviving spouse’s social, financial, and emotional status. Consistent with other findings,37 participants expressed decreased stress and much gratitude for the financial assistance their families gave them, which helped them through the sad times. It behooves nurses to be sensitive to this finding and not to minimize financial concerns that might be expressed by a grieving widow. There appear to be several universal themes, such as changing feelings, that transcend cultural heritage and life experiences. Yet, there are several implications that are of particular interest to nurses providing care to older African American widows. Nurses should be especially aware of the role of the church, value of the family (immediate and extended), and significance of life stories when exploring the bereaved widow’s support systems. Nurses are also often in the position to bridge the connection between formal health care services and community support services when providing this bereavement care. 15
L I M I TAT I O N S Several limitations are inherent in this study. Representativeness is limited because of the small sample size (N = 11), exclusion of men, and location (Northwest). The findings in this study may be relevant only to older African American widows with similar characteristics. The current trend is for nurses to use a more interpretive approach when doing phenomenological research. Colaizzi’s28 methodology looks less at the full picture and richness of a particular phenomenon but, rather, focuses more on extracting the meaning from the experience and then formulating the meaning of the experience. CONCLUSION Storytelling, based on the participants’ cultural background of a rich oral tradition, was at the heart of every participant’s description of her bereavement experience. Nurses can engage the older African American widow in storytelling not only as an effective therapeutic intervention but also, and especially, as a means to gain in-depth understanding and cultural insight into the meaning of the widow’s grief experience. For nurses to effectively intervene in the lives of bereaved older African American widows, they must consider the widow’s culture, heritage, and lived experiences, which can be ascertained through life stories told by the widow. Nurses should challenge the current prescriptive grief model that does not take into account cultural differences or social factors. Additional bereavement studies are needed to systematically explore the bereavement experience of older African American widows and widowers, taking into account cultural heritage and life experiences. Research on differences between older African Americans and the dominant culture should be sensitive to cultural barriers and variations. One way to pursue this research is to incorporate the Afrocentric paradigm. REFERENCES 1. Burggraf V. Ethnicity and health. Geriatr Nurs 2000;21:183-7. 2. Kitson GC. Adjustment to violent and natural deaths in later and earlier life for black and white widows. J Gerontol 2000;55B:S341-S351. 3. Lund DA, Caserta MS, Dimond MF. The course of spousal bereavement in later life. In: Stroebe MS, Stroebe W, Hansson RO, editors. Handbook of bereavement: theory, research, and intervention. New York: Cambridge University Press; 1993. p. 240-54. 4. Parkes CM. Bereavement: studies of grief in adult life. 3rd ed. London: Routledge; 1996. 5. Gallagher-Thompson D, Futterman A, Thompson L, Peterson J. The impact of spousal bereavement on older widows and widowers. In: Stroebe MS, Stroebe W, Hansson RO, editors. Handbook of bereavement: theory, research, and intervention. New York: Cambridge University Press; 1993. p. 227-39. 6. Anderson KL, Dimond MF. The experience of bereavement in older adults. J Adv Nurs 1995;22:308-15. 7. Solari-Twadwell PS, Bunkers SS, Wang C, Snyder, D. The pinwheel model of bereavement. Image J Nurs Sch 1995;27:323-6. 8. Carter SL. Themes of grief. Nurs Res 1989;38:354-8. 9. Clavon A. The black elderly. J Gerontol Nurs 1986;12:6-12. 10. Detmer CM, Lamberti JW. Family grief. Death Studies 1991;15:363-74. 11. Bureau of the Census, National Institutes of Health. Profiles of America’s elderly: racial and ethnic diversity of America’s elderly population. Current population reports, series POP/93-1. Washington (DC): US Government Printing Office; 1993. 12. Hobbs FB, Damon BL. 65+ in the United States: current population reports, special studies. (Department of Commerce Publication No. P23-190). Washington (DC): US Government Printing Office; 1996.
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13. Harper MS, Alexander CD. Profile of the black elderly. In: Harper MS, editor. Minority aging: essential curricula content for selected health and allied health professions. Washington (DC): US Government Printing Office; 1990, p. 193-222. 14. Satcher D, Thomas DJ. Dimensions of minority aging: implications for curriculum development for selected health professions. In: Harper MS, editor. Minority aging: essential curricula content for selected health and allied professions. Washington (DC): US Government Printing Office; 1990. p. 23-32. 15. Stroebe M, Schut H. The dual process model of coping with bereavement: rationale and description. Death Studies 1999;23:197-224. 16. Davis RA. The black family in a changing black community. New York: Garland; 1993. 17. Portes A, Jensen L. The enclave and the entrants: patterns of ethnic enterprise in Miami: before and after Mariel. Am Sociol Rev 1989;54:929-49. 18. Asante MK. Afrocentricity. Trenton, NJ: Africa World Press; 1988. 19. Keto T. The Africa-centered perspective of history. Blackwood, New Jersey: KA Publications; 1989. 20. Mbiti JS. African religions and philosophy. New York: Anchor; 1970. 21. Perry CM, Johnson CL. Families and support networks among African American oldest-old. Int J Aging Hum Dev 1994;38:41-50. 22. Allen CS. The search for applicable theories of black family life. J Marriage Family 1978;40:117-29. 23. Dula A. The life and death of Miss Mildred: an elderly black woman. Clin Geria Med 1994;10:419-30. 24. Hill-Lubin MA. The African-American grandmother in autobiographical works by Frederick Douglass, Langston Hughes, and Maya Angelou. Int J Aging Hum Dev 1991;30:173-85. 25. Johnson CL, Barer BM. Life course effects of early parental loss among very old African Americans. J Gerontol 2002;57B:S108-S116. 26. Padgett D. Aging minority women: issues in research and health policy. In: Grau L, editor. Women in later years: health, social, and cultural perspectives. New York: Haworth; 1989. 27. Taylor RJ, Chatters L. Patterns of informal support to elderly blacks: family, friends, and church members. Social Work 1986;29:432-8. 28. Colaizzi PF. Psychological research as the phenomenologist views it. In: Valle RS, Halling S, editors. Existential-phenomenological perspectives in psychology. New York: Plenum; 1989. p. 48-71. 29. Polkinghorne DE. Phenomenological research methods. In: Valle RS, Halling S, editors. Existential-phenomenological perspectives in psychology. New York: Plenum; 1989. p. 41-60. 30. Taylor J, Banks-Wallace J, Tripp-Reimer T. Storytelling and violence against women. ABNF J 2001;12:28-31. 31. White-Means SI. Informal home care for frail black elderly. J Appl Gerontol 1993;12:18-33. 32. Salahu-Din SN. A comparison of coping strategies of African American and Caucasian widows. Omega 1996;33:103-20. 33. Taylor RJ, Chatters LM. Nonorganizational religious participation among elderly black adults. J Gerontol 1991;46:S103-S111. 34. Jones PS, Martinson IM. The experiences of bereavement in caregiving of family members with Alzheimer’s disease. Image J Nurs Sch 1992;24:172-6. 35. Hegge M, Fischer C. Grief responses of senior and elderly widows. J Gerontol Nurs 2000;26:35-43. 36. Rosenbaum J. Widowhood grief: a cultural perspective. Can J Nurs Res 1991;23:61-76. 37. McDonald JM. Support systems for American black wives and widows. In: Lopata HZ, editor. Widows: North America. Vol. II. 1987; p. 139-57.
LAURA S. RODGERS, RN, PhD, is professor in the Nursing Department of the College of Saint Benedict/Saint John’s University, at Saint Joseph, Minnesota. Acknowledgements This study was supported in part by grant NR07048, Institutional Research Service Award, Nursing Care of Older People, School of Nursing, Oregon Health Sciences University, Portland, Oregon. 0197-4572/$ - see front matter © 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.gerinurse.2003.11.012
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Laura S. Rodgers, RN, PhD
In spite of the increase in research on spousal bereavement, researchers have not specifically addressed the impact that ethnicity may have on the bereavement experience. The results of this descriptive phenomenological study increase the understanding of spousal bereavement among older African American widows. Storytelling was at the heart of every participant’s description of her bereavement experience. Six themes were identified: awareness of death, care giving, getting through, moving on, changing feelings, and financial security. For nurses to effectively intervene in the lives of bereaved older African American widows, they must consider each widow’s culture, heritage, and lived experiences, which can be ascertained through eliciting and listening to the widow’s life stories. (Geriatr Nurs 2004;25:10-16)
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n the past 20 years, there has been an increase in bereavement research, especially regarding widowhood among the older population. Despite this accumulating knowledge, researchers have either failed to include elderly members of minority ethnic groups in their study samples or neglected to address the impact that ethnicity may have on the bereavement process or outcome. The trend in spousal bereavement research, unfortunately, has been to assume all elderly populations have bereavement experiences similar to those of the mainstream population, thus ignoring the unique historical and cultural heritage of elderly members of minority ethnic groups.1,2 Spousal bereavement is both a life stressor and life event associated with considerable physical and mental health problems,3,4 which can negatively affect the health behaviors and daily activities of older persons.5,6 The bereavement experience, as a dynamic process,7 is a unique and personal phenomenon influenced by culture, social context, one’s perception of death, personal history, environment, and the nature of the relationship between the spouses.8-10 Yet, there are virtually no empirical studies that examine the meaning of bereavement among older African American widows. The older population in ethnic minority groups is expected to triple by the year 2025, constituting more than 15% of the entire older population.11 More specifically, older black Americans are the fastest growing segment of the older population, with the population of black women aged 80 years and older growing the most rapidly.12 The majority of black women aged 65 and older are widowed (57.7% as compared with 51.1% of older white women),13 and there is an increasing tendency for black women to be widowed earlier than white women.14 Recently, Stroebe and Schut15 have proposed a new bereavement model, which would take into account both cultural and gender differences while questioning the current grief work hypothesis as being limited in its explanation of bereavement among different cultures. Yet in spite of the increase in the number of older black American widows, the process and meaning of bereavement among these women has not been adequately studied. Application and generalization of the current knowledge of bereavement through nursing interventions to this population may be premature. There are three distinct ethnic groups in the black community: American-born, Caribbean-born, and Africanborn.16 Because of this ethnic diversity, which is the result of a disparate historic past, these three groups should not be considered a single ethnic group.17 Both the Americanborn and Caribbean-born groups were part of the African diaspora; even so, these groups have had very different experiences since then.16 In addition, African-born blacks do not have the history of North American slavery, segregation, and racism as do Caribbean-born and American-born blacks. Rather, African-born blacks have experiences of apartheid, colonialism, and political instability. In spite of the differences among the three black ethnic groups, there is a worldview that links the groups with African history January/February 2004
and culture. This paradigm has been called Afrocentricity. Afrocentric scholars describe Afrocentricity as a philosophy, a lifestyle, a perspective, an analytical approach, and a cultural orientation.18,19 Asante18 believes that Afrocentricity includes every element of human orientation such as perception, religion, interpersonal relationships, philosophy, communication, language, and fashion. For instance, the African American oratory, used by pioneers of the Civil Rights movement, illustrated the power of the spoken word through sermons, lectures, gospel songs, and poetry and is a carryover of the ancestral practice of oral expression from Africa, which included storytelling and praise singing. Another example is that an African-based culture emphasizes the centrality of the family and personal integrity20 as compared with a European-based culture, which emphasizes the idea of survival of the fittest and individuality. The African American family consists of an extended, communal family that includes both blood relatives and nonblood relatives (also known as fictive kin or kin network) and reflects the African heritage in which families live together in communities.14,21 In addition, there is also a great respect for age,22,23 with the elderly occupying a special place of leadership and honor in the family.14 In the African American community, the older black woman “sits on a throne of grace, emanating an aura of dignity that permeates her being. She is respected for her wisdom, admired for her strength, and honored for her contributions to the health and well-being of both the black family and community.”23 The older black grandmother uses stories to teach skills of survival and transmit values and ideals to her family.24 Participation in the church and religious activities is an extension of family life, as well as a source of social integration, for older blacks.25 Consequently, any study of the African American experience should consider the African heritage and the American experience. PURPOSE OF THE STUDY AND METHODS Even though the majority of older African American women are widows, there are virtually no empirical studies of bereavement among this particular population. The overarching goal of this phenomenological study is to use the findings to increase the knowledge base for nursing practice to enhance the nurse’s ability to provide culturally sensitive care to this population. The research question addressed was “From the perspective of older African American widows, what is the meaning of their lived experiences of bereavement after the death of their husbands?”
Description of Participants In a middle-size city in the Pacific Northwest, 11 participants were interviewed (age range, 63-94 years) in their own homes. It is believed that some ethnic groups may age physiologically sooner than others.26,27 Study participants 11
Table 1. Representative Significant Statements of Awareness of Death
“That was when I realized that he, uh, probably would [not last the day].” “I couldn’t go golfin’ (hesitates), he was too sick! I said, (very softly) ‘uhn-nhn’ (softer) I said, ‘I can’t go…with him in the condition he’s in.’” “ ‘bout ten o’clock on this particular night. I went [in] there. I just (slower) kn-ew, I just knew (takes breath), I could just tell, …he was dy-in. I kept tellin’ my children.”
met four criteria: African American/American-born, 55 years or older, widowed, and verbally able to share the bereavement experience. Participants were recruited through personal acquaintances and professional contacts with several local black ministers, which led to a “snowballing” effect. All participants maintained regular contact with family and friends. Participants identified an affiliation with a church and described the church as a place to obtain not only spiritual nurturance but also to retain important social contacts. The educational backgrounds varied from master’s preparation to less than sixth grade. All participants actively participated in a variety of social and community organizations. The length of marriages ranged from 11 to 57 years.
Data Collection Procedure Data were collected by means of tape-recorded in-depth interviews (range, 1-31⁄2 hours) and a research journal. All field notes, personal assumptions and reflections, interactions with nursing professionals, demographic data, and coding strategies were maintained in this journal. Several open-ended questions were asked of each participant to elicit her description of her bereavement experience after the death of her husband. As themes and meanings emerged, interview questions were modified. For example, after several interviews, it became apparent that a participant’s faith was an important aspect of her bereavement experience; and consequently, an open-ended faith question was included in subsequent interviews. In addition, it became evident that stories told by the participants provided some of the richest and most descriptive data about their bereavement experience. Another open-ended question was added such as “Tell me a story about…(like when he died).” Although the interview guide was developed to probe the participant’s perspective to the fullest, each participant was encouraged to share her lived experiences in her own way.
Data Analysis Data were analyzed by using Colaizzi’s28 seven-step method. Each taped interview was transcribed verbatim and verified. Trustworthiness and accuracy in the synthe-
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Table 2. Awareness of Death Formulated Meanings
“ After close observation of their husbands, the participants became cognitively aware that their husbands were going to die shortly and they were able to verbalize this awareness to others.” “ The participants became aware of their husbands’ impending deaths through past personal experiences with deaths of other close family members and/or health care workers providing information of direct personal observation of husbands’ physical condition.” “ The widows changed their daily activities when they became aware of their husbands’ imminent deaths in order to be at their husbands’ bedsides.”
sis of the transformed meanings into an essential structure of the description of bereavement were addressed according to Polkinghorne’s29 five questions, which could be used to establish validity for a phenomenological study. Thematic analysis was validated by expert consultation with two nurse researchers (an expert in bereavement care and an expert in phenomenological research). Final validation occurred when the participants were re-contacted and confirmed that the final analyses accurately described their bereavement experiences. One participant provided more stories about her bereavement experience that further corroborated the findings. However, no new information was elicited. R E S U LT S As a result of analysis of the data, seven themes emerged. Six themes were identified from the participant’s description of her bereavement experience: awareness of death, care giving, getting through, moving on, changing feelings, and financial security. One theme, storytelling, emerged as distinct from the bereavement experience in that it provided a vehicle by which the participants shared their life experiences. The names, factual places, and dates have been changed in the following examples to protect the confidentiality of the participants.
Storytelling A pervading and prevalent theme, storytelling was at the heart of every widow’s description of her lived bereavement experience after the death of her husband. These stories, which were told throughout the entire interview, provided rich, colorful, and detailed descriptions that involved the participant’s artful ability to describe a particular situation in her past. Storytelling involved more than merely relating a particular incident in chronological and narrative fashion. Rather, through storytelling, the participant took on the various roles, mannerisms, and speech patterns of the persons who were part of the story. Participants changed tones and accents to mimic the voices of the people involved in the event
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Table 3. Representative Significant Statements of Caregiving: Task-oriented
“I took him to the doctor.” “I would give him a bath, and give him his medication…” “I did everything for him…I had to do everything for him.” “…then, the next thing, I went in, my sister and I decided, well, ‘Let’s go and turn him, he’s been on that side too long.’”
and used their hands, body language, and facial expressions to share stories.
Table 4. Caregiving Formulated Meanings: Task-oriented
“The wives provided direct and indirect physical care to their husbands before their deaths.” “Caregiving involved ‘doing for’ their husbands.” “Task-oriented care meant the wives were the doers, or they arranged to have another person provide the physical care.” “Task-oriented care meant meeting the physiologic needs of the dying husbands as perceived by the wives.” “Task-oriented care included touching their husbands (such as bathing), manipulating environmental props (such as beds and medications), or transporting their husbands (such as from house to hospital or room to room).”
Awareness of Death Awareness of death was a widow’s realization that her husband’s death was imminent. This occurred when the widow actually knew and could verbalize that her husband was going to die within the next 24 to 30 hours. Table 1 provides representative examples of significant statements, and Table 2 provides the formulated meanings for the significant statements related to the theme awareness of death.
Caregiving Caregiving included formal care that was solicited by the widows and provided by health care professionals such as nurses and physicians. Informal care, such as bathing and feeding, was provided by the widow, her family, or friends. For either type of care, the widows were present whenever possible. The participants described four aspects of care giving: task-oriented, problem-solving, decision making, and learning.
Task-oriented care. Task-oriented care included direct hands-on physical care for the husband, which was preferred to be done by the wife or family, and if needed, by a professional. Examples of task-oriented care are bathing, toileting, brushing teeth, and driving their husbands to and from a physician’s appointment. Professionals provided task-oriented care such as changing dressings, doing a physical assessment, or drawing blood for lab work.
Problem solving. The widows described specific caregiving situations in which they either directly or indirectly resolved a perplexing problem. For instance, one husband adamantly refused to have a hospital bed at home. However, the wife was concerned that he would fall out of bed as a result of restlessness. She placed four large dining room chairs next to one side of his bed after having friends push the bed against a wall. The same widow, herself not well or too strong, had difficulty getting her husband from his chair in the living room to his bed at night. She resolved that probJanuary/February 2004
lem by having her husband sit on the portable commode chair, which allowed her to roll him into the bedroom.
Decision making. Another aspect of care giving entailed making decisions. One participant decided whether her husband would have a surgical procedure, be admitted to the hospital, or take his medicines. Decision making also included determining when to call the nurse or physician for advice, when to call an ambulance, or who should be involved in the formal and informal care giving tasks. At times, the widows acted as gatekeepers in that they made decisions for their husbands and protected them from others. For example, three participants monitored who could come to the house and visit their husbands.
Learning. Participants found themselves learning many new things. For example, they were learning about their husbands’ diagnoses and treatments, how to replace a nasogastric tube, how to give injections, and how to recognize the physical signs of impending death. Table 3 is a representative sample of significant statements, and Table 4 provides the formulated meanings of task-oriented care giving.
Getting Through The actual dying process was singled out as an especially difficult moment for them. Emotional support from family, friends, professionals, and the church enabled the participants to “get through” their husbands’ moments of death. For example, nurses and social workers, either by being present at the bedside or available by telephone, provided emotional reassurance, as did family and friends by being physically present, telephoning, or bringing food. Participants found that keeping busy and recalling or retelling positive memories to others present at the bedside or other willing listeners facilitated getting through those difficult moments. Church members and the minister were expected to actively participate in the widows’ grief expe13
riences both during their husbands’ actual dying and after the funeral services. The widows stated that they expected every family member to come home to pay their last respects to their husbands, no matter how far away they lived. Knowing that family was coming and would provide support was very reassuring to the participants. Finally, four participants clearly stated that knowing that everything possible had been done to help their husbands during the illness and the actual dying process provided overwhelming comfort to them and helped them “get through” their husbands’ actual deaths.
ing. Praying to God for inner strength was described by the widows as “believing in a higher source of strength” to help them deal with the pain of losing their husbands. In addition, the participants obtained strength by being remembered by others in ways such as receiving telephone calls, gifts of food, visits, and invitations to dinner. The widows actively solicited these encounters. This subtheme, strength seeking, is different from using support, even though there are similarities. Strength seeking was an intentional act by the participant to obtain emotional and spiritual strength.
Moving On
Unlike strength seeking, using support occurred when the widow received unsolicited support from others. The participants willingly and gratefully accepted support offered by others in forms such as doing yardwork or providing advice related to finances. Using support as described in this subtheme of “moving on” is different from using support in the theme “getting through.” Using support in the theme “moving on” was provided in a specific time frame and for a specific purpose—a means of helping the widows get through the final moments of their husbands’ deaths. On the other hand, using support in moving on is of an indefinite nature in that family and friends provide encouragement and assistance to the widows on an ongoing basis.
After their husbands had died, the widows described intentional activities and behaviors that allowed them to continue living meaningful lives. This theme was labeled moving on because of the vivid descriptions the widows provided reflecting their moving forward with their lives or “putting the next foot forward.” This multifaceted theme consisted of five subthemes: positive memories or recall, personal or self-growth, strength-seeking, using support, and life-oriented.
Positive memories. Positive memories or positive recollections of pleasant times with their husbands were shared through storytelling. These stories were rich, colorful descriptions about their husbands and special times in their marriages. Each participant was eager to share positive aspects about her husband such as “He was such a good man,” “Everybody liked David,” or “He had a way with the children.”
Personal or self-growth. Personal or self-growth occurred as the widows began to reformulate their identity. Many widows said that to go on with life, they had to grow from a personal inward perspective. They came to the realization that unless they gained insight into themselves, it would be more difficult to cope with daily living. Such comments as “It’s [loss of husband] something you have to learn to live with; you can’t give up” or “I knew it was something I had to handle” demonstrate personal insight into the realization of the impact their husbands’ deaths had on their daily lives. The widows had to learn new skills, as well as chose to learn new skills. For example, one widow had to learn how to balance a checkbook, and another chose to learn how to play duplicate bridge, which would also provide her the opportunity to travel. Moreover, widows assumed new roles after their husbands’ deaths. One widow said she found it difficult to identify herself as only “Mrs. _____” rather than “Rev. and Mrs. _____.”
Strength-seeking. Strength-seeking from the widow’s church (minister and members), family, friends, professionals, and God was a common means of helping her move on with her daily liv-
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Using support.
Life-oriented. All the participants expressed a desire and need to live life to the fullest in spite of the deep pain and loss they felt for their husbands. They oriented many of their daily activities and behaviors toward living life positively. Regular participation in a variety of activities, such as bowling, Bible classes, or fishing, helped the widows through their grief experiences. Telling stories about their husbands and happier times added meaning to their lives and allowed the widows to remain connected to their husbands. Moreover, the widows gained self-understanding by reflecting on the past. Doing for others (e.g., volunteering at a local school) and giving advice (e.g., offering advice to other widows) were important aspects of being life-oriented. Tables 5 and 6 provide representative significant statements of connectedness and their formulated meanings.
Changing Feelings. The widows described feelings and emotions that they experienced both during and after their husbands’ deaths, which were often very painful and poignant. The early feelings were described as shock, “I didn’t feel anything…it just can’t be happenin,’ you know, he couldn’t really be gone!” As time elapsed, they described feelings of emptiness and loneliness, “It’s a vacant spot that never really goes away.” Events or memories that reminded the participants of their husbands would bring sudden feelings of sadness and often tears. Eventually, as time passed, the participants’ feelings changed from shock and intense sadness to “learning to live with it [the pain].”
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Financial Security Having financial security provided relief to the participants and allowed them to focus on other aspects of their lives. The widows described financial security as having good insurance or monthly income and took comfort from the assurance that if their children had good incomes, they would have fewer financial worries. Family and friends often provided financial support in the form of money trees or by directly paying bills for the widow. D I S C U S S I O N A N D I M P L I C AT I O N S The pervading and overarching theme of the grief experience of the older African American widow was her ability to communicate her experience through vivid and descriptive stories. Storytelling, rooted in a historical context,24 is used by older African American women to transmit ideals and values to their families. Retelling stories about their husbands and marriages to willing listeners (family, friends, and health care professionals) allowed the widows not only to pass on these values but also to facilitate moving on with their normal life activities and going through the grieving process more efficaciously. Because older African American widows have a rich background in the oral tradition, it is important for nurses to listen to their stories. Nurses should be aware that older African American widows may share their stories using very vivid and interactive dialogue, which can be very dramatic in nature (using hands, changing voices, mimicking gestures of people about whom they are talking). Nonjudgmental and active listening on the part of the nurse can be of much benefit to the older African American widow. Nurses can use storytelling as a therapeutic intervention, as well as a means to increase their understanding of the impact that culture and life experiences have on the bereavement experience of older African American widows.30 Six themes were identified: awareness of death, care giving, getting through, moving on, changing feelings, and financial security. Each widow stated that it was extremely important for her to be at her husband’s bedside when he was dying. Consequently, it is recommended that nurses provide accurate information regarding the exact status of the husband’s impending death. In regard to care giving, it is important for nurses to recognize that having family and extended family provide assistance with daily tasks is a unique pattern in the care system of older African Americans31 in that whites typically only request help from immediate family members.32 The participants consistently stated that their family and friends provided invaluable support in helping them get through their grief and move on with their lives. Findings from this study were consistent with observations in other studies33,34 that family and church members were prominent in the support of grieving older widows, enabling them to get through their grief and move on with their lives. Hegge and Fischer35 identified several effective coping strategies used by older widows such as visiting with othJanuary/February 2004
Table 5. Representative Significant Statements of MovingOn: Connectedness “We had a very unique relationship. There wasn’t a bit of
jealousy in our life. He was a wonderful husband.” “[my husband] influenced a lot of people; he was a really good person.” “Those boys [nephews] thought more of him [husband] than they did their own father. There was nothing in the world he couldn’t do.” “He an’ I had a very good relationship and he sure could dance, too.”
Table 6. Moving-On Formulated Meanings: Connectedness
“The widows remained connected to their husbands by recalling and retelling stories of happier times with their husbands.” “The widows stayed emotionally linked with their husbands by sharing attributes of their husbands and their marriages.”
ers, keeping busy, reflecting on positive memories, developing new skills, and relying on others including God and the church. These same coping strategies were used by the participants in this study. Nurses can encourage older African American widows to use these strategies when providing bereavement care to this population. All of the participants described changing feelings throughout their bereavement experience. With time, the widows stated that they learned to live with the pain of their loss. Rosenbaum’s study of Greek widows36 revealed that the widows never fully accepted their husbands’ death but rather became resigned to it. Indeed, the participants in this study expressed this sentiment in 26 significant statements such as “It’s a vacant spot that will never go away.” The death of a spouse can have a negative impact on the surviving spouse’s social, financial, and emotional status. Consistent with other findings,37 participants expressed decreased stress and much gratitude for the financial assistance their families gave them, which helped them through the sad times. It behooves nurses to be sensitive to this finding and not to minimize financial concerns that might be expressed by a grieving widow. There appear to be several universal themes, such as changing feelings, that transcend cultural heritage and life experiences. Yet, there are several implications that are of particular interest to nurses providing care to older African American widows. Nurses should be especially aware of the role of the church, value of the family (immediate and extended), and significance of life stories when exploring the bereaved widow’s support systems. Nurses are also often in the position to bridge the connection between formal health care services and community support services when providing this bereavement care. 15
L I M I TAT I O N S Several limitations are inherent in this study. Representativeness is limited because of the small sample size (N = 11), exclusion of men, and location (Northwest). The findings in this study may be relevant only to older African American widows with similar characteristics. The current trend is for nurses to use a more interpretive approach when doing phenomenological research. Colaizzi’s28 methodology looks less at the full picture and richness of a particular phenomenon but, rather, focuses more on extracting the meaning from the experience and then formulating the meaning of the experience. CONCLUSION Storytelling, based on the participants’ cultural background of a rich oral tradition, was at the heart of every participant’s description of her bereavement experience. Nurses can engage the older African American widow in storytelling not only as an effective therapeutic intervention but also, and especially, as a means to gain in-depth understanding and cultural insight into the meaning of the widow’s grief experience. For nurses to effectively intervene in the lives of bereaved older African American widows, they must consider the widow’s culture, heritage, and lived experiences, which can be ascertained through life stories told by the widow. Nurses should challenge the current prescriptive grief model that does not take into account cultural differences or social factors. Additional bereavement studies are needed to systematically explore the bereavement experience of older African American widows and widowers, taking into account cultural heritage and life experiences. Research on differences between older African Americans and the dominant culture should be sensitive to cultural barriers and variations. One way to pursue this research is to incorporate the Afrocentric paradigm. REFERENCES 1. Burggraf V. Ethnicity and health. Geriatr Nurs 2000;21:183-7. 2. Kitson GC. Adjustment to violent and natural deaths in later and earlier life for black and white widows. J Gerontol 2000;55B:S341-S351. 3. Lund DA, Caserta MS, Dimond MF. The course of spousal bereavement in later life. In: Stroebe MS, Stroebe W, Hansson RO, editors. Handbook of bereavement: theory, research, and intervention. New York: Cambridge University Press; 1993. p. 240-54. 4. Parkes CM. Bereavement: studies of grief in adult life. 3rd ed. London: Routledge; 1996. 5. Gallagher-Thompson D, Futterman A, Thompson L, Peterson J. The impact of spousal bereavement on older widows and widowers. In: Stroebe MS, Stroebe W, Hansson RO, editors. Handbook of bereavement: theory, research, and intervention. New York: Cambridge University Press; 1993. p. 227-39. 6. Anderson KL, Dimond MF. The experience of bereavement in older adults. J Adv Nurs 1995;22:308-15. 7. Solari-Twadwell PS, Bunkers SS, Wang C, Snyder, D. The pinwheel model of bereavement. Image J Nurs Sch 1995;27:323-6. 8. Carter SL. Themes of grief. Nurs Res 1989;38:354-8. 9. Clavon A. The black elderly. J Gerontol Nurs 1986;12:6-12. 10. Detmer CM, Lamberti JW. Family grief. Death Studies 1991;15:363-74. 11. Bureau of the Census, National Institutes of Health. Profiles of America’s elderly: racial and ethnic diversity of America’s elderly population. Current population reports, series POP/93-1. Washington (DC): US Government Printing Office; 1993. 12. Hobbs FB, Damon BL. 65+ in the United States: current population reports, special studies. (Department of Commerce Publication No. P23-190). Washington (DC): US Government Printing Office; 1996.
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13. Harper MS, Alexander CD. Profile of the black elderly. In: Harper MS, editor. Minority aging: essential curricula content for selected health and allied health professions. Washington (DC): US Government Printing Office; 1990, p. 193-222. 14. Satcher D, Thomas DJ. Dimensions of minority aging: implications for curriculum development for selected health professions. In: Harper MS, editor. Minority aging: essential curricula content for selected health and allied professions. Washington (DC): US Government Printing Office; 1990. p. 23-32. 15. Stroebe M, Schut H. The dual process model of coping with bereavement: rationale and description. Death Studies 1999;23:197-224. 16. Davis RA. The black family in a changing black community. New York: Garland; 1993. 17. Portes A, Jensen L. The enclave and the entrants: patterns of ethnic enterprise in Miami: before and after Mariel. Am Sociol Rev 1989;54:929-49. 18. Asante MK. Afrocentricity. Trenton, NJ: Africa World Press; 1988. 19. Keto T. The Africa-centered perspective of history. Blackwood, New Jersey: KA Publications; 1989. 20. Mbiti JS. African religions and philosophy. New York: Anchor; 1970. 21. Perry CM, Johnson CL. Families and support networks among African American oldest-old. Int J Aging Hum Dev 1994;38:41-50. 22. Allen CS. The search for applicable theories of black family life. J Marriage Family 1978;40:117-29. 23. Dula A. The life and death of Miss Mildred: an elderly black woman. Clin Geria Med 1994;10:419-30. 24. Hill-Lubin MA. The African-American grandmother in autobiographical works by Frederick Douglass, Langston Hughes, and Maya Angelou. Int J Aging Hum Dev 1991;30:173-85. 25. Johnson CL, Barer BM. Life course effects of early parental loss among very old African Americans. J Gerontol 2002;57B:S108-S116. 26. Padgett D. Aging minority women: issues in research and health policy. In: Grau L, editor. Women in later years: health, social, and cultural perspectives. New York: Haworth; 1989. 27. Taylor RJ, Chatters L. Patterns of informal support to elderly blacks: family, friends, and church members. Social Work 1986;29:432-8. 28. Colaizzi PF. Psychological research as the phenomenologist views it. In: Valle RS, Halling S, editors. Existential-phenomenological perspectives in psychology. New York: Plenum; 1989. p. 48-71. 29. Polkinghorne DE. Phenomenological research methods. In: Valle RS, Halling S, editors. Existential-phenomenological perspectives in psychology. New York: Plenum; 1989. p. 41-60. 30. Taylor J, Banks-Wallace J, Tripp-Reimer T. Storytelling and violence against women. ABNF J 2001;12:28-31. 31. White-Means SI. Informal home care for frail black elderly. J Appl Gerontol 1993;12:18-33. 32. Salahu-Din SN. A comparison of coping strategies of African American and Caucasian widows. Omega 1996;33:103-20. 33. Taylor RJ, Chatters LM. Nonorganizational religious participation among elderly black adults. J Gerontol 1991;46:S103-S111. 34. Jones PS, Martinson IM. The experiences of bereavement in caregiving of family members with Alzheimer’s disease. Image J Nurs Sch 1992;24:172-6. 35. Hegge M, Fischer C. Grief responses of senior and elderly widows. J Gerontol Nurs 2000;26:35-43. 36. Rosenbaum J. Widowhood grief: a cultural perspective. Can J Nurs Res 1991;23:61-76. 37. McDonald JM. Support systems for American black wives and widows. In: Lopata HZ, editor. Widows: North America. Vol. II. 1987; p. 139-57.
LAURA S. RODGERS, RN, PhD, is professor in the Nursing Department of the College of Saint Benedict/Saint John’s University, at Saint Joseph, Minnesota. Acknowledgements This study was supported in part by grant NR07048, Institutional Research Service Award, Nursing Care of Older People, School of Nursing, Oregon Health Sciences University, Portland, Oregon. 0197-4572/$ - see front matter © 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.gerinurse.2003.11.012
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