Living with Chronic Sorrow The middle range theory of chronic sorrow theory was researched in the 1980’s validating parent’s feelings over the loss of not having the perfect child and having a child with a disability. Chronic sorrow provided a framework for understanding the reactions of individuals to various loss situations and offered a way to view the experience of bereavement. Involvement in an experience of a significant loss is the necessary antecedent to the development of chronic sorrow (Peterson & Bredow, 2009).
or any similar topic only for you
The loss may affect individuals and family members at any time. Chronic sorrow may come to any of us during our lifetime.
Chronic sorrow can best be described as a natural response to a tragic situation. Where life experiences cause deep distress, sadness, or regret especially for the loss of someone or something loved ( Gordon, 2009 ). Chronic sorrow is followed by a permanent loss of a personal attachment that may be ongoing with a sadness of such intensity that it recurs for the lifetime of the person. Mental pain, suffering and despair can all occur from chronic sorrow regardless if the loss is caused by injury, trauma or by death ( Alligood, & Tomey,(2010). Washington Irving says it best, “There is a sacredness in tears.
They are not the mark of weakness, but of power. They speak more eloquently than ten thousand tongues. They are messengers of over whelming grief and unspeakable love. ” The rational for choosing the middle range theory of chronic sorrow was because this theory was easy to identify with. From losing a home to a natural disaster, a job, and even in death of family members, friends and numerous pets this theory really hit home from personnel experiences. Possible Antecedents, Defining Attributes and Consequences Let’s start but trying to understand the antecedents of chronic sorrow and how they relate to ach other and affect each of us as individuals. This may help to understand how strongly emotions control and play an important part in our everyday lives. The antecedents that go along with chronic sorrow are loss and grief. They are experienced periodically by individuals of all ages through their life time. Whether in the death of a family member, friend or pet, losing a home and all worldly possessions or losing a functioning body part. To be able to get through these powerful feelings and emotions can be very difficult and even more difficult for others to understand (Peterson & Bredow, 2009).
People all over the world are forced to deal with this daily, but until it happens to you, do you truly begin to understand the impact this has on ones’ own life. Every one of us will have to deal with loss at some time in our life. A loss can be described as “a pervasive psychic pain and sadness, stimulated by certain trigger events, which follows loss of a relationship of an attachment” (Teel,1991, pg. 1316). Losses come in many forms both large and small, such as loss of a job, a home, a way of life, a relationship, or loss of a significant other, spouse, family member or even a pet.
The perception of the event, the situational supports, and the coping mechanisms all influence return of equilibrium or homeostasis. A person either advances or regresses as a result of the crisis, depending upon how the person manages the crisis (Potter & Perry, 2009). Experiencing a loss can trigger the grief process. Everyone is different and comes to terms with loss in different ways, so it is difficult to say how long a person’s process may take. Losses that are smaller and have less of an impact on peoples’ lives will take a much shorter time to resolve emotionally than more significant losses (Foust, 2006).
Some people deal with the loss a day at a time, yet for some people it may be an hour at a time. As long as the person is not denying the loss, they are working through it. Action oriented is an internal management for coping with a loss. This includes continuing to be involved in interests, hobbies, activities, talking with friends, professionals and even joining a support group (Peterson and Bredow,2009). Lost your job, your home, a loved one, or a beloved pet? There are many forms of loss, and all are felt individually on a very personal level (Foust, 2006). A loss is losing or being deprived of something you once had.
Any loss can have a profound effect on your life. Loss can happen at any time day or night and does not need a reason. A consequence of a loss can stop you from socializing, cause you to have lack of interests, and take you emotionally away from those who love you. A loss can impact your job, your home, your finances, and your relationships. This is a real emotion that people around the world experience daily. Coping with loss and grief can be challenging in many ways (Teel. 1991). A loss may be felt physically and emotionally, like something is missing. A feeling of worry and emptiness may be felt deep inside.
Two types of losses most relevant to depressive symptoms are related to self, goal attainment, and loss of financial resources (Van Horn & Mischel, 2008). One may begin to suffer physical symptoms such as headaches, gastrointestinal upset, anxiety, sleeplessness, or anorexia. Emotionally you may feel tired, lack the ability to care about what is going on around you, sleep too much or too little, over eat or under eat, and neglect yourself and those around you. These are all feelings and emotions a person may experience in grief. Loss is an experience caused by changes and recognizing these changes are important in dentify feelings and most importantly, by allowing individuals to feel and express themselves begins the healing process (Love, 2007). Grief comes in many shapes and sizes. There is no “one size fits all” for the grieving process. Grief is the series of emotions that a person goes through after a loss.Grief may involve feelings of sadness, anger, guilt, shame, relief, jealousy, hopelessness and powerlessness ( Love, 2007). Many people allow for grief after the passing of a loved one, but many of today’s views tend to ignore the grief that can follow other kinds of losses.
As a result, people find themselves unexpectedly alone dealing with the sorrow, anger and other emotions associated with grief at various times in their life. Confused and even ashamed, they may attempt to hide or avoid these emotions, pushing them inward rather than letting them out. This may cause destructive and devastating repercussions which can follow. Yet all of this can be avoided, if people recognize that there are all kinds of grief (Castledine,2002). Learning to deal with the loss and cope with ones misfortunes is where grief comes in. So, how long is the grieving process?
Basically, a person grieves as long as it takes to come to terms with their loss and the impact that it has had on their life (Foust, 2006). The obvious time for grieving is after the death of a loved one. Many people experience this first with grandparents and parents, as well as aunts, uncles and family pets. Some people may suffer the difficult loss of siblings or spouses and still others may experience the tragic loss of a child. There is no way to measure grief, and no instrument or scale to measure for sorrow. Each person grieves these losses uniquely and differently. When a death of a loved one occurs those left ehind are often allowed time and space for grieving and usually supported by family and friends (Burglass, 2010). But what happens when someone loses a beloved pet? Or when a family loses a home? Or better yet the loss of a functioning body part, example hearing, seeing or loss of limb? These too are times of great loss. Unfortunately, they are seldom recognized as such and because of this the grieving are left alone to work through emotions that are many times misunderstood by those around them (Castledine, 2002). Coworkers, friends or even spouses can find it hard to understand ones grief and even find it difficult to handle.
A person must grieve in order to heal and move forward. The suffering of dazed confusion, distress and unrelenting despair will generally ease with time (Love, 2007). At home, whenever you are alone, don’t push or force yourself to do anything. Relax and do what comes naturally. Many cultures do not encourage people to grieve openly. Crying and other ways of expressing distress can be seen as signs of weakness. Crying can actually help relieve stress, so cry, take a bath or watch television (Gipson, 2009). Do whatever makes you feel comfortable and helps you relax. Management forms of grief can be in the form of faith, istractions, like work, hobbies, and honoring your loss through ritual is important in overcoming the loss. There are many ways to go through the grieving process, regardless of how one grieves, grief is critical in the healing process (Potter & Perry, pg. 496). Any loss can warrant grief. Grief is a normal reaction to loss and is not usually associated with long term negative consequences. Grief is a natural psychological and sometimes physical response to loss or change. Though death is most commonly associated with grieving, many other life changes can have the same result (911, Oklahoma City bombing).
Losing a job (being laid off after working several years for the same company), losing a home (natural disaster, fire, tornado or even hurricane), having children leave home ( go away to college, military service, get married), retiring, divorce, declaring bankruptcy (loss of financial resources) a breakup, even moving can all create a sense of real loss and grief (Love, 2007). Grieving is a natural and healthy reaction to all losses. The five stages of grief denial, anger, bargaining, depression and acceptance are all natural feelings when one experiences a significant loss.
These can also be overlapped with shock, yearning and protest, despair, and recovery (Buglass, 2010). Grieving helps people understanding what has occurred and how to adapt to a new set of circumstances in their life. What makes the grieving process so challenging, is that many of the emotions we experience are painful and most people do not want to feel painful emotions. Another challenging piece is that many people are not prepared for the variety of emotions that occur. Most people expect to feel sad, but may not expect to feel angry, anxious, hopeless, terrified, confused, frustrated, lonely, and so on.
The emotions felt do not occur in any predictable pattern and many people often tend to cycle through them throughout the grieving process (Drench, 2004). Grief is something that cannot be fixed and one cannot take a pill to make the grief go away. A person needs to experience the loss and all the negative emotions that result in order to accept the loss. Grief cannot be medicated with pills or alcohol. In fact, individuals that do attempt to take medication are using their own form of denial which usually lengthens the process and may even add a drug or alcohol addiction problem on top of their grief.
The good news is that there are things that people can do to help cope and work through the grief process (Potter and Perry, pg. 496). These are a few examples people may use to help work through the grieving process. Take care of yourself by getting rest, eating regularly and maintain a regular routine. This can be challenging during the early process, but is essential with recovery (Potter & Perry, pg. 496). Support systems of family, friends and colleagues who will listen, offer advice and provide emotional support can benefit you. Talk about your loss helps get your thoughts and feelings ut. Journaling is also a helpful to get your thoughts out. In a private journal or diary people are able to express their emotions and vent their feelings honestly without hurting anyone or without concern for how they may appear to others (Potter & Perry, pg. 496). Time management techniques include developing a list of tasks that are felt to be important and need to be accomplished. Perform the tasks at the top of the list that require immediate attention, those that are not as important can be delayed (Potter & Perry, pg. 497). Guided imagery and visualization can help with relaxation.
Gather pictures and other things that remind you of your loss, person, pet, house or phase of your life you have lost. Try talking with family and friends about your memories. Funniest, worst, happiest, anything you share will help with adjusting to the loss. Play music that reminds you of your loss. Music is a powerful memory that can make you feel good or is comforting to you (Potter & Perry, pg. 497). Progressive muscle relaxation may help with physiological tension. Exercise, fresh air, Sunshine, visiting with friends may all help. Deep breathing exercises may help reduce stress nd relax muscles (Potter & Perry, pg. 497). Have a friend share in an activity that may have been your activity with what or whom you lost. An example would be if you went to breakfast every morning at McDonalds, it can make you sad and upset to think about going back there. Sharing the activity with a friend will not replace your loss, but may help establish a new routine for you. That is what grieving is about, facing and dealing with your new circumstances rather than avoiding them (Gipson, 2009). Many of these suggestions are easy things to do. What is not easy is managing negative motions. The grieving process does take time, but you can get through the loss and grief by dealing with your emotions one day at a time. None of these suggestions will take grief away, but may help to manage feelings and emotions that are experienced. Managing ones feelings can assist in feeling like the person is taking an active role again in their life. If the feelings a person experiences becomes overwhelming or significantly interferes with their life (can’t go to work, feeling suicidal, panic attacks, difficulty in carrying out every day routines, etc. ). This person ould likely benefit from seeing a therapist that can assist them with the grieving process and help them with acceptance and recovery (Buglass, 2010). Grieving can be difficult and a person does not have to go through this alone (Gipson, 2009). Case Study Three young men, Brad, Tom and Mike return home from active military duty with the loss of a lower leg while fighting for our country. Each man experiences their loss differently and uniquely. The first, Brad, is supported by his wife, parents, two children and many other family members and friends. Brad’s leg has healed and a useful diverse type of prosthesis has been itted to his lower leg. After many months of rehabilitation Brad is able to walk again with the use of his new prosthesis. The prosthesis fits well with no skin irritations. Brad is able to enjoy many of the things he did prior to losing the leg (fishing, dancing, playing ball with his child). Brad is a very spiritual man and with the help of his wife, parents, family and friends he has been able to accept his loss and move forward. The quality of life Brad once new has slowly returned to an almost normal state. Although Brad does miss the loss of is leg he has adjusted to his new life and faces daily challenges as they come.
The second, Tom, is also supported by his wife, parents, one child and many friends and family. The leg due to infection took longer than Tom expected to heal delaying his recovery time. Tom had a useful diverse type prosthesis fitted to his lower leg. Tom attended many more months of rehabilitation than Brad, do to skin integrity problems. Skin issues have disrupted the daily use of the prosthesis interfering with Tom’s independence and lifestyle. Tom has had difficulty at first adjusting to his new lifestyle. Everyday tasks have been very challenging for Tom at times. Toms’ wife, parents, family and friends have een very supportive to Tom every step of the way. A remote controlled wheel chair is available for Tom on the days he is unable to wear his prosthesis. Tom has learned to do many tricks with his wheel chair and has joined a wheel chair basketball team because he likes showing off. Toms’ acceptance and recovery was a lot slower, but in the end he was able to adjust to his new lifestyle. The third, Mike, is supported by his wife, parents, family and friends. Mike was diagnosed with Diabetes after returning home from active duty. Mikes’ leg had a hard time healing due to infection and adjustment to having Diabetes.
Mike did not like having Diabetes and would refuse to eat the right foods. Mikes’ blood sugar was out of control because of his refusal to take medication prescribed and frequently drinking. These actions were responsible for causing skin integrity problems. After a long, hard, trying year, the leg finally healed. Mike was fitted with a useful diverse type prosthesis. Skin issues continued to be a problem because of Mikes Diabetes and his refusal to eat healthy and take his medication properly. The prosthesis was painful and awkward for Mike to use. Just looking at the prosthesis filled Mike with such an incredible loss.
Mike was angry with everyone that tried to help him. He sat day after day in a wheelchair drinking beer. Mike refused to take a bath, shave, eat, or go anywhere he might be seen by people that knew him. Mike would stay for days at a time in bed and refuse to get up. Counseling was verbally rejected every time counseling was brought up by anyone. Mikes’ doctor placed him on depression medication which he refused to take on a regular basis. Mikes friends stopped dropping by to see him. Mikes’ wife was having difficulties dealing with Mikes’ drinking and verbal abuse. She would argue with Mike till she cried and could no onger take Mikes’ drinking and feeling sorry for himself. His parents tried being very supportive, but also found Mike really difficult to deal with. Mike continued to drink and blamed everyone for the loss of his leg. Mike refused to accept the loss or move forward. Mikes’ wife finally after two years had all the verbal abuse she could handle and left him. Mike ended up moving back home and living with his parents. He still is unable to wear the prosthesis and to this day rarely leaves his parents’ home. As a nurse working with individuals, families and patients we need to be able to recognize hese individuals that are suffering. By listening to what the person is saying and their body language should be triggers for nurses if this is a person wanting, needing or requiring some kid of outside assistance. Chronic sorrow is characterized as pervasive, permanent, periodic sadness or other grief- related feelings associated with ongoing disparity resulting from a loss experience (Lindgren, Burke, Hainesworth, & Eakes,1992). The concept of chronic sorrow as you have read may go hand in hand with the antecedents grief and loss. For a person to experience one, they can experience the other.
Even though the loss may have been for seen or was totally unexpected, a person does not always overcome the loss or grief over night. For some people this may take days, weeks or even years. Then for others like Mike, they may be so devastated over the loss with grief that the loss is unbearable. They never overcome the loss and live with chronic sorrow. Reference Alligood, M. R. , & Tomey, A. M. (2010). Nursing Theorists and Their Work (7th ed. ). Maryland Heights, Missouri: Mosby Elsevier Inc. Bickerstaff, K. A. , Grasser, C. M. , and McCabe, B. (2007). How elderly nursing home residents transcend losses of later life.
Holistic Nursing Practice May/June 159-166 Bui, K. M. , Raugi, G. J. , Nguyen, V. Q. , & Reiher, G. E. , (2009). Skin problems in individuals with lower-limb loss: Literature review and proposed classification system. Journal of Rehabilitation Research & Development 46(11)1085-1090 Retrieved September 22, 2011, from: http://web. ebscohost. com/ehost/detail? vid=12&hid=17&sid=fb4631bd-e30d-4d04-86b9-9daef0a7f731%40sessionmgr104&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3 d#db=rzh&AN=2010582711 Castledine, G. ,(2002). Recognizing problems of loss in patients. Britsh Journal of Nursing Retrieved September 5, 2011, from: http://ezproxy. ardner webb. edu/login? url=http://search. ebscohost. com/login. aspx? direct=true&d b=c8h&AN=2009019179&site=ehost-live. Chan, C. , NG, S. , HO, R. , & Chow, A. , (2006). East meets West: applying Eastern spirituality in clinical practice. Journal of Clinical Nursing 15(7): 822-832 Retrieved September 18, 2011, from: http://ezproxy. snu. edu:2056/ehost/detail? vid=6&hid=8&sid=82932029-8cc8- 434b-afd5-63517ab0000e%40sessionmgr14&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ %3d%3 d#db=rzh&AN=2009258194 Clements, P. T , Benasutti, K. M. , & Carmone, A. , (2003). Support of Bereaved owners of pets.
Perspectives in Psychiatric Care 39(2), 49-54 Retrieved September 18, 2011, from: http://web. ebscohost. com/ehost/detail? vid=20&hid=127&sid=1346ad7f-572a-4072-b160- a0ba9b0916e1%40sessionmgr104&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db= rzh&AN=2003162539 Curtis, R. C. , (2010). Social worker practitioners and the human-companion animal bond: a national study. Social Work 55(1), 38-46 Retrieved September 18, 2011, from: http://web. ebscohost. com/ehost/detail? vid=19&hid=127&sid=1346ad7f-572a -4072-b160-a0ba9b0916e1%40sessionmgr104&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ 3d%3d#db=rzh&AN=2010505488 Dickson, A. , Knussen, C. , & Flowers, P. (2007). “That was my old life; it’s almost like a past- life now”: Identity crisis, loss and adjustment amongst people living with chronic fatigue syndrome. Psychology and Health 23(4), 459-476. Dougherty, P. J. , McFarland, L. V. , Smith, D. G. , Esquenazi, A. , Blake, D. J. , & Reiber, G. E. (2010). Multiple traumatic limb loss: A comparison of Vietnam veterans to OIF/OEF service members. Journal of Rehabilitation Research & Development 47(4), 333-348 Drench, M. E. (2004).
Loss, grief, and adjustment: A primer for physical theraphy, part 1 Retrieved September 5, 2011, from: http://ezproxy. snu. edu:2056/ehost/detail? vid=18&hid= 126&sid=69ff5835-74c8-43e1-bffd-3252bfa3a859%40sessionmgr111&bdata=JnNp dGU9ZWhvc3QtbGl2ZQ%3d%3d#db=rzh&AN=2003126574 Durkin, A. , (2009). Loss of a companion animal understanding and helping bereaved. Retrieved September 5, 2011, from: http://ezproxy. snu. edu:2056/ehost/detail? vid= 22&hid=126&sid=69ff5835-74c8-43e1-bffd-3252bfa3a859%40sessionmgr111&bdata= JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=rzh&AN=2010347175 Dugan, B. ( 2007). Loss of identity in disaster: How do you say goodbye to home? Perspectives in Psychiatric Care . 43(1),41-46 Retrieved September 8, 2011, from: http://content. ebscohost. com/pdf18_21/pdf/2007/22L /01Feb07/23785080. pdf? T=P&P=AN&K=2009508445&S=R&D=rzh&Ebsco Ehrlich, M. , Harville, E. , Buekens, P. , Pridjan, G. , & Elkid-Hirsch, K. , (2010). Loss of resources and hurricane experience as predictors of postpartum depression among women in southern Louisiana. Journal of Womens Health 19(5), 877-884 Epstein, R.
A. , Heinemann, A. W. , and McFarland, L. V. ,(2010). Quality of life for veterans and servicemembers with major traumatic limb loss from Vietnam and OIF/OEF conflicts. Journal of Rehabilitation Research & Development 47(4), 373-386. Retrieved September 18, 2011, from: http://web. ebscohost. com/ehost/detail? vid=22&hid=127&sid=1346ad7f-572a- 4072- b160-a0ba9b0916e1%40sessionmgr104&bdata=JnNpdGU9ZWhvc3QtbGl2 ZQ%3d%3d#d b=rzh&AN=2010714399 Foust, J. , (2006). Re: Grief sorrow loss and morning [Online forum comment].
Retrieved September 5, 2011, from: http://theraphyinphiladelphia. com/selfhelp/tips/C86/ Gailey, R. , McFarland, L. V. , Cooper, R. A. , Czerniecki, J. , Gambel, J. M. , Hubbard, S. , Maynard, C. , Smith, D. G. , Raya, M. , & Reiber, G. E. (2010). Unilateral lower-limb loss: Prosthetic device use and functional outcomes in servicemembers from Vietnam war and OIF/OEF conflicts. Journal of Rehabilitation Research & Development 47(11) 317-332 Gipson, J. , (2009) Living with loss. Mental Health Practice 12(5), 22-24.
Retrieved September 18, 2011, from: http://ezproxy. snu. edu:2056/ehost/detail? vid=7&hid=8&sid=82932029- 8cc8-434b-afd5-63517ab0000e%40sessionmgr14&bdata=JnNpdGU9ZWhvc3Q tbGl2ZQ%3d %3d#db=rzh&AN=2010193668 Gordan, J. , (2009). An evidence-based approach for supporting parents experiencing chronic sorrow. Retrieved september 5, 2011, from: http://ezproxy. snu. edu:2056/ehost/pdfviewer /pdfviewer? sid=69ff5835-74c8-43e1-bffd-3252bfa3a859%40sessionmgr 111&vid=41&hid=126 Hamilton, M. , (2005). Grief and bereavement: coping with loss of a spouse.
Journal of Nursing and Residential Care 7(5), 214-216 Retrieved September 22,2011, from: http://ezproxy. snu. edu:2056/ehost/detail? vid=6&hid=8&sid=82932029-8cc8-434b-afd5- 63517ab0000e%40sessionmgr14&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db =rzh&AN=2005101521 Kratza, A. , Williams, R. , Turner, A. , Raichle, K. , Smith, D. , & Ehde, D. (2010). To lump or to split? Comparing individuals with traumatic and nontraumatic limb loss in the first year after amputation. Rehabilitation Psychology 55(2), 126-138. Retrieved September 22,2011, from: http://web. bscohost. com/ehost/pdfviewer/pdfviewer? sid=fb4631bd-e30d- 4d04-86b9- 9daef0a7f731%40sessionmgr104&vid=13&hid=17 Lees, J. , (2008). A spiritual perspective on loss and bereavement. International Journal for Human Caring 12(2), 90-94. Love, A. W. , (2007). Progress in understanding grief complicated grief, and caring for the bereaved, Contemporary Nurse 27, 73-83. Mak, M. K. Y. , Yang, F. , & Pai, Y. , (2011). Limb collapse, rather than instability, causes failure in sit-to-stand performance among patients with Parkinson disease.
American Physical Therapy Association 91(3), 381-391. Retrieved September 18, 2011, from: Peterson, S. J. & Bredow, T. S. ,( 2009). Middle Range Theories Application to Nursing Reasearch (2nd ed. ). Philadelphia, Pennsylvania: Wolters Kluwer Lippincott & Wilkins Potter, P. A. & Perry, A. G. , (2009). Fundamentals of Nursing (7th ed. ). St. Louis, Missouri: Mosby Elsevier Inc. Risley-Curtis, C. , (2010). Social work practitioners and the human-companion animal bond: a national study. Social Work 55(1), 38-48.
Retrieved September 18, 2011, from: http://web. ebscohost. com/ehost/detail? sid=0d5bc274-2c67-4cb4-8eca- 959ee2d730dd%40sessionmgr12&vid=1&hid=17&bdata=JnNpdGU9ZWhvc3 QtbGl2ZQ%3d%3d#db=rzh&AN=2010505488 Scaletti, R. , & Hocking, C. , (2010). Healing through story telling: an integrated approach for children experiencing grief and loss. New Zealand Journal of Occupational Therapy, 57(2), 66-71. Smallbone, C. , & Staniland, K. , (2011). Care in the community; what would happen if the lights went out?
British Journal of Community Nursing 16 (7), 342-346. Teel, C. S. , (1991). Chronic sorrow: analysis of the concept, Journal of Advanced Nursing, 16, 1311-1329. Van Horn, E. & Mishel, M. , (2008). Loss of resources and depressive symptoms after traumatic injury. Southern Online Journal of Nursing Research 8(3), 15-37. Retrieved September 22, 2011, from: http://web. ebscohost. com/ehost/detail? vid=11&hid=17&sid=fb4631bd-e30d- 4d04-86b99daef0a7f731%40sessionmgr104&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d% 3d#db =rzh&AN=2010058219
Wells, D. L. , (2009 ). Associations between pet ownership and self-reported health status in people suffering from chronic fatigue syndrome, The Journal of Alternative & Complementary Medicine 15(4), 407-413. Retrieved September 18, 2011, from: http://web. ebscohost. com/ehost/detail? vid=20&hid=127&sid=1346ad7f-572a- 4072-b160-a0ba9b0916e1%40sessionmgr104&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ ]=%3d%3d#db=rzh&AN=2010261702 Wilson, H. S. , (1989). Research in Nursing (2nd ed. ). Redwood City, California. Addison Wesley