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Bereaved Caregivers' Descriptions of Sleep:
Impact on Daily Life and the Bereavement Process
Patricia A. Carter, PhD, RN, CNS
Key Points . . .
Purpose/Objectives: To describe how sleep and bereavement may
be related in family caregivers.
Design: Descriptive and qualitative.
➤ Bereavement is a process that requires emotional, mental, and
Setting: Participants' homes.
Sample: 9 adults with no previous diagnoses of clinical depression
➤ Quality sleep includes sufficient restorative stage 3 or 4 sleep
or sleep disorders who had been providing care to family members who
to provide emotional, mental, and physical energy.
died in the previous six months.
Methods: Participants provided narrative accounts of sleep quality,
➤ Bereaved caregivers suffer sleep disruption that appears to
bereavement, and daily functioning since the death of their family mem-
affect their lives following the death of their family members.
bers. Participants' sleep quality and depressive symptoms also were
measured with the Pittsburgh Sleep Quality Index (PSQI) and Center
for Epidemiological StudiesDepression Scale (CES-D).
Main Research Variables: Sleep quality, depressive symptoms,
death of disabled relatives to assess the effects of death on the
bereavement, and daily functioning.
caregivers (Schulz, Newsom, Fleissner, DeCamp, & Nieboer,
Findings: Narratives revealed five themes: nightmares, wake after
1997). Similarly, bereavement researchers rarely explore the
sleep onset, scheduling, daily life, and bereavement. Participants scored
high on the PSQI and CES-D.
extent to which family members were involved in care prior
Conclusions: Sleep quality appears to affect bereavement and daily
to the death of their relatives as a factor affecting bereavement
functioning. Participants reported severe levels of sleep disturbance and
outcomes. Studies that have explored caregiver bereavement
typically focused on emotional symptoms (e.g., depression,
Implications for Nursing: Studies are needed to explore sleep quality
anxiety) and the impact on the bereavement process (Kelly et
in bereaved caregivers and to examine the relationship between sleep
al., 1999; Kissane, McKenzie, & Bloch, 1997; Schulz et al.,
quality and an individual's ability to accomplish the tasks of bereave-
2001; Wyatt, Friedman, Given, & Given, 1999). A few studies
have begun to report the physiologic effects of bereavement,
including changes in prolactin, growth hormone, cortisol,
and epinephrine levels (Hall et al., 1998); an emphasis on in
ore than 2.4 million people died in the United
vitro correlates of cellular immunity (Irwin & Pike, 1993);
States in 2003 (Hoyert, Kung, & Smith, 2005). Of
and changes in the patterns of the level of sleep (Reynolds et
those, about 2.2 million died from chronic, dis-
al., 1993). A question not answered by these studies is how
abling conditions that compromised their ability to function
physiologic variables (e.g., sleep quality) affect the achieve-
independently prior to death. A typical death is preceded by
ment of bereavement tasks and depression levels.
an extended period of time during which one or more family
Further information is needed about how sleep quality
members provide health care and support services to a dis-
changes from caregiving through bereavement and how the
abled relative (Emanuel et al., 1999; Emanuel, Fairclough,
changes influence caregivers' quality of life, daily functioning,
Slutsman, & Emanuel, 2000). Almost one of every four
households (23%, or 22.4 million households) is involved
in caregiving for people aged 50 and older with chronic,
Patricia A. Carter, PhD, RN, CNS, is an assistant professor of nurs-
disabling conditions. This number is estimated to increase
ing in the School of Nursing at the University of Texas at Austin. This
research was supported by a pilot research grant from the Center for
to 39 million by the year 2007 (Family Caregiver Alliance,
Health Promotion and Disease Prevention in the School of Nursing
2004). Although researchers have documented repeatedly
at the University of Texas at Austin. (Submitted July 2004. Accepted
the psychiatric and physical health effects of family caregiv-
for publication February 21, 2005.)
ing (Schulz & Beach, 1999; Schulz, O'Brien, Bookwala,
& Fleissner, 1995), caregivers rarely are followed after the
Digital Object Identifier: 10.1188/05.ONF.E70-E75
ONCOLOGY NURSING FORUM VOL 32, NO 4, 2005
physiologic health, and processes of bereavement. To begin to
bereaved. For example, Steeves (2002) reported that, during
understand this complex process, researchers must interview
the process of bereavement, caregiver sleep quality changed
caregivers who are having these experiences. Only through
several times, fluctuating with the "rhythm" of bereavement.
their eyes can researchers see how the road of bereavement is
Other researchers have explored sleep in the bereaved from
traveled and how sleep quality can influence the smoothness
a quantitative viewpoint. Researchers showed relationships
of that road.
among level of depression, number of losses, and negative
The purpose of this descriptive study was to explore
sleep changes (increased sleep latency and wake after sleep
changes in caregiver sleep quality during caregiving and
onset [WASO] times and decreased REM sleep) (Pasternak
after the death of a family member. Family caregivers were
et al., 1992, 1994; Reynolds et al., 1992, 1993). The link be-
tween sleep and the bereavement process is unclear. Irwin and
asked to describe their caregiving experiences, changes in
Pike (1993) hypothesized a different relationship: that stress
their sleep during caregiving, and how their sleep changed
associated with bereavement (frequency of bereavement-
following the death of their family members. Caregivers also
related intrusive thoughts and avoidance behaviors) leads to
were asked to describe how their sleep quality influenced
sleep disruptions (increased sleep latency and WASO times),
their daily functioning, quality of life, physical health, and
which, in turn, lead to decreased immune function (natural
killer cell functioning). Reynolds et al. (1993) suggested that
preservation of sleep quality was associated with decreased
depressive symptoms and a smoother transition through the
bereavement process for caregivers.
Bereavement is defined as the time period in which a loss
The relationship between bereavement and sleep is far from
is experienced. During this time period, bereaved people ex-
being well understood. Ongoing quantitative studies, such
perience a crisis of meaning (Steeves & Kahn, 1995; Steeves,
as the examples provided earlier, are beginning to reveal the
Kahn, Wise, Baldwin, & Edlich, 1993; Steeves, Kahn, Wise,
changes that occur in sleep architecture and patterns during
Sepples, & King, 1997). To reconstitute meaning, individuals
bereavement; however, the impact that these changes have on
who experience loss and bereavement must diffuse the emo-
bereaved individuals' daily lives and movements through the
tional energy of the loss (grief), re-knit their social networks,
bereavement process still is unknown. These complex relation-
ships can best be understood using a qualitative approach.
and establish a new meaning of life without the deceased.
Each of these three tasks of bereavement as described by
Steeves and Kahn requires emotional, mental, and physical
energy. Poor sleep quality can affect the amount of energy
A descriptive design was used to explore changes in care-
available to accomplish these tasks.
giver sleep quality during caregiving and after the death of
a family member. Family caregivers were asked to describe
People spend, on average, a third of their lives asleep. A
their caregiving experiences, changes in their sleep during
basic physiologic need of all people, sleep is a dynamic behav-
that time, and how their sleep changed since the death of their
ioral state. During sleep, complex physical and biochemical
family members. Caregivers also were asked to describe how
changes occur in the brain and throughout the body. Hormones
their sleep quality influenced their daily functioning, quality
are released, and cells are nourished and restored (Mendelson,
of life, physical health, and bereavement processes. Bereaved
Gillian, & Wyatt, 1977). Integrative functions, repair, reorga-
family caregivers were recruited from hospice bereavement
nization, and the formation of new connections occur in the
services. Participants were required to be at least 21 years of
neuronal system to support memory and learning. Also, sleep
age; have been living with and providing care for a family
mediates stress, anxiety, and tension and assists people in re-
member who had died in the past six months; be able to read,
gaining energy for concentration, coping, and interest in daily
write, and speak English; and freely consent to participate.
activities (Brown, 1999; Clark, Flowers, Boots, & Shettar,
Individuals were excluded from study participation if they
1995). The brain and body follow oscillating cycles of differ-
had been diagnosed with a sleep disorder other than insomnia
ent depths, some with the presence of dream activity. Sleep is
(e.g., sleep apnea, restless leg syndrome, periodic leg move-
ments) or preexisting clinical depression.
divided into two categories, comprising a total of five stages.
Following approval from the university institutional review
Non-rapid eye movement sleep (non-REM) includes stages
board, the principal investigator (PI) met with bereavement
1, 2, 3, and 4. REM sleep is the fifth stage. A typical night
service staff at the hospice to explain the study purpose, meth-
includes four to six sleep cycles with as many as four sleep
ods, and design; to answer questions regarding the study; and
stages in each. Quality sleep provides individuals with emo-
tional, mental, and physical energy needed to accomplish the
to provide recruitment materials. Recruitment materials were
tasks of daily living as well as to recover from the loss of loved
distributed during bereavement support group meetings to all
ones. Poor-quality sleep, such as the insomnia experienced by
participants by the group facilitators. Individuals who were
the bereaved, saps individuals of such energies.
interested in learning more about the study were instructed to
contact the PI by phone or e-mail. A study research nurse using
Bereavement and Sleep
a written script screened all potential participants for eligibil-
Disrupted sleep is a normal reaction to bereavement and loss
ity. If an individual was deemed eligible and provided verbal
of a loved one; however, what is not well known is the rela-
consent to participate, an interview meeting was scheduled at
tionships among sleep loss, poor sleep quality, disrupted sleep,
a time and location of convenience for the participant.
and an individual's ability to function during bereavement.
At the first meeting, the research nurse explained the study
Some qualitative studies have begun to describe sleep in the
purpose, methods, and design and answered any questions the
ONCOLOGY NURSING FORUM VOL 32, NO 4, 2005
potential participant had regarding the study. The participant
used to measure caregivers' depressive symptoms. The CES-
was provided with a copy of the consent form and was given
D is a 20-item, 4-point Likert scale. Respondents are asked
time to read the document and ask questions. If the participant
to indicate how often they have experienced a particular
symptom during the past week using a scale of 1 (never) to
signed the consent form, he or she was given a copy of the form;
4 (most of the time). Scores are summed, with higher scores
then demographic information, self-report health status, sleep,
indicating more depressive symptoms. A score greater than
and depressive symptoms data were collected. Participants
16 is indicative of increased risk for clinical depression
were asked three open-ended questions and also were asked
(Radloff). Empirical evidence indicates that the CES-D is a
to provide any additional information about their experiences
valid measure of depressive symptoms among caregivers. The
that they believed might be of interest to the researcher or other
CES-D has demonstrated high internal consistency (alpha =
family caregivers. At the conclusion of interview 1, participants
0.85), and test-retest reliability (2 weeks r = 0.51; 8 weeks r =
were asked if they would be willing to meet with the research
0.59), supporting the CES-D's ability to measure current and
nurse to review the interview transcripts in about one month. All
immediate past symptoms (Bergman-Evans, 1994; Lawton,
participants agreed, and second interviews were scheduled.
Moss, Kleban, Glicksman, & Rovine, 1991; Li, Seltzer, &
At the second interview, approximately a month after inter-
view 1, participants were provided with copies of their tran-
Greenberg, 1997). For the current study, the alpha was 0.95.
Open-ended questions: Because the primary focus of the
scripts and were given time to read their answers. Participants
were asked if they wanted to add to their answers or make any
investigation was to elicit caregiver narratives to describe
clarifications. All responses were tape recorded, transcribed,
perceived relationships between sleep quality and bereave-
ment experiences, three questions were used to elicit caregiver
and added to the participants' files.
narratives. Participants were asked to describe sleep while
At the conclusion of each interview, each participant was
providing care for their family members, sleep since the death
provided with a $20 money order as a thank you for their par-
ticipation (total = $40). All study-related interviews occurred
of the family members, and how sleep influenced their daily
in participants' homes. Following each interview, participants
functioning, quality of life, physical health, and bereavement
were given the opportunity to listen to the tapes and erase any
processes. Standard probes (e.g., "go on," "tell me more,"
portions of the tapes they chose. All audiotapes, transcripts,
"that is interesting; can you give me an example?") were used
to clarify and elicit further information from all participants.
and questionnaires were kept in a locked file cabinet in the
PI's office. Access to study materials was controlled strictly;
only key personnel had access to study data. All key personnel
Descriptive data analysis was performed for quantitative
completed human subject protection training prior to having
measures (demographics, overall health, the PSQI, and the
access to participants or participant data.
CES-D) using SPSS® (SPSS Inc., Chicago, IL). Frequencies,
means, and standard deviations were computed to obtain a
Demographics: Participants were asked to provide infor-
profile of the sample.
mation about themselves and their caregiving experiences
Narrative data were managed via the Ethnograph 5.0 (Qua-
lis Research Associates, Amherst, MA) computer program
(age, gender, ethnicity, educational level, relationship to the
to facilitate coding and analysis. All interviews were tape
deceased, duration of caregiving experience, and length of be-
reavement). They also were asked to provide information about
recorded and transcribed verbatim. The transcriptions were
the deceased (age at time of death, gender, and diagnosis).
examined using the principles of content analysis described by
Overall health: A single item was used to describe care-
Strauss and Corbin (1990). Analysis began with open coding
giver perceptions of personal overall health: "How would you
that included extensive reading of the interview material, a
rate your overall health at this time? Excellent, good, fair,
line-by-line analysis search for words, phrases, or descrip-
tions to uncover evidence of caregiver sleep and bereavement
poor or very poor?"
Sleep quality: Perceptions of sleep quality were assessed
experiences to provide units of data. As the units of data were
with the Pittsburgh Sleep Quality Index (PSQI) (Buysse,
coded, each code representing one of the five conceptual clus-
ters of sleep and bereavement was entered into the Ethnograph
Reynolds, Monk, Berman, & Kupfer, 1989). Reliability
alphas range from 0.830.89 in healthy and chronically ill
Trustworthiness of the study findings was achieved through
individuals and family caregivers (Buysse et al.; Carpenter
procedures to ensure credibility, consistency, dependability,
& Andrykowski, 1998; Carter, 2001, 2002; Carter & Chang,
and transferability (Sandelowski, 1986). Credibility (valid-
2000). For the current study, the alpha was 0.92. The PSQI
ity) was achieved by returning to the transcripts to confirm
has 19 questions that are used to calculate seven sleep com-
ponent scores (sleep quality, sleep latency [time to fall asleep
interpretations. Consistency (reliability) was attained by the
upon going to bed], sleep duration, habitual sleep efficiency
PI conducting all interviews and by asking the same questions
[time asleep ÷ time in bed X 100%], sleep disturbances, sleep
to all participants. Dependability (validity and reliability) was
medications, and daytime dysfunction). Higher scores indicate
ensured by having a PhD-prepared coinvestigator familiar
more sleep difficulties. The possible score range for each sleep
with qualitative analysis code 30% (n = 3) of the interviews
component is 03; the desired range is 01. Sleep component
along with the investigator. Coding procedures and resultant
scores are summed to produce a global sleep quality score.
codes for themes were evaluated in a work session. A 95%
Global scores range from 021. Global scores greater than 5
agreement existed between the researchers regarding coded
indicate moderate sleep problems in at least three sleep com-
data. A consensus session was held to refine procedures for
ponent areas or severe sleep problems in two areas.
the disputed data. Transferability (generalizability) was at-
Depressive symptoms: The Center for Epidemiological
tained by conducting the interviews in participants' natural
StudiesDepression Scale (CES-D) (Radloff, 1977) was
ONCOLOGY NURSING FORUM VOL 32, NO 4, 2005
nightmares took several forms. Whereas some caregivers ex-
pressed that their nightmares were focused on "re-living" the
deaths of their loved ones, others stated that their nightmares
centered on questions about "making the right decisions."
A total of nine caregivers participated in the study. Caregiv-
In all cases, caregivers found the nightmares to be repetitive
ers were mostly female (78%), Caucasian (89%), and spouses
and severely disruptive to their sleep patterns. Some caregiv-
of the patients (77%). The mean age of caregivers was 52
ers went as far as to say that they were afraid to try to sleep
years, with a range of 2867 years. Educational level ranged
for fear that the nightmares would come. Caregivers gave the
from 1225 years, with a mean of 16 years. Patients' mean
following descriptions of their nightmares.
age was slightly older than the caregivers' (68 years), with a
· "Same dream . . . of not being able to breath . . . since that
range of 3689 years. Patients were diagnosed with a range
is how she died. . . . I wake up and I have to really work to
of illnesses (cancer, cardiac, and respiratory), and caregiving
catch my breath. I feel like I can't breathe."
ranged from days to months. Length of bereavement ranged
· "I have a lot of nightmares and trouble staying asleep."
from 16 months, with a mean of 5.5 months.
· "After my mom's death, every time [my husband] moved,
Three instruments were used to describe the sample: over-
I'd scream. And he'd say, `Don't scream.' I said, `I didn't
all health, sleep (PSQI), and depressive symptoms (CES-D).
know I'd screamed.' You know, because it was in my
Although the primary focus of the exploratory study was
the participants' experiences, the context provided by a full
· "I'm just so afraid to go to sleep. I have bad dreams, and
description of the individuals was improved with the use of
they are so horrible. Everybody wants to have this happy
these instruments. Given the sample size, the quantitative
dream about the person they loved; it hasn't happened."
findings are intended only to offer descriptive information
· "Being the nurse in the family, I had all the pressure about
about the sample.
making the right decisions; I had all these dreams about
making the wrong decisions."
Natural sleep serves a restorative function for the mind
Caregivers most frequently reported their overall health as
and body. Sleep must occur in a regular pattern with only
good or fair (n = 6), two caregivers reported their health as
minimal disruptions to be fully effective in this function.
excellent, and one reported having poor overall health.
WASO is a way to measure the frequency and duration
(number of minutes) that an individual is awake during
sleep episodes--roughly translating into the amount of
Caregivers reported a mean PSQI score of 12 (SD = 6.2).
restlessness experienced during sleep times. Individuals
Scores greater than 5 indicate moderate to severe sleep problems
are expected to awaken for short, infrequent times during
in two or more of the seven component areas. Components where
sleep episodes; however, the WASO experiences expressed
participants experienced the greatest sleep disruptions were la-
by participants in the current study can be considered
tency, duration, and efficiency. Sleep latency scores ranged from
extreme. Participants described this experience in the fol-
0120 minutes, with a mean of 37 minutes (SD = 43). Sleep dura-
tion scores ranged from 17.5 hours, with a mean of 4.3 hours
· "Sometimes I'll go to sleep and wake up an hour later, or
(SD = 2.2). Sleep efficiency scores ranged from 27%87.5%,
30 minutes later, then it'll take me another half hour to get
with a mean of 58.7% (SD = 18) for eight of the nine caregiv-
to sleep, and then I'll wake up again . . . over and over."
ers. With the exception of one caregiver who reported a sleep
· "What was hard was waking up suddenly for no good rea-
efficiency of 94%, the findings indicate that the participants in
son and then not being able to get back to sleep. Being in
this sample were experiencing severe levels of sleep disruption.
that [patient's] bed, in that room."
The American Academy of Sleep Medicine recommends that
As mentioned earlier, sleep is most effective in its restor-
individuals have sleep latency below 15 minutes, duration of
ative functions when it follows a regular and predictable
more than seven hours, and sleep efficiency of greater than 85%
pattern. Small amounts of disruptions to sleep patterns can
(Buysse et al., 1989).
be tolerated and compensated for in the body; however,
prolonged disruptions can result in negative physiologic,
Seven caregivers reported a mean score of 34.5 on the CES-
psychological, and sociologic outcomes. Family caregivers'
D. Scores ranged from 1155 (SD = 17.8). With the exception
sleep patterns frequently are dictated by the needs of patients.
of two caregivers who reported CES-D scores of 0, the par-
Once patients are deceased, the caregivers have no schedule to
ticipants in this study were experiencing moderate to severe
follow. This can result in experiences such as those expressed
depressive symptoms. A score greater than 16 is indicative of
by the participants in the current study.
increased risk for clinical depression (Radloff, 1977).
· "I don't have to be to work until nine, so I try to stay in bed
until eight. Other nights it is about three or four [hours of
Interviews ranged in length from 1.52 hours each. Par-
· "My sleep pattern is very irregular. I can fall asleep imme-
ticipants expressed that the interviews were helpful in that
diately. I sleep for approximately one hour, then I'm up. I
they provided an opportunity for catharsis in a safe and non-
clean or something, and then I go back to sleep."
judgmental environment. Analysis of participant narratives
· "I nap a lot. I count five or six hours of nap time as my
revealed five themes: nightmares, WASO, scheduling, daily
sleep, too. It's just about 20 minutes or so at a time."
life, and bereavement.
· "My sleep is fairly bad, because it's been the two or three
Sleep was described by most caregivers as severely dis-
hours sleep and awake for two or three hours and then back
rupted. Caregivers frequently spoke of having nightmares. The
to sleep for two or three hours. So, that to me is very bad."
ONCOLOGY NURSING FORUM VOL 32, NO 4, 2005
Individuals' ability to successfully accomplish daily tasks
that poor sleep quality appeared to be affecting their ability
often is dictated by the level of physical, emotional, and men-
to carry out their daily life tasks. Quality sleep provides the
tal energy available. Sleep quality (latency, duration, efficien-
emotional, mental, and physical energy needed to function
cy, and WASO) determines the amount of energy available.
optimally during the day. Even one night of poor sleep can
Participants expressed how their lack of quality sleep often
result in feelings of inability to concentrate or function opti-
mally during the day (Naitoh et al., 1990). Prolonged sleep
led to low energy levels, which, in turn, resulted in an overall
loss may affect decision making and physical response times,
inability to accomplish even the simplest of daily tasks.
placing people at risk for injury.
· "I have trouble staying awake in church; isn't that awful? I
Common in the bereavement literature are reports of night-
have a real hard time."
mares (Steeves, 2002); however, existing literature fails to
· "At work I can get it done, but personally, no. I feel I'm not
make a connection between nightmares and WASO episodes.
The literature only mentions that nightmares are a common
· "Every day it's a struggle getting out of bed. Every day!"
occurrence, without discussion of how nightmares may af-
· "Physically, I feel just really drained. I don't feel like I'm
fect the overall sleep quality of the bereaved. The number
giving 100% at work like I should be doing."
of WASO episodes (frequency and duration) speaks to the
· "I'm just scattered. I mean, I'll start to do something and
fragmentation of sleep. Fragmented sleep results in less time
then forget what I was doing. . . . That's just lack of sleep
spent in the restorative sleep stages (3 and 4). Sleep literature
as far as I'm concerned."
suggests that commonly used stimulus-control techniques
· "It's like going around in circles and trying to do something,
might be helpful to allow caregivers to return to sleep with-
but I just can't get it done."
out prolonged WASO periods. No studies to date have used
Bereavement is a normal process resulting from loss. To
stimulus-control techniques in bereaved caregivers.
move through the process, individuals must accomplish
Poor sleep is recognized in bereavement literature as a fre-
various tasks, all of which require energy. Many participants
quent occurrence during the bereavement process (Lavie &
expressed that poor sleep left them with low energy levels.
Berris, 1996; Reynolds et al., 1993; Steeves, 2002). What has not
Two participants clearly articulated sentiments expressed by
been explored but appears to be suggested in the current study's
all participants about the relationship between low energy and
participant narratives is the impact of sleep quality on movement
movement through their bereavement.
through the bereavement process. Participants expressed that
· "I'm having a real hard time. I guess it's grief. I'm tired all
poor sleep quality affected their ability to carry out their daily
the time, and I have no energy to get it done [sell mother's
tasks, but they also mentioned that poor sleep quality impeded
their ability to accomplish their bereavement tasks. Steeves and
· "Inside, I think I am having a lot of turmoil, a lot of prob-
lems. I have a son to take care of, so I put on my happy face.
Kahn's (1995) qualitative work with bereaved individuals sug-
gested that three tasks must be accomplished in bereavement
But I'm having a rough time."
(grief work, re-knitting of the social fabric, and finding meaning
without the deceased). These tasks require emotional, mental,
and physical energy. Without quality sleep, energy may not be
The data presented in this article suggest that bereaved
available to accomplish the tasks of bereavement.
family caregivers suffer from severe levels of sleep problems
and depressive symptoms. This supports the findings of other
Implications for Nursing
studies with the bereaved (Lavie & Berris, 1996; Reynolds
Bereavement is a complex process that usually resolves
et al., 1993; Steeves, 2002). The participants in the current
with time. The author is not suggesting that a "good night's
study had been providing care to individuals with chronic
sleep" is all that is needed to move successfully through
illnesses who had died in the past six months. Research sug-
gests that people in the first six months of bereavement are at
the process; however, this article raises the question, "Does
the greatest risk of suffering from grief symptoms, including
improved sleep impact the available energy needed to accom-
plish the tasks of bereavement successfully?" The purpose of
sleep problems and depression (Steeves). The findings from
the current small sample seem to support this.
the descriptive study reported in this article was to begin to
Sleep quality is influenced by several internal and external
explore the relationship between sleep and bereavement in
factors. The participants identified through their narratives sev-
family caregivers. The findings suggest an important connec-
eral aspects of their daily routines that appeared to be contribut-
tion between sleep and bereavement; however, as is common
ing factors to their inability to obtain quality sleep. For example,
in descriptive studies, more questions were generated than
participants stated that they did not have a routine time for
answered. Future directions include (a) longitudinal quan-
titative and qualitative explorations of sleep patterns during
sleep. Failure to have a routine sleep schedule has been shown
bereavement, (b) development and testing of a behavioral
repeatedly to affect sleep quality (Naitoh, Kelly, & Englund,
intervention to improve sleep quality for bereaved individu-
1990; National Sleep Foundation, 2005; Riedel & Lichstein,
als, and (c) an exploration of the impact of sleep quality on
2000). With prolonged sleep loss, an increasing drive to sleep
physical and emotional health in bereaved family caregivers.
develops. The drive to sleep can be over-ridden, resulting in a
Qualitative and quantitative methods are necessary for further
disruption of the sleep-wake cycle. If the sleep-wake cycle is
studies, as the context is of great importance in understanding
disrupted, the body does not know when it is supposed to be
the relationship between sleep and bereavement outcomes.
asleep or awake, ultimately disrupting both states.
Although the sample size was small (N = 9) and the data
Poor sleep quality contributes to an inability to accomplish
cannot begin to be generalized to the overall population, im-
activities of daily living (Clark et al., 1995; Riedel & Lich-
stein, 2000). Participants expressed through their narratives
portant information was generated, meeting the study's aim.
ONCOLOGY NURSING FORUM VOL 32, NO 4, 2005
Qualitative and quantitative researchers who are interested in
The author would like to thank Corrine Grimes, RN, DNSC, assistant pro-
fessor of clinical nursing in the School of Nursing at the University of Texas at
conducting research to evaluate and hopefully improve sleep
Austin, for her tireless work on this project. Without her support, this project
quality in bereaved individuals can use the information as a
would not have occurred. Similar thanks goes to Marjorie Mulanax, MBA,
starting point to design future studies. Sleep is a basic physi-
executive director at Hospice Austin, for her support and encouragement.
ologic need that healthcare professionals are only beginning
to understand. Bereaved individuals are under a substantial
Author Contact: Patricia A. Carter, PhD, RN, CNS, can be reached
amount of stress; having quality sleep may provide the energy
at firstname.lastname@example.org, with copy to editor at rose_mary@
needed to accomplish the tasks of bereavement.
Bergman-Evans, B. (1994). A health profile of spousal Alzheimer's caregiv-
Naitoh, P., Kelly, T.L., & Englund, C. (1990). Health effects of sleep depriva-
ers. Depression and physical health characteristics. Journal of Psychoso-
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