FAWCETT ANALYSIS AND EVALUATION MODEL APPLIED TO THE THEORY OF CHRONIC SORROW

MODELO DE ANÁLISIS Y EVALUACIÓN DE FAWCETT APLICADO A LA TEORÍA DE LA TRISTEZA CRÓNICA

ABSTRACT

Objective:

to analyze the Theory of Chronic Sorrow, following the model of analysis and evaluation of Nursing theories proposed by Jacqueline Fawcett.

Method:

a reflective study, developed through the investigation of the Theory of Chronic Sorrow and its application in the nursing practice. The sample consisted of eighteen studies that used the theory as a reference. A Model for Analysis and Evaluation of Nursing Theories was used, which involved, in the first stage, a detailed examination of the referred theory in terms of scope, context and content. In the second stage - evaluation - the criteria of clarity, significance, internal consistency, parsimony, testability, empirical adequacy and pragmatic adequacy were used.

Result:

This is a mid-range theory that is predictive in relation to the scope. As for the context, it is based on the stress and adaptation model. The content presents well-defined and interrelated concepts. The concepts of meta-paradigm have significance, internal consistency and are operable. It features a usable instrument: The Chronic Sorrow Questionnaire, reliable as a tracking tool to detect the presence of chronic sorrow. The theory is parsimonious, it can be used with chronic diseases and directed to people in the final phase of life and their family caregivers.

Conclusion:

this study may contribute to indicate the use of the Theory of Chronic Sorrow and support nursing care in promoting effective strategies and, consequently, improve the comfort of patients and their families in coping with chronic sorrow.

DESCRIPTORS:
Nursing; Nursing theory; Grief; Sadness; Palliative care

RESUMEN

Objetivo:

analizar la Teoría de la Tristeza Crónica (Theory of Chronic Sorrow), sobre la base del modelo de análisis y evaluación de las teorías de Enfermería propuesto por Jacqueline Fawcett.

Método:

estudio reflexivo, desarrollado por medio de la investigación de la Teoría de la Tristeza Crónica y su aplicación en la práctica de enfermería. La muestra estuvo formada por dieciocho estudios que utilizaron la teoría como referencia. Se utilizó un Modelo de Análisis y Evaluación de Teorías de Enfermería, que involucró, en una primera etapa, un examen detallado de la referida teoría referida en términos de alcance, contexto y contenido. En la segunda etapa - la de evaluación - se utilizaron los criterios de claridad, significación, consistencia interna, parsimonia, testeo, adecuación empírica y adecuación pragmática.

Resultado:

es una teoría predictiva y de mediano alcance en relación a sus objetivos. En relación al contexto, se basa en el modelo de estrés y adaptación. El contenido presenta conceptos definidos, bien delimitados e interrelacionados. Los conceptos de metaparadigma tienen significado, consistencia interna y son operativos. Presenta un instrumento utilizable: Chronic Sorrow Questionnaire, confiable como herramienta de cribado para detectar la presencia de tristeza crónica. La teoría es parsimoniosa, puede ser utilizada por los enfermeros y está dirigida a personas con enfermedades crónicas en la etapa final de la vida y a sus cuidadores familiares.

Conclusión:

este estudio puede contribuir a indicar el uso de la Teoría de la Tristeza Crónica y respaldar la atención de enfermería en la promoción de estrategias efectivas y, en consecuencia, mejorar el bienestar de los pacientes y sus familias en el afrontamiento de la tristeza crónica.

DESCRIPTORES:
Enfermería; Teoría de enfermería; Duelo; Tristeza; Cuidados paliativos

RESUMO

Objetivo:

analisar a Teoria da Tristeza Crônica (Theory of Chronic Sorrow), seguindo o modelo de análise e avaliação de teorias de Enfermagem proposto por Jacqueline Fawcett.

Método:

estudo reflexivo, desenvolvido por meio da investigação da Teoria da Tristeza Crônica e sua aplicação na prática de enfermagem. A amostra foi composta de dezoito estudos que utilizaram a teoria como referencial. Foi utilizado um Modelo de Análise e Avaliação das Teorias de Enfermagem que envolveu, na primeira etapa, um exame detalhado da referida teoria quanto ao escopo, ao contexto e ao conteúdo. Na segunda etapa - a de avaliação - empregaram-se os critérios de clareza, significância, consistência interna, parcimônia, testabilidade, adequação empírica e adequação pragmática.

Resultado:

trata-se de uma teoria de médio alcance e preditiva em relação ao escopo. Quanto ao contexto, fundamenta-se no modelo de estresse e adaptação. O conteúdo apresenta conceitos definidos bem delimitados e inter-relacionados. Os conceitos de metaparadigma têm significância, consistência interna e são operacionáveis. Apresenta um instrumento utilizável: o Chronic Sorrow Questionnaire, confiável como ferramenta de rastreio para detectar a presença de tristeza crônica. A teoria é parcimoniosa, pode ser utilizada por enfermeiros e direcionada a pessoas com doenças crônicas em fase final de vida e seus familiares cuidadores.

Conclusão:

este estudo poderá contribuir para indicar o uso da Teoria da Tristeza Crônica e respaldar a assistência de enfermagem na promoção de estratégias eficazes e, consequentemente, melhorar o conforto de pacientes e de suas famílias no enfrentamento da tristeza crônica.

DESCRITORES:
Enfermagem; Teoria de enfermagem; Tristeza; Luto; Cuidados paliativos

INTRODUCTION

Contemporary nursing is challenged by the significant growth of technology, biosciences and globalization, which impact not only on its practice but also on education.1 It is considered as a profession that takes care of people, their family and the community, in several situations related to health. This care also involves action planning, and this requires the application of knowledge and skills to provide effective care. To maintain an appropriate balance between theory and practice, nurses need to be up-to-date in relation to the field of knowledge and action.2 For this, Nursing also needs to regularly use Theories in activities that involve the entire dimension of health care.

Theory is a set of statements or principles designed to explain a group of widely accepted facts or phenomena. It can be used to describe, explain, predict or prescribe responses, events or situations, in nursing care,3 to describe the relationships and interactions that exist in the practice and to consolidate the profession as a science and art in the health field.4 The theories are multidimensional, consist of several tangible and intangible components and are relevant for the present and future practice, for research and for nursing teaching strategies.5

A research study verified that nursing theories guided the practice in eastern and western countries. Most used Orem's self-care model, Roy's adaptation model and Peplau's Theory of Interpersonal Relations. The effect of interventions guided by theories was evaluated in relation to improving quality of life, self-efficacy, self-care and stress in patients with chronic, acute, cardiac and psychological diseases. The findings indicated that most nursing theories were developed in the United States, but they used to guide research studies and practices in other parts of the world, showing the cross-cultural usefulness of these theories.6

Nursing reflects holistic care carried out throughout life, in different care contexts, with the ability to offer efficient and good quality work to human beings at all phases of life: birth, childhood, adolescence, adulthood and the old age. This care involves from prevention to assistance on the threshold between life and death, such as, for example, chronic diseases that threaten the continuation of life, which requires palliative care.

According to the World Health Organization (WHO), palliative care is an approach that aims to alleviate human suffering. It is suitable for people suffering from chronic diseases that threaten the continuity of life, through early identification, impeccable assessment and treatment of pain and other physical, psychosocial and spiritual problems. It also offers a support system to help the family deal with the patient's disease and in their own grief.7

Some examples of diseases for which palliative treatment is indicated include cancer, heart disease, severe respiratory disease, kidney failure, HIV/AIDS, chronic liver disease, multiple sclerosis and Alzheimer. Each year, 40 million people require palliative care; however, only 14% of them currently receive this care.7

Palliative care is promoted by a multi-professional team,6 of which nurses are an essential members, as they promote comprehensive and humanized care to the patient, from the initial diagnosis of a pathology that threatens the continuity of life to finitude and support the family during the coping with the disease until the grieving process.

It is noteworthy that the nurse's work influenced palliative care through the following actions: discovering and fighting the conspiracy of silence; helping patients under palliative care so that they can re-signify and redirect their lives; promoting collaborative approaches to care, manage pain and other symptoms; integrate anticipatory grief as part of patient and family-centered care, conducting research studies and educating nurses to fully satisfy their patients.8 Anticipatory grief is a response to the impending loss of life and identity, function, hopes and future plans, which causes anxiety, depression and hopelessness and implies the tension of communication in the families.9

Thus, considering the relevance of the topic addressed for the nurse's care practice and to put into practice the nursing care in the anticipatory grief process in palliative care, the need arose to identify Nursing theories that can guide the realization of this care so that the purposes that are intended to be achieved are substantiated in the theory chosen. In this perspective, the Chronic Sorrow Theory stands out, which proposes effective coping strategies to deal with situations of loss resulting from a disease that threatens the continuity of life for the patient and their family.10

In the scientific literature, the Theory of Chronic Sorrow was first documented in 1998. It is a theoretical basis of Nursing not only for the experience of chronic sorrow in situations of loss, but also to face the phenomenon. In addition, due to the increasing multiplicity and competences of nursing care, this theory has the ability to incorporate the complexity of modern nursing and to provide the basis for the contemporary nursing practice.

The aim of this study was to analyze the Theory of Chronic Sorrow, following the model of analysis and evaluation of Nursing theories proposed by Fawcett. The examination of this theory is justified due to the production of a critical description, with the aim of deepening understanding, improving its concepts and disseminating its proposals to the scientific community and the insertion in the clinical practice of nurses.11 Therefore, reflective analysis is of fundamental importance to be applied in the context of anticipatory grief in palliative care.

METHOD

This is a reflective study, based on the Mid-Range Nursing Theory of Chronic Sorrow and on research studies that used the theory as a reference. In order to achieve the objective of the study, the Analysis and Evaluation Model of nursing theories11 was used, which reflects attention to a language that encompasses all situations and configurations of the nursing practice, highlights the most relevant characteristics of large theories and of mid-range theories and is suitable for the level of abstraction of these two types of nursing theory.11

This modality of research has been strengthening Nursing and has been used as a reference to evaluate other theories, in order to confirm its usefulness, its applicability and its value in education, practice and research. In this sense, the following publications deserve a special mention: Analysis and evaluation of the peaceful end of life theory according to Fawcett's criteria;12 Adequate for the practice: Analysis and evaluation of Watson's Theory of Human Care;13 and Peplau's Theory of Interpersonal Relations: An assessment based on Fawcett's criteria.14

The papers analyzed in this study were retrieved in a search in the portal of Capes journals and in the virtual libraries and databases MEDLINE/PubMed, Wiley, SAGE, Scielo, Scopus (Elsevier), using the following keywords: ‘teoria de enfermagem’, ‘teoria da tristeza crônica’, ‘teoria de médio alcance de enfermagem’, ‘cuidado de enfermagem’, ‘nursing theory’, ‘chronic sorrow theory’, ‘mid-range nursing theory’ and ‘nursing care’.

The following inclusion criteria were adopted to select the studies: articles where the theory was used as a reference; that dealt with the proposed theme and published in any language. A time frame was not delimited in order to know when the Theory of Chronic Sorrow became the object of investigation and publication in the scientific literature. Manuscripts that did not address the subject matter in question were excluded.

With the final sample defined, the structural model of analysis and assessment of nursing theories proposed by Jacqueline Fawcett was used, whose application produces a descriptive, analytical and critical comment, which improves the understanding of the Mid- Range Theory of chronic sorrow and can lead to refinements in its concepts and proposals.11

The analysis proposes a detailed and impartial investigation, including the scope, context and content of the Theory. The assessment is based on the results of the analysis, the review of previously published reviews, research reports and reports of practical applications. This theory claims judgments to be made in order for a theory to meet certain criteria, namely: significance, internal consistency, parsimony, testability, empirical adequacy and pragmatic adequacy.

RESULTS AND DISCUSSION

Theories vary in level of abstraction and scope, and the most abstract and broadest type is defined as a large theory. The Mid-Range Theory is more concrete and with less scope and has a more limited sphere of action. Mid-Range Theories can be classified into three types: descriptive, explanatory, and predictive.11

One of the first stages is to classify the theory as to its scope. The Theory of Chronic Sorrow aims to improve the quality of life of people with chronic sorrow resulting from an experience of significant, real or symbolic loss in patients with progressive chronic diseases that threaten the continuity of life and their family members who have the responsibility to care, in death and in grief, and to achieve positive coping strategies related to nursing interventions and specific results for these people.15 For this reason, it can be considered a mid-range and predictive theory.

The second stage of the analysis is the definition of the context, which consists of identifying the philosophical claims on which the theory is based.11 The term 'chronic sorrow' was introduced in the literature 55 years ago and originated with the work entitled “Chronic Sorrow: A response to having a mentally defective child”, in 1962, to characterize the recurrent grief experienced by the parents of children with intellectual disabilities. The theory is also based on the stress and adaptation model, in which it formed the basis for understanding how people deal with chronic sorrow.15^-16

With regard to the content of the theory, it is articulated through its concepts and proposals. The concepts of a theory are words or groups of words that express a mental image of some phenomenon and attribute meaning to what can be imagined or observed through the senses.11 The Mid-Range Theory of Chronic Sorrow is supported by the following concepts:15^-16

Chronic Sorrow - Periodic recurrence of permanent and widespread sorrow or other feelings related to grief resulting from an experience of loss.

Experience of loss - Significant loss, real or symbolic, which can be constant, without a predicted end or a more circumscribed event of isolated loss.

Disparity - A gap between the current and the desired reality as a result of an experience of loss.

Triggering events or milestones - They are situations, circumstances and conditions that generate negative disparity resulting from loss and initiate or exacerbate feelings of suffering.

Coping mechanisms - They are means by which the individuals deal with chronic sorrow. They can be internal (positive personal coping strategies used for dealing with periodic episodes of chronic sorrow) or external (interventions by nurses to help individuals cope with chronic sorrow).

Ineffective coping - Ineffective management results from strategies that increase the individual's discomfort or feelings of chronic sorrow.

Effective coping - Effective management results from strategies that enhance the comfort of the affected individual.

Figure 1 illustrates the concepts adopted by the Theory of Chronic Sorrow and shows a structure to understand the responses to several situations of loss and a new way of examining this experience.

Figure 1 -
Diagrammatic model that explains the situations experienced by the person during the life cycle from the concepts of the Theory of Chronic Sorrow.

Upon examining the content of the theory, it is necessary to highlight the non-relational proposals, which describe concepts and their constitutive definition. According to the Theory of Chronic Sorrow, chronic sorrow is widespread, in which the experience is permanent, periodic and potentially progressive; the milestones (triggers) are events that trigger chronic sorrow; designate inner personal coping strategies. The external coping mechanism was conceptualized as nursing interventions that help people with chronic sorrow feel more comfortable through roles with empathic, caring and competent presence.15

Relational proposals are the associations or connections between two or more concepts and are expressed in theory as follows: chronic sorrow is a normal human response related to the continuing disparity created by experiences of loss; the patients have inherent coping strategies that can be effective in restoring normal balance. Nursing interventions (external coping strategies) aimed at achieving normal balance can be applied in different scenarios, especially in palliative care services in assisting patients with chronic and end-of-life diseases and their family members.15^-16

The evaluation of a theory allows inferences and the judgment of materials that were based on certain criteria defined by the author in the theory.11 The first criterion focuses on the context of the theory, is called significance, requires justification of the importance of the theory for the 'Nursing' discipline and is met when the meta-paradigmatic origins and influential nursing authors are explicit.11

Fawcett mentions four central nursing units: human being, environment, health and Nursing, and formalized these concepts as a meta-paradigm: concepts that define practical Nursing, which is care in all its complexity.17 For the Theory of Sorrow, the main concepts are:15 person: people compare their experiences with the ideal and the others around them. Although everyone's experience is different and each loss is unique, there are common characteristics about the experience of loss; nursing: In the scope of the nursing practice, chronic sorrow is diagnosed and interventions are carried out that include empathic presence, experience in teaching and care and professional competence; health: a person's health depends on their adaptation to the disparities associated with the loss; environment: it involves the interactions that take place in a social context, which include family, social and work environments. The individuals respond to their self-evaluations in relation to the social norms regarding the loss process.

For the theoreticians, there is no particular theory of Nursing that directly influenced the development of their work. However, in the 1980s and 1990s, research studies were conducted to describe chronic sorrow among various groups of people in situations of loss. Thus, the Mid-Range Theory of Chronic Sorrow was developed in an inductive manner, using concept analysis, extensive literature review, critical research review and validation in qualitative and quantitative studies of several loss situations.10^,15^,16^,18^-21

As for the internal consistency criterion, the analysis and evaluation model suggest that, in order for this parameter to be maintained, it is necessary to analyze the semantic and structural aspects of the theory's context and content.11 However, the Theory of Chronic Sorrow meets the criterion of internal consistency. Hypothesis concepts and relationships can be easily applied in clinical contexts. The content of the theory is congruent with Olshansk's philosophical statements, since semantic clarity is evident in the constitutive definitions given to the concepts of the theory and congruent with the styles identified in the established theory on stress and coping by Lazarus and Folkman, in which the effective personal coping strategies used by people with chronic sorrow are consistent among those affected.15^-16

The theory clearly delineates the relationship between concepts and makes intuitive sense, as for example, it is clear that effective management, internal or external, will provide more comfort, and ineffective management, more discomfort and intensity of chronic sorrow. There is a limited number of variables that seem to be sufficient to explain the phenomena. The description that accompanies the theory is succinct and easy to understand.

The theory has structural consistency, that is, it is logically organized and described in detail. In this sense, a model is offered (Figure 1) that helps to explain the links of the concepts.15 The concepts used in the Theory of Chronic Sorrow are interrelated, which provides a unique view for the nursing practice, without there being evident contradictions in the relational proposals. The parsimony criterion assesses the content of the theory and requires that fewer concepts and proposals be used to explain the phenomena presented by the theory.11 This means that its content must be stated clearly and concisely.

The Theory of Chronic Sorrow can be characterized as parsimonious because its key concepts are clearly described and easily understood. The Theory of Chronic Sorrow specifically addresses the grief needs and the experience of loss. In addition, it can be easily used by educators, researchers, nursing administrators and nurses, when providing care to patients with chronic diseases, in any situation of loss and in the most different cultures through empirical data.

This mid-range theory is suitable for research studies on the effectiveness of interventions for both patients and family caregivers. It can also be used to determine the conditions that are most likely to trigger an exacerbation of feelings of sorrow and begin an experience of chronic sorrow. With this knowledge, nurses will be able to anticipate needs and promote actions for an effective result.

A study aiming to explore the concept of chronic sorrow emphasized internal coping strategies, based on the experiences of a group of mothers of children with cancer, and external, with nurses' interventions to help mothers to face the suffering of their children due to a serious disease. The research also indicated that subsequent events, such as recurrence of the disease, for example, could cause more severe suffering than that experienced at the time of diagnosis, which manifests itself in different ways, such as feelings of anger and guilt.22

The results of this study contributed for nurses who work with children with cancer and their families to prepare guidelines and plan holistic and family care that includes, among others: including the family in the care plan; helping the family understand the disease process, so that they can play other roles; intervening in the emotional responses, such as fear, sorrow, isolation, and hope; seeking social support and respecting culture and religiosity.22

The testability criterion is considered the main feature of the Mid-Range Theory's usefulness. This approach requires that the concepts of a theory are observable through appropriate empirical instruments and indicators to measure the claims made by the proposals that will produce evidence about the theory.10 In this perspective, the theory influences several nursing interventions and is widely used. A series of studies, which form the basis of the Mid-Range Theory of Chronic Sorrow,10^,15^,16^,18^-24 are full of practical applications.

Eighteen studies were retrieved, five of which were published by the authors of the Theory of Chronic Sorrow, including the main article of the theory “Middle-Range Theory of Chronic Sorrow”; 12 articles dealt with the theory in question, and one about the Mid-Range Nursing Theory: basic elements for development and practice, as shown in Chart 1.

Chart 1 -
Distribution of the selected articles regarding the journal, title and year of publication. João Pessoa, PB, Brazil, 2019 (n=18)

Journal	Title of the article	Year of publication
Death Studies	Current knowledge and research on chronic sorrow: a foundation for inquiry 10	1992
Issues in mental health nursing	Coping with chronic sorrow20	1994
Archives of Psychiatric Nursing	Chronic sorrow: the lived experience of parents of Chronically mentally III individuals19	1995
Image: journal of nursing scholarship	Middle-range theory of chronic sorrow15	1998
Journal of family nursing	Milestones of chronic sorrow: perspectives of chronically ill and bereaved persons and family caregivers18	1999
Revista Aquichan	Middle-range nursing theories are necessary for the advancement of the discipline17	2005
Journal of Neuroscience Nursing	Chronic sorrow and depression in parents of children with neural tube defects25	2004
Journal of Clinical Nursing	The presence and meaning of chronic sorrow in patients with multiple sclerosis26	2007
Journal of Neuroscience Nursing	Chronic sorrow in next of kin of patients with multiple sclerosi27	2008
Philippine Journal of occupational therapy	Filipino Mothers' Experience of Chronic Sorrow28	2010
African Journal of Traumatic Stress	The experience of chronic sorrow among war victims with traumatic facial disfigurement in northern Uganda29	2014
Journal of Pediatric Oncology Nursing	Chronic sorrow in mothers of children with cancer30	2015
Journal of primary health care	The impact of non-motor manifestations of Parkinson’s disease on partners: understanding and application of chronic sorrow theory31	2015
Supportive and Palliative Care in Cancer	Translation and Psychometric properties of Persian Version of “Kendall Chronic Sorrow Instrument” in Mothers of Children with Cancer25	2017
European Journal of Oncology Nursing	Experience of chronic sorrow in mothers of children with cancer: a phenomenological study22	2017
Perspect Psychiatr Care	The chronic sorrow experiences of caregivers of clients with schizophrenia in Taiwan: a phenomenological study32	2017
Journal compilation	Chronic sorrow at the elderly who has lost partner with pakurenan culture (extended family) In Indonesia33	2018
BMC Psychology	Existence, triggers, and coping with chronic sorrow: a qualitative study of caretakers of children with sickle cell disease in a National Referral Hospital in Kampala, Uganda23	2018

Regarding the testability criterion, a study carried out by the theoreticians provided a usable instrument - the Chronic Sorrow Questionnaire - to determine when chronic sorrow occurs and what characteristics it exhibits in a variety of populations throughout life.10 The authors of the theory developed another quantitative assessment tool: the Burke/Eakes Chronic Sorrow Assessment Tool. This instrument can be applied in situations of loss and involves family caregivers, patients with chronic diseases and people in anticipatory grief or who experience the grief process after the death of a loved one.16

A research study carried out in Uganda explored the existence of chronic sorrow and coping with grief-related feelings among caregivers of children with sickle cell disease, and the most effective means of determining the presence of chronic sorrow was the Burke Chronic Sorrow Questionnaire for caregivers.23

Another study conducted in the United States adapted and evaluated the instrument to understand the nature and meaning of the experiences of parents with chronic sorrow who are caring for a child with a chronic medical condition.24 Findings signal that the Burke Chronic Sorrow Questionnaire is reliable as a tracking tool to detect the presence of chronic sorrow in the population and enabled the nursing intervention with efficacy.23^-24 Another survey evaluated the psychometric properties of the Kendall Chronic Sorrow Instrument and concluded that this version can be used as a valid and reliable instrument to measure chronic sorrow in Iranian mothers of children with cancer.34

It should be emphasized that, in the Brazilian literature, no publications were found in which the theory was used in the period under investigation. However, it cannot be deduced that the Theory of Chronic Sorrow is devalued in the field of national scientific research. The production of knowledge about Nursing theories represents a relatively low frequency. It is necessary to consider the current tendency of Nursing to diversify the theoretical and/or methodological framework used in its studies, because nurses have been seeking the contribution of other areas of knowledge to account for the complexity of the phenomena that are part of their practice, as the study points out.35 Thus, it is necessary to disseminate the Mid-Range Theory of Chronic Sorrow, in order to support research studies in the field of Nursing in the national context.

Empirical Adequacy is the criterion for evaluating a mid-range theory and requires that the statements made by it be congruent with the empirical evidence. This parameter requires an assessment of the degree of reliability of the theory.11 As it is characteristic of the Mid-Range Theory, the limited scope makes it immediately possible for the researchers to study the phenomenon.

With a limited number and defined relationships of variables, not all statements are empirically supported. Therefore, this theory requires tests to assert their empirical validity and determine whether all statements are indispensable or whether additional statements are necessary, in order to test the theory and to find external and internal management strategies to reduce the chronic sorrow created by the process of anticipatory grief in palliative care patients and their family members.

In assessing a theory, the Pragmatic Adequacy Criterion is a step that focuses on its usefulness for the nursing practice and requires from these professionals’ knowledge about its content and skills necessary for its application, in order to achieve favorable results for the people who participate in the care actions.11

It is important to mention that the theory is used in the health care practice and in the scope of research, but it has not yet been widespread, especially in institutions aimed at patients under palliative care. However, some specific actions are implemented in the practice, such as, for example, the University of La Sabana in Bogotá (Colombia), whose nursing assistance and research studies in the obstetrics and gynecology service are based on the theory. This study group maintains a website that provides general information about mothers facing the experience of losing a child, intended for educational purposes, for research and for the clinical practice.36

The literature on standardized nursing languages reveals that chronic sorrow is a diagnostic category of NANDA International (NANDA-I). This term was approved in 1998 and reviewed in 2017. It is defined as a “cyclical, recurrent and potentially progressive pattern of widespread sorrow, experienced (by a parent, caregiver or individual with a chronic disease or disability) in response to the continuous loss along the path of a disease or disability”.37:681 It is also a diagnostic concept in the International Classification for Nursing Practice - CIPE®, since Version 1, published in 2005, defined as a ‘negative emotion: feelings of grief and melancholy associated with lack of energy”.38

The relationships between the diagnostic categories in NANDA International (NANDA-I), the Nursing Outcomes Classification (NOC) and the Nursing Interventions Classification (NIC) provide educational applications for nursing educators who design curricula and teach Undergraduate Nursing Students in Clinical Decision Processes. In addition, the links focus on outcome-based care planning, an essential step in the teaching of evidence-based practices.38^-40

Thus, it is important to disseminate the concepts of the theory to guide patients and family members who live an extremely disturbing experience simultaneously with the trajectory of the patient's end of life, not only due to the physical and emotional stress inherent to care, but also to feelings of loss and separation caused by a chronic disease, of rapid progression and with the imminent possibility of death. Anticipatory grief encompasses many areas of the person's life. Thus, palliative care must provide comfort, which can result from health and nursing care practices, reconciling rationality, sensitivity and maintenance of the dignity of the patients and their family.

CONCLUSION

Loss is a common experience for the human being. When dealing with patients with chronic, degenerative or late-life diseases, the nurse must face the real or perceived loss that covers grief. This is a frequent experience in the experience of many family members. The Theory of Chronic Sorrow uniquely addresses the grief needs and the experience of loss. As a mid-range predictive theory, it can be easily applied in different Nursing scenarios: care, teaching and research. In addition, the use of this theory is envisaged by a standardized language, which translates for Nursing the relevance of addressing aspects associated with chronic sorrow.

The theory's own instrument is an adequate tool to determine the presence of chronic sorrow in patients and family caregivers, both in the anticipatory grief process and in the family's mourning, after they lose their loved one, as well as to enable the nursing intervention.

The study limitation was the absence of publications on this theory in the Brazilian scenario. For this reason, it is suggested that future research studies focus on a content validation process of the theory instrument by the palliative care area nurses and on a clinical validation, to be tested with relatives of patients with chronic diseases and in the final phase of life.

It is hoped that this study may come to contribute, in the sense of indicating the use of the Theory of Chronic Sorrow, to endorse nursing assistance in promoting effective strategies, providing comfort and improving the quality of life in the physical, psycho-spiritual, environmental and socio-cultural contexts of the patients and their families, who face a process of chronic sorrow related to grief.

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NOTES

• ORIGIN OF THE ARTICLE

  Paper developed in the “Critical Analysis of Nursing Theories” subject of the Graduate Program in Nursing, of the Universidade Federal da Paraíba, in 2019.

• FUNDING INFORMATION

  Study funded by the Coordination for the Improvement of Higher Level Personnel (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior, CAPES).

Publication Dates

• Publication in this collection
  05 May 2021
• Date of issue
  2021

History

• Received
  12 Feb 2020
• Accepted
  30 Apr 2020