NSG/415 Week 4: Theory Application Case Analysis, sample paper

Grief That Returns at Every Milestone: A Case Analysis Using the Middle-Range Theory of Chronic Sorrow With the Parents of a Six-Year-Old With Autism

[Student Name]

University of Phoenix

NSG/415: Theory-Based Nursing Practice

Week 4 Assignment

[Instructor Name]

[Date]

The family and clinic are a composite written for a model paper. No real family is described.

Case Summary

A composite six-year-old boy was diagnosed with autism spectrum disorder at age three. With speech therapy, occupational therapy and applied behavior analysis, he has made progress: he speaks in short phrases, follows routines and enjoys puzzles. His parents, a mechanic and a bank teller, were described by clinic staff as well adjusted and actively involved. At his six-year well-child visit, a month after he started kindergarten, his mother cried when the nurse asked how school was going. She said she thought they had "gotten past this," but seeing him beside typically developing children at the school's welcome night made her feel the diagnosis all over again. His father said little but mentioned that he had stopped going to his nephew's soccer games. The parents were not failing to cope; they were meeting a new milestone with an old loss, and a theory built for exactly that pattern explains what the nurse was seeing.

The Theory of Chronic Sorrow

The concept of chronic sorrow was first described by Olshansky (1962), a social worker who observed that parents of children with intellectual disabilities experienced recurrent sadness throughout the child's life and argued that this was a natural response rather than a sign of neurosis. Teel (1991), in a concept analysis, clarified chronic sorrow as a normal response to an ongoing loss, characterized by periodic sadness that recurs over time, may be triggered by circumstances and does not necessarily progress to resolution.

Eakes et al. (1998) developed the concept into a middle-range theory from research with individuals with chronic conditions, family caregivers and bereaved people. The theory defines chronic sorrow as the presence of pervasive sadness that is permanent, periodic and potentially progressive in nature. It proposes that chronic sorrow arises from an experience of loss that creates a disparity between the current reality and the desired one. Trigger events, which bring the disparity into focus, reactivate the sorrow. Management methods may be internal, such as action-oriented coping, cognitive strategies and talking with others, or external, provided by health professionals through empathic presence, teaching and caring, professional competence and other supports. Effective management leads to increased comfort; ineffective management leads to increased discomfort.

Applying the Concepts

Loss and disparity. The loss is not a death but the difference between the child the parents imagined and the child they have, along with an uncertain future. The disparity is ongoing: the boy is loved and making progress, and at the same time his development differs from that of his peers.

Trigger events. Kindergarten entry is a classic trigger. The welcome night placed him beside typically developing peers and made the disparity visible. Eakes et al. (1998) identified milestones, comparisons with norms and anniversaries of diagnosis as common triggers, and the father's avoidance of his nephew's soccer games suggests another trigger: watching same-age children do what his son cannot yet do.

Periodic, pervasive sadness. The mother's tears three years after diagnosis, after a period of apparent adjustment, fit the theory's description of sorrow that recurs rather than resolves. Without the theory, a clinician might interpret her reaction as depression or as a failure to accept the diagnosis.

Internal management methods. The parents have used action-oriented coping, pursuing therapies and learning about autism. The father's withdrawal from certain events is an avoidance strategy that may protect him in the short term but could isolate him.

External management methods. The theory identifies the nurse's role: empathic presence, teaching, caring professionalism and connection to resources.

Nursing Implications

The theory guides several nursing actions. First, empathic presence: the nurse acknowledged the mother's tears, named the experience as common among parents at milestones and did not rush to reassure her that her son was doing well. Second, normalizing without dismissing: the nurse explained that many parents feel renewed sadness at transitions and that this does not mean they have not accepted the diagnosis. Third, anticipatory guidance: the nurse helped the parents anticipate future triggers, such as birthday parties, sports seasons and the transition to middle school, so the sorrow would not take them by surprise. Fourth, supporting coping: the nurse asked the father gently about how he was managing, offered information about a fathers' group run by the local autism society and suggested that the family find activities where the boy's strengths show. Fifth, screening: because recurrent sorrow can coexist with depression, the nurse offered both parents a brief depression screen, which the mother completed with a score in the mild range and the father declined; the nurse left the door open for him.

The Learning Team's Discussion

When our learning team discussed the case, one member argued that the mother's reaction looked like adjustment disorder and should be referred. Applying the theory's definition helped settle the disagreement: her sadness was tied to a clear trigger, coexisted with active, effective parenting and had been absent for long stretches, which fits chronic sorrow rather than a disorder. The team agreed, however, that the theory does not rule out depression and that referral should follow if sadness became persistent, impaired functioning or was accompanied by hopelessness. The discussion showed one practical value of a shared theory: it gave four nurses with different instincts a common language for deciding what the family needed.

Evaluating the Theory's Fit

The theory fits this case well. Its concepts, loss, disparity, triggers and management methods, map directly onto the family's experience, and its view of sorrow as normal and recurring prevents a pathologizing interpretation. It also gives the nurse a concrete role. Its limitations are that it was developed from interviews in particular populations and has been tested less often in diverse cultural groups, where the meaning of disability and ways of expressing grief differ, and that it offers less guidance on distinguishing chronic sorrow from clinical depression, which is why screening remains important.

Conclusion

The parents of a six-year-old with autism experienced renewed grief when he started kindergarten. The middle-range theory of chronic sorrow explains that reaction as a normal, recurring response to an ongoing loss, reactivated by a trigger that highlighted the disparity between hopes and reality. Applying the theory changed the nurse's interpretation from possible maladjustment to expected sorrow and guided actions of empathic presence, normalization, anticipatory guidance, support for coping and screening, which are the external management methods the theory identifies.

References

Eakes, G. G., Burke, M. L., & Hainsworth, M. A. (1998). Middle-range theory of chronic sorrow. Image: The Journal of Nursing Scholarship, 30(2), 179-184. https://doi.org/10.1111/j.1547-5069.1998.tb01276.x

Olshansky, S. (1962). Chronic sorrow: A response to having a mentally defective child. Social Casework, 43(4), 190-193.

Teel, C. S. (1991). Chronic sorrow: Analysis of the concept. Journal of Advanced Nursing, 16(11), 1311-1319. https://doi.org/10.1111/j.1365-2648.1991.tb01559.x