Hiyn Wng ,Wrporn Chiywt ,Jintn Yunibhnd

a Faculty of Nursing,Chulalongkorn University,Rama 1 Road,Wangmai,Pathumwan,Bangkok,10330,Thailand

b School of Nursing,Kunming Medical University,1168 Chunrong Road,Kunming,650500,Yunnan,China

Keywords:China Grounded theory Living process Only child Qualitative study

ABSTRACT Objectives:Losing an only child is a life-altering event that destroys Chinese women’s lives and health in several dimensions.However,there is no unified theory exists to guide nursing practice.This study aimed to discover the substantive theory of how Chinese women live with the loss of their only child.Methods:This qualitative study used the grounded theory method.Purposive sampling,snowball sampling,and theoretical sampling were used to recruit participants.Saturated data from the in-depth interview,observation,and field notes with 13 Chinese women who have lost an only child in Southwest China were analyzed using the constant comparative method concurrently supplemented by the ATLAS.ti program,memo writing,and diagramming.Findings:Struggling to live a new normal life among Chinese women after losing an only child emerged as the substantive theory.It consists of three phases:living in agony,coming to terms,being alive in a new way.Receiving support motivated them to deal with such a loss.However,it brought them back to the previous phase(s) whenever they encountered adverse triggering situations.Therefore,they moved back and forth between these phases.The findings also illustrated that this process was profoundly affected by Chinese culture and personal beliefs.Conclusions:This substantive theory may guide nursing practice based on understanding the living process by working through the three phases.It would help develop a professional care plan recognizing individual diversity and incorporating socio-cultural and religious knowledge to effectively support women to deal with the loss of an only child.

What is known?

·Chinese women who have lost their only child faced many difficulties and challenges.

·Chinese women reported significant psychological,physical,

and social problems after losing their only child.·Nurses play a central role in the grieving process.

What is new?

·This study identifies a substantive theory;that helps narrow the gap in understanding Chinese women’s lived process after losing an only child.

·This study explains how Chinese women who have lost an only child struggled to live a new normal life by living in agony,coming to terms,and being alive in a new way.

·This study also provides new insights into strategies,needs,effective support,adverse triggering situations,fears,and difficulties in the lives of Chinese women who have lost an only child.

1.Introduction

Lossing an only child can be devastating; it is more intense,complicated,and long-lasting than other losses [1].This loss becomes all the more painful for women in China owe to its onechild policy,which has been in place for more than 40 years [2,3],and the ineradicable influence of Confucianism [4].The loss of an only child permanently affects surviving mothers’ lives as well as their psychological,physical,and social health [5-8].A holistic understanding of how Chinese women live after losing their only child can assist healthcare workers,including nurses,in administering appropriate care and developing care systems for numerous affected women.

The plight of the Chinese women who have lost an only child(CWLOC)needs to be viewed in the one-child policy’s political and historical contexts [2],which restricted each family to one birth.Specifically,CWLOC refers to Chinese women aged over 49 years who have lost their only child[9].It is estimated that there will be 1.51 million CWLOC by 2038 [10].The loss of an only child is extremely challenging for Chinese women because of their deeply rooted love and their dependence on precious offspring.The phenomenon of child-centeredness emerged with the imposition of the one-child policy [11].An only child came to hold a special meaning for the family,and mothering became both a significant investment and achievement for life.Chinese mothers who were primary caregivers invested massive amounts of love,energy,money,effort,and time into their only child’s upbringing.They came to place all their expectations,hopes,and dreams on their only child [11,12].An only child’s death terminates all kinds of cultural and legal anticipated support from the child[3];therefore,the loss can be catastrophic.

Confucianism advocates filial piety,which requires children to ensure the continuity of the family line,provide for the mental and material wellbeing of aging parents,perform the ceremonial duties of ancestral worship,and not bring disgrace to the family name[4,13].Having no progeny equals being extremely non-filial [2,8]since losing the family name’s sole carrier decimates its lineage[11].In Chinese society,some bereaved are stigmatized as those cursed with“bad luck”[2]because,from a cultural perspective,the death of children is blamed on sin [14].As a result of this tragedy,some mothers withdrew from society [8,15],and the divorce rate spiked with many men leaving their partners and remarrying younger women to continue the family line [16].CWLOC has to spend their lives alone [17]with financial distress [18].Besides,since most CWLOC did not want to burden their families or relatives,they had to rely on society and government [19].

Moreover,CWLOC was found to be grief-stricken because they were unlikely to have another child for medical limitations [2,8],with some being in various stages of menopause [8],and others faced with declining physical functionality[20].They were found to be afflicted with chronic diseases,suffering poor physical health,characterized by high morbidity,frequent hospital visits [5],and high mortality[21].CWLOC struggled with the poor adjustment to their changed lives and various health problems over long periods.CWLOC commonly displayed significant psychological or psychiatric symptoms,such as prolonged grief,depression,anxiety,and post-traumatic stress disorder [5-8].Because of the loss of hope and happiness,some suffered from suicidal thoughts [22],and some even committed suicide[23].Therefore,the meaning of such loss in real terms has a significant influence on the health of CWLOC，and the considerable number of women in this situation has brought a significant challenge to health services.There is an urgent need and high demand for assistive care through appropriate care systems,especially nursing care,to help CWLOC deal with life after losing an only child.Nursing staff plays a central role[24]in their care to help alleviate grieving mothers’distress[18,25].

However,up to date,not many studies have focused on the care of CWLOC [26].Existing literature revealed that nurses often felt unprepared while supporting bereaved persons [27].Many nurses were unaware of the unique challenges faced by CWLOC and were even unfamiliar with the concept of“l(fā)oss of an only child”[9].Due to their limited knowledge,nurses could not play a useful role as they should; it may even have a detrimental impact on these women’s health.

CWLOC’s continued suffering and a lack of support can further increase their risk of severe health problems.As life expectancy increases in China,CWLOC may suffer for an extended period.In sum,CWLOC experienced the loss of a child distinctively because of the unique one-child policy,Chinese culture,the special meaning of an only child,and declined physical functionality [2,3,11,20].However,there is no existing suitable theory or knowledge that could guide nurses to handle this situation effectively.This study aimed to explore the substantive theory on the process of living from the perspectives and experiences of CWLOC.Such knowledge may guide healthcare workers to facilitate more efficient nursing care to help CWLOC cope with losing their only child and improve the quality of life after loss in the future.

2.Methods

This study was qualitative research with Glaserian grounded theory methodology.Grounded theory methodology focused on exploring the richness of the human experience to generate and develop middle-range theories in nursing [28].It allowed the researchers to get participants’ inner experiences to obtain multiple perspectives on events and build variation into their analytic schemes to thick and rich understand experience in social,political,and cultural information [29].Therefore,Glaserian grounded theory approach was chosen based on it can provide a sound procedural method that allowed the researchers to explore,conceptualize,and generate substantive knowledge [30,31]to explicate the living process through Chinese women’s perspectives and experiences.The guideline of the 32-item Consolidated Criteria for Reporting Qualitative Studies was used for providing this manuscript [32].

2.1.Study setting and sampling

This study was conducted in Yunnan province in Southwest China.Most participants were recruited in communities.Nursing staff from a Non-Governmental Organization (dedicated to caring for families with lost only children) and the Community Services Center (dedicated to caring for community residents) who know well the potential participants were invited to help recruit participants through recommendations after the researchers provided inclusion criteria.The first participant was recruited by purposive sampling.The following three participants were recruited through snowball sampling that being introduced by the previous participant who was interviewed,respectively.The other nine participants were recruited through theoretical sampling until data saturation(there was no new emerging data in any category,and all categories were well-developed in terms of properties,dimensions,and relationships among categories were established and confirmed) was reached.Saturated data were obtained from 13 participants.

2.2.Data collection and data analysis

The first author collected data using an individualized face-toface in-depth interview simultaneously accompanied by digital recordings as well as observations and field notes.The in-depth interviews were conducted from January 2017 to March 2019.An in-depth interview guide constantly revised and added more focused questions to augment category properties and dimensions and to expound on developing hypotheses after the pilot test and data analysis.The in-depth interview guide was shown in Appendix A.

The in-depth interview comprised three phases.It began with the open phase with an open-ended question(e.g.,would you please tell me about a typical day after losing your child),followed by the probing phase (e.g.,what was going on after that,how did you do),and the closing phase(e.g.,is there anything else that you would like to let me know).Each participant was interviewed for 61-129 min,at an average of 90 min.Each participant was interviewed once because the acquired information was complete,clear,and sufficiently detailed.

All digital records were transcribed verbatim in Chinese within 24 h after each interview and then translated into English.The transcription and translation were done by the first author and a translator to achieve equivalence and consistency through forwardtranslation,backward-translation,and discussion.In case of any inconsistencies and discrepancies in the translation,the text was discussed and/or clarified by the participants.Two bilingual individuals confirmed the final English translation.

The data collection and analysis performed simultaneously were guided by Glaser [30,31]using the constant comparative method supplemented by a qualitative data analysis program,namely ATLAS.ti; memo writing; and diagramming.Substantive coding(open coding and selective coding) and theoretical coding were applied [30].During the open coding process,the researcher“broke” the raw data and coded line-by-line by naming and grouping to generate units of categories and their properties.The researcher compared each code continuously to all other codes,such as similarities and differences.During the selective coding process,the researcher synthesized,examined,and collapsed the codes into categories or more abstract concepts.Then the analysis was guided by the selected core variable.During the theoretical coding process,the researcher conceptualized how the substantive codes relate to each other as hypotheses to be integrated into a theory.The researcher systematically linked categories and developed properties or dimensions by applying the coding families such as the six C’s,the process,the degree family,the strategy family,type family,and the dimension family [30].The first and second authors coded independently and then compared their work to ensure the fit,work,and relevance.If there were any inconsistencies and discrepancies in the data analysis,the team members addressed them accordingly.

2.3.Ethical consideration

This study obtained ethical approval from the Research Ethics Review Committee of Chulalongkorn University (No.208/2016).Data collection,management,and analysis were in line with the ethical standards outlined for justice,security,and confidentiality.All participants were familiar with the study’s aims and objectives and were willing to participate in the study to help other CWLOC.Informed consent was obtained from participants before taking part.The interview settings were chosen according to the participants’ preferences,considering their safety,confidentiality,convenience,and comfort.Code numbers were assigned to participants for anonymity.All information has been confidentially and securely kept and will be deleted after the completion of this study.Any information about participants will be reported as part of a larger picture.

2.4.Trustworthiness

This study used various strategies to enhance its credibility,dependability,confirmability,and transferability [33].Techniques that establish credibility were ensured by facilitating prolonged engagement and observation on the part of interviewers to build trust and enhance understanding with interviewees.Procedures for ensuring dependability included the maintenance of sufficiently analytic processes and peer-debriefings among colleagues.There was complete documentation in terms of the informed consent forms,digital records,field notes,transcripts,and the ATLAS.ti program to ensure opportunities to retrace and scrutinize data to enhance confirmability.Researchers supported the study’s transferability with elaborate descriptions of the context,location,and participants,by being transparent about analysis.

3.Findings

3.1.Demographics of participants

The 13 participants’ age ranged from 50 to 68 years,with an average of 59.9 years.Participants have lost their only child ranging from 2.8 years to 24.8 years.Demographics of participants and their deceased children are listed in Tables 1 and 2.

3.2.Struggling to live a new normal life among Chinese women after losing an only child

The findings derived from the raw data illustrated the basic social process that CWLOC underwent,namely“struggling to live a new normal life among Chinese women after losing an only child”(Fig.1).It refers to the process wherein the women were struggling to form a new life by adapting thoughts and behaviors and developing strategies in daily life even though it had been destroyed by child loss.A new normal life includes integrating the deceased child with their own lives peacefully,balancing the present with a planned future,and living in society appropriately while receiving support and despite encountering adverse triggering situations.

Table 1 Demographic characteristics of the participants (n=13).

Table 2 Demographic characteristics of the participants’ deceased child (n=13)

The living process is not linear; it is dynamic and phased.It consists of three phases:living in agony,coming to terms,and being alive in a new way.Receiving support urge the process while encountering adverse triggering situations caused by CWLOC to relapse to the previous phase(s).Thus,CWLOC repeatedly went through the various phases of life processes mentioned by constantly struggling,moving forward,and regressing.However,as time went by,with effective strategies and support,CWLOC tended to return to the first phase less often,and they had to expend less effort to move on.From the first phase to the third phase,receiving support and encountering adverse triggering situations decreased,too.Furthermore,Chinese cultural and personal beliefs play vital roles in the living process.The details of this process were explained as follows.

3.2.1.Living in agony

Living in agony refers to the status wherein CWLOC lived with extreme distressing and suffering in daily life.It consists of losing their life’s anchor and sinking into grief and fear,both of which can mutually influence each other;CWLOC moved between them back and forth.Each subcategory consisted of many dimensions that had no precise sequence; some dimensions existed at the same time.

3.2.1.1.Losing their life’s anchor.Losing their life’s anchor refers to CWLOC suffering because of how they view the loss,which involves what they have lost and foreseen the loss based on actual or potential assumptions.It involves losing the most precious only child,losing support,and losing the only family.In particular,losing the most precious only child implies losing the continuation of life,the center of their life,their future and expectations,and spiritual comfort.Losing support implies losing the primary caregiver,financial support,main legal guardian,and support related to death.Losing the only family implies the fact that CWLOC has no families and relatives in the world,losing their husbands after losing an only child,abandoned by husbands,or divorced.

“…You know,for us Chinese,we are living our life for our children.Now,the child is gone,what we live for?Nothing.”(Participant 2).“… When she was alive,she did everything for me … Now my daughter is gone,[I have]no support at all.” (Participant 7).

“… His father abandoned me because I got [diagnosed with]schizophrenia.Moreover,I could not get pregnant.”(Participant 9).

Fig.1.The model of struggling to live a new normal life among Chinese women after losing an only child.

3.2.1.2.Sinking into grief and fear.Sinking into grief and fear can have several manifestations that were expressed psychologically(e.g.,denying,not understanding,being unable to bear the loss,depression,having suicidal thoughts,always yearning for the deceased child,anger,and feeling fear,unfairness,helplessness,hopelessness,loneliness,emptiness,inferiority,guilt,regret),physically (e.g.,almost being unable to stand,dizziness,a blank mind,loss of appetite,sleeping disorder,various diseases),behaviorally and socially (e.g.,crying,asking “why” repeatedly,altering dietary patterns,not sleeping,blaming oneself,yelling at others,socially withdrawing,smoking,drinking,committing suicide).

Specifically,CWLOC felt fearful about the present and the future.They frequently and intensely fear being unable to get timely support and care or facing health problems in the future.The participants were found to be “self-stigmatizing”; they labeled themselves as“l(fā)osers”,“non-filial people”,“unlucky”,and“bitter”.Thus,they feared being laughed at and having to live without dignity.

“… My most cherished person has left me; I didn’t want to live in the world.Then I committed suicide by cutting my wrist … the traditional belief of‘there are three kinds of unfilially piety,no child is the serious’ … I feel I have no face to meet the ancestors after death … I have broken the four generations of the only sons.”(Participant 12).

“…What will I do when I am old with nobody to care for me?What will be when I pass away,and there will be nobody to hold the funeral for me?” (Participant 9).

“…On the days that I did not step outside,I could only cry.I was not in the mood to eat,so I did not eat.” (Participant 7).

3.2.2.Coming to terms

Coming to terms refers to the thoughts and actions of CWLOC that put great effort into decreasing agony.They did so by accepting the loss and self-controlling by constantly developing various strategies.The strategies have no particular sequence; some are simultaneously applied,and some are reciprocal.

3.2.2.1.Accepting the loss.Accepting the loss refers to CWLOC acknowledging reasonable explanations of the loss and understanding it from new,positive perspectives.It could be expressed by ending feelings of unfairness and not asking why repeatedly.Accepting the loss is the key turning point in the living process.If participants had not accepted the loss,they would not have proceeded to the third phase.Accepting the loss involves believing the loss to be an act of fate and ended the child’s suffering,turning to religion,performing rituals after the child’s death,and finding solace in similar cases.The religious perspectives helped participants understand the loss and afterlife,as the fifth participant said,“…It is God who has designed our destiny… My daughter went to a place where she should go.”

3.2.2.2.Self-controlling.Self-controlling means that CWLOC made efforts to alleviate grief and regain courage and confidence in life by developing strategies that involve avoiding thinking about the loss and self-consoling.

3.2.2.2.1.Avoiding thinking about the loss.Avoiding thinking about the loss is the strategy wherein CWLOC made a conscious choice to not think about their loss by avoiding adverse triggering situations and keeping busy.The participants kept busy by doing housework,focusing on here and now,communicating,and going outside.During this process,the participants were from withdrawing from society to gradually returning to social activities.

“…We chose not to cook what my daughter liked to eat.Moreover,we avoided the places where we had been gone together.”(Participant 5).

“…I took part in some sports…I learned dancing…I took care of dogs…I am very busy every day.Keeping busy let me with no time to think about too many things.” (Participant 1).

3.2.2.2.2.Self-consoling.Self-consoling refers to CWLOC comforting and encouraging themselves by developing various strategies,such as soliloquizing,forcing themselves to think in positive ways,seeking spiritual support,making downward comparisons,gaining a sense of recognition from others,pretending to be strong,and establishing a self-confident external image.The participants also acquired tremendous spiritual support through peer role models.

“…I tell myself that the child is watching me.If I am not happy,she will be sad.” (Participant 13).

“… having this (Buddhism) belief could … comfort my soul.”(Participant 7).

“…We can date and play outside.Others need to take care of their grandchildren.They cannot go,but we can go.When I think like this,I feel better.” (Participant 3).

In the second phase of the living process,participants had gained the ability to manage negative emotions and feelings,resulting in develop the mental strength (inner strength) and desire to live that helped CWLOC move on to the final phase.

3.2.3.Being alive in a new way

Being alive in a new way involves actively dealing with hardships in new constructive ways based on continuously adjusted life goals and living a peaceful life.It consists of treasuring the deceased child,resetting life goals,and reconstructing a new life.

3.2.3.1.Treasuring the deceased child.Treasuring the deceased child refers to CWLOC cherishing their deceased child through continuing bonds by material means and spiritual connections.Believing the deceased child is beside them and fulfilling the deceased child’s wishes are significant ways of treasuring the deceased child.The participants also expressed taking care of the deceased child’s belongings,doing things they used to do with the child,saying to the deceased child,and willingly talking about the deceased child.

“…I made a necklace with my son’s photo…I wear it,and I feel my son is with me.” (Participant 9).

“… I thought of what my son told me while he was alive:not to leave from his father…I took good care of his[stroke]father…At least,let my son not worry about us.“ (Participant 6).

3.2.3.2.Resetting life goals.Resetting life goals refers to CWLOC reorganizing their lives based on the deceased child’s wishes,others’expectations,and personal hopes.In other words,they seek reasons,purposes,directions,and new meanings in life.Moreover,planning for their old age is also essential.CWLOC planned to spend their old age traveling and getting old-age care in a Shidu(loss of an only child) mutual support care center,smart care communities and homes,or institutions.

“…Once my daughter and I saw her[a leader of public welfare]on TV,and my daughter suggested[I]do some charity with her in the future…Now,I am doing[charity].It is also to fulfill my daughter’s wish.” (Participant 1).

“… I thought that if I died,she [the participant’s mother]will also have lost her daughter.I could not bring the same grief to my mother … Therefore,I live my life strongly for my mother.”(Participant 12).

“… We plan to travel abroad once a year … It is also a way to spend the old-age … Besides,we will live here (the housing for living now)until we cannot climb the stairs,and we will sell this house then go to the nursing home or elderly care center.”(Participant 7).

3.2.3.3.Reconstructing a new life.Reconstructing a new life refers to the actions that CWLOC put into coping with barriers and achieving life goals by developing strategies.

3.2.3.3.1.Acquiring new knowledge/information and skills.CWLOC sought to acquire new knowledge/information and skills or strengthen existing knowledge/information and skills by experiencing directly or actively seeking help by watching television,accessing the Internet,or communicating with others.The participants paid close attention to medical knowledge (e.g.,how to prevent diseases).

“… I learned [how to use]the computer … There is a lot of information on the Internet that I can learn.” (Participant 4)

“… I mainly watch the news and The Doctor is In [A program of China Central Television].I have learned a lot of medical knowledge through this program … because I want to know and want to learn.” (Participant 8).

3.2.3.3.2.Building health.Building health refers to the actions CWLOC perform to maintain and promote physical and social health.The participants tried to promote bodily health or reduce illnesses and diseases by actively seeking treatment and monitoring their health status.They promoted their social health by regularly communicating and strengthening their connection with others.They also tried to repay someone through spiritual or material assistance.

“… Moreover,my health is poor … I bought some Chinese traditional medicine to eat.” (Participant 8)

“…I have hypertension…I have a blood pressure meter.I measure my blood pressure every day.” (Participant 4)

“… Sometimes they [peers]called me and talked about their grief.Every time,I listened patiently … Then I try to comfort them by sharing my story or my thoughts.” (Participant 5).

3.2.3.3.3.Managing financial and housing issues.Managing finances and housing issues encompasses strategies of managing financial issues (by following principles of rational consumption,increasing income,seeking financial support,and marrying a man with a high income) and housing issues (by seeking support and marrying a man who owns a house).

“… I always save money … I usually only buy things that I really need,and they are worth the price.” (Participant 13)

“…After my son passed away several months…I applied for a lowrent house where I live now.” (Participant 3)

3.2.3.3.4.Achieving a peaceful life.Achieving a peaceful life refers to CWLOC having a peaceful state of mind and experiencing positive feelings.For example,they felt warmhearted,appreciative,happy,secure,or fulfilled,as the fifth participant described,“…Work is essential and helpful for me both in the economic and spiritual aspects… I felt fullest in my heart while working.”

3.2.4.Receiving support

Receiving support refers to CWLOC gaining psychological,financial,practical,and material assistance from organizations,individuals,and pets through verbal and nonverbal means.The support urged them to deal with life after loss and move on.Successful peer role models play a crucial supportive role in recalling the deceased child’s fortitude and wishes.

3.2.5.Encountering adverse triggering situations

Encountering adverse triggering situations includes people,scenes,places,and objects that would bring negative psychological and emotional feelings associated with difficulties in daily life,financial difficulty,reuniting at festivals and days of mourning,seeing a doctor or going to a hospital,and being hospitalized.One trigger can cause another,while some adverse triggering situations exist simultaneously.

3.2.6.Needs

The participants of this study expressed their intense needs for support in spiritual (e.g.,understanding,respect,care,and love),professional (e.g.,psychological counseling,nursing care,health education),financial and housing-related (e.g.,the government increasing the solatium and health insurance support,providing public-rentals and low-income housing),and practical aspects(e.g.,government providing a job,solving the issue for difficulties when seeing the doctor).

4.Discussion

This study identified a substantive theory,namely,struggling to live a new normal life among Chinese women after losing an only child.The findings can help healthcare workers understand the living process of CWLOC and develop an efficient and professional care plan by working through the three phases (living in agony,coming to terms,and being alive in a new way)with incorporating socio-cultural and religious knowledge.Some parts of the findings support the previous grief and loss theories,such as four phases in grief work[34]and the task theory of grief and loss[35].However,differences in the specific contents of this study and previous studies also reflected the uniqueness of the living process of CWLOC.The contents of this study are discussed in the following section.

The first phase was a period of “l(fā)iving in agony,” wherein CWLOC felt they were “sinking into grief and fear” because of“l(fā)osing their life’s anchor.” Some manifestations such as denial,anger,yearning,depression,and longing for the deceased were consistent with the Kübler-Ross model [36]and Shear et al.’s four critical features of complicated grief [37].Besides,the immediate environment caused cultural differences to seep into the living process.Some manifestations,such as guilt and self-blame in this study,were influenced by cultural beliefs such as filial piety stemming from Confucianism and Karma or retribution from Buddhism.They stigmatized themselves as non-filial people and blamed themselves for breaking the family’s lineage and bring disgrace to the family name.

To achieve “coming to terms” in the second phase,CWLOC was inclined to“self-controlling”with their own effort instead of actively seeking professional support.A study in Hong Kong demonstrated how the participants (from a cancer hospital and a communitybased bereavement counseling center) commonly shared their experiences with professionals[38].However,CWLOC in this study rarely did so.Not seeking professional support does not mean they did not need it.During the interview,some participants acknowledged that they wanted to seek professional support,but they did not know where and how to seek it.Therefore,healthcare workers may work to encourage them to seek support actively.At the same time,there also is an urgent need to establish professional institutions that provide appropriate care.Besides,beliefs play a significant role in “accepting the loss.” Most participants either turned to religion or became more intensely religious and spiritual than before.It is a crucial point to be noted by healthcare workers who assist CWLOC.

It was also found that CWLOC did not cut ties with the deceased but continued to maintain a strong bond.It is different from Freud’s“grief work” theory,which involves breaking off ties with the deceased [39].While a study showed that mothers were more inclined to display negative connections,such as visual hallucinations[40],“treasuring the deceased child” brought great comfort and power to CWLOC.They expressed developing strong and healthy bonds from initially negative ones.Klass and Walter[41]suggested that continuing bonds can be expressed in four ways;one is talking about the dead.However,only two participants were willing to talk about the deceased.It could be influenced by Confucian philosophy that holds death to be associated with something terrible [14].However,a study pointed out that the more the bereaved individuals discussed their loss with others,the fewer health problems they had [42].Thus,healthcare workers need to encourage them to discuss their loss openly.This study found that WeChat and QQ applications have become important social media tools among CWLOC,whereby they can express themselves online without inhibition.Healthcare workers can also use these applications to send messages and provide health education.

Besides the efforts made by CWLOC,the surroundings and people in contact with them took on a significant supportive role.The findings are consistent with the literature that effective social support can help persons who have lost their only child deal with psychological and physical health hardships[7,43,44].In particular,peers’ supportive role can be critical and may even serve as professional help [2].Regarding the constant and intense fear related to the unavailability of care in old age,CWLOC planned to get access to care through a Shidu mutual support care center.Thus,healthcare workers should consider how to let them hugging together for warmth.Meanwhile,adverse trigger situations can play a crucially negative role in daily living.Healthcare workers ought to educate CWLOC to circumvent and deal with adverse trigger situations.

5.Implications

The substantive theory of struggling to live a new normal life can increase nurses’ and healthcare workers’ understanding of Chinese women after losing an only child,which can lead them to provide appropriate and adequate support congruent with the need of CWLOC in each stage.For those who want to develop effective interventions for this group of women,more quantitative research to test the proposed theory is required.

6.Limitations

Notwithstanding these insights,the findings are likely to be limited when it comes to applying this theory to CWLOC in general because of the qualitative approach for generalization purposes.Moreover,all participants were Han ethnic since the one-child policy was mainly implemented in Han families.China has 56 ethnicities,and each ethnicity may experience the loss of an only child differently owing to various beliefs,customs,and lifestyles.Accordingly,research that conducts in all ethnicities is necessary to support the current findings.

7.Conclusions

This study has generated a substantive theory that has closed the existing knowledge gap and can guide healthcare workers toward better care practice.This study found that Chinese culture and personal beliefs profoundly affected day to day living for CWLOC.The study also provided new insights into strategies,needs,practical support,adverse triggering situations,fears,and difficulties.In sum,incorporating these understandings into clinical practice would help CWLOC deal with the loss effectively and improve their future quality of life.

CRediT authorship contribution statement

Haiyan Wang:Conceptualization,Methodology,Investigation,Formal analysis,Data Curation,Software,Writing-Original Draft,Writing -Review & Editing.Waraporn Chaiyawat:Methodology,Formal analysis,Data Curation,Writing-Review & Editing,Supervision.Jintana Yunibhand:Methodology,Supervision,Writing -Review & Editing.

Declaration of competing interest

The authors have no conflict of interest to declare.

Acknowledgements

The authors acknowledge financial support from The Scholarship Program for Neighboring Countries and the Faculty of Nursing,Chulalongkorn University.Special thanks are given to all participants for participating in this study.

Appendices.Supplementary data

Supplementary data related to this article can be found at https://doi.org/10.1016/j.ijnss.2020.11.004.