Spirituality as a Coping Mechanism for Chronic Illness

Introduction

It is universally accepted that healthcare, including management of chronic illness, entails more than physical treatment of the sick. Healthcare relational models indicate that adequate care for the sick involves making sure that all the patient’s lifestyle relationships are taken care of. In other words, such issues as “biological, neurological, psychological, social, and spiritual” must be taken care of in the treatment process (Wachholtz & Pearce, 2009, p.1539). Logically, such a problem may present a technically difficult task for the physicians who have limited time to create a good relationship with the patient, do assessment, carry out diagnosis, and draw a treatment plan for the patient. Considering the competing issues within the limited time allocated for the treatment process, one may doubt if there is need to discuss spirituality in the clinical process as well as in the chronic illness management. One such features of spirituality in the clinical treatment is chronic pain, which becomes technically difficult to manage especially when spiritual background of the carer and the patients are different.

It is acknowledged that spirituality do influence the ability of the patient to “cope with chronic pain”, either negatively or positively (Wachholtz & Pearce, 2009, p.1539). It thus follows that spirituality is an important aspect of treatment and therefore the need to discuss it. In this paper, we illustrate that spiritual beliefs of the patients are relevant in the practice of healthcare, particularly for chronic illness, discuss how spirituality may help or hinder the patient from coping with chronic pain, and finally, elaborate how a physician can attend to as well as give care in the dimension of spiritual healthcare.

Examination of background variables and spirituality and cultural factors that impact the issue

The most common definition of spirituality is that it is “every person’s inherent search for ultimate meaning and purpose in life” (Wilber, 2008a, p.53). Religion as a concept is based on the fact that it is associated with the “teachings and rituals of various faith traditions” in the contemporary professional nursing practice. Practically, it is not obvious that spirituality will include specific belief in higher power, but may just entail an expression of philosophically designed beliefs as far as art, nature, and music is concerned. It may also involve special relationship with the loved ones or significant others (Wilber, 2008a, p.54). In fact, spirituality supports the information on how we are unique within the context of our views of the world. This understanding plays an important role in the determination of how we develop our understanding of the negative events such as illness, and more importantly, how we choose to cope with such issues. Significantly, studies have suggested that patients have a belief that spirituality should never be a private affair as some medical practitioners believed in the past. Instead, spirituality should be a shared concern between the patient, carer, and the medical practitioner. Supporting this argument is a study conducted by Koenig (2009), which showed that “41% to 94% of patients want their physicians to address spiritual issues” during treatment. Additionally, a national Gallup survey found out that about 70% of adults reported that it is necessary to have physicians who understand their spiritual orientation or those who share spiritual belief with them (Fitchett, 2009).

Critical Healthcare practitioners have acknowledged the need to therapeutically treat the whole person during the time of treatment. However, it has emerged that just a few do manage to tackle the issue of spirituality in their daily professional practice (Kendrick & Robinson, 2008; Fitchett, 2009). Recent studies have shown that even though many practitioners have known the importance of addressing the issue of spirituality, just a few have taken the initiative to practice religions during their professional practices (Landis, 2007; Fitchett, 2009; Purdy & Dupey, 2009). Moreover, a recent meta-analysis has suggested that there is a positive correlation between spiritual practices and the application of spirituality in the calming down patient under chronic pain.

Notably, it is prudent to state that the lack of discussion about spirituality in the medical practices is largely due to the little attention the issue has received in the training sessions for the medical practitioners (Monroe, Bynum & Susi, 2008). The other possibility is that there is a self-perceived less adequate faculty member to include the topics as per the needs of the modern healthcare. This issue needs attention considering the fact that 90% of Americans belief in the existence of God, while 80% have believed that prayers and meditation have positive impact in the cure of the diseases (Monroe, Bynum & Susi, 2008). It was reported that about 90% of Americans prayed and that majority of them (70%) engaged themselves in daily prayers (Gallup and Lindsay, 1999, cited in Monroe, Bynum & Susi, 2008). Considering this large number of people who believe in spirituality, medical practitioners may be remiss in case they fail to include the issue during treatment. In fact, spirituality and cultural belief have the potentiality to impact on the lives of the critically ill patient.

The issues surrounding the role of spirituality and cultural beliefs in the treatment process have moved from questioning their relevance to increased efforts to understand the best way to practice it and maximize their roles. Turner (2006) observed, “there are various ways to express why and how spirituality relates to human development, and there also various ways to attend to how and why counseling and psychotherapy must involve attention to spirituality” (p.489). Such findings and observations have raised several issues concerning spirituality as included in the treatment process for the chronically ill adults. But one main conclusion is that it is a framework in which medical practitioners should work with in their duty planning and executions.

Recently, the dominant theme has been how best medical practitioners should be trained on spirituality issues and how to use it during treatment sessions (Stefano & Esch, 2007). Additionally, “issues surrounding various groups of people have emerged as important areas of study and many scholars have strived to engage in researches that involve such group interests” (Stefano & Esch, 2007, p.627). For example, some researchers have concentrated on the effort to investigate groups that have conservative Christian interests (Stefano & Esch, 2007); the elderly group, African American people, and disable people (Stefano & Esch, 2007). Adding to the complexity is the issue of chronic illness that is likely to worsen the situation.

Studies that have concentrated on the role of spirituality for the disable and critically ill patients suggest that there’s an inconsistent expression as concerns the benefits that religion or spirituality brings during treatment and recovery process. Wilber (2008b) however, notes that spirituality and cultural belief is used by certain disable and chronically ill patients to help them heal as well as cope with disability issue. The recent studies on disability and spirituality have typically focused on the roles of spirituality in helping individuals cope with various forms of losses that people who are critically ill or are traumatized by accidents would go through.

Theoretical framework

It must be noted that chronic pain can sometimes leads to poor quality of life. Again medication options to pain management are important but sometimes have side effects to the patients. This may subsequently drive the patient to seek another option to pain relief in the practice of spiritual belief in his or her daily life (Cohen & Wheeler & Scott, 2007). According to Gate Control/Neuromatrix Theory of Pain, there are conceptual spiritual beliefs and practices that have significant influence in the treatment and management of pain. These beliefs and practices can be theoretically explained by the relationship between psychological and biological factors. In fact, these theories propose that personal experiences of pain go beyond the biochemical transmission of pain from the spinal cord to the brain. They involve the expression of multiple “senses of cognitive, emotional expressions, and behavioral habits of the person under pain” (Cohen & Wheeler & Scott, 2007). Consequently, these senses are likely to lead to the actual reduction or increment of pain experience. The Gate Control/Neuromatrix models of pain put a lot of emphasis on the role of psychological aspects of mediation in an effort to reduce pain for the chronically ill patient.

Secondly, theoretical constructs emphasizes the need to keep an eye on the societal and cultural context in which the patient’s coping models are developed (Cohen & Wheeler & Scott, 2007). Basically, this would mean there’s need for cross-cultural research if the psychology of coping is to be developed further in the context of primary healthcare provision and religious contexts. It is therefore critical to state that there’s need to move the framework of coping from general term to the spiritual dimension and primary healthcare concept.

Methodology or procedure

The study focused secondary research, that is, the search for materials from specific databases which have latest information on contemporary nursing. Some of the databases accessed are: Lexisnexis academics, NetLibrary e-books, and Directory of open access journals. Google scholar was also used to search for general issues related to nursing and spirituality as well as religious beliefs.

In the search, terms used were: “nursing and spirituality”, “spirituality as a coping mechanism for chronic illness”, “cultural dimension of spirituality in nursing”, “spirituality, policy and healthcare”, “spirituality, ethics and healthcare”, and “spirituality, human rights and nursing”. Even though there were hundreds of results generated in the search, it was narrowed down to articles, e-books and journals written in English, specifically publications in the last 3 years. This was to ensure that latest studies with relevant information are used to find appropriate issues needed for contemporary nursing, hence avoidance of information that have been overtaken by events. However, some sources were used as guidance references that helped support the current information needed for this task.

The research is descriptive in nature, that is, descriptive research methods were used to provide a comprehensive summary of information in an understandability and usability. I preferred this option due to the limited research in the area and the possibility of promoting understanding of attitudes and perceptions of medical practitioners during the general treatment of chronic illness.

Findings

Spiritual care nursing and ethics

The need to provide respectful care has generated into an important aspect in the treatment of chronic illness among the critically ill adults. Healthcare providers need to understand basic issues concerning the “patient’s spiritual needs, resources and preferences” (Wachholtz & Pearce, 2009, p.1533). Respectful care requires that the healthcare professional follow the patient’s spiritual wishes as he or she expresses them during treatment. Again healthcare professionals should never prescribe for the patients any spiritual or religious practices, neither should he or she insist nor urge the patient to abandon his or her spiritual belief for another. This can be achieved through preservation of professional practices and maintenance of integrity among the people.

There is also the need for professionals in the critical care for chronic illness to develop professional understanding of their own spirituality. Finally, whenever they practice in the professional care, they need to participate in a consonant manner with professionalism and integrity.

Whenever a patient faces life threatening health complication, the first thing he or she is likely to think of is to seek spiritual sustenance. This normally occurs despite the fact that the person may not have been involved in any form spiritual practice before. It therefore follows that every healthcare professional, especially the primary healthcare nurses need to develop mechanisms to understand basic healthcare provisions and the place of ethical spiritual care.

Ethical healthcare provision demands that professional in this field respect the patient’s wishes as expressed during treatment. Fitchett (2009) notes, “Essential ethical characteristic of professional health care is based on a relationship of trust with the patient” (p.132). I would add that even the role of the patient’s significant others such as family members and friends should never be assumed at all as they have had significant influence on the patients spiritual growth. In fact, the patient’s acknowledgement of his or her spiritual inclination is normally associated with how he or she has been made vulnerable by the illness; hence, they count on their care nurses’ trustworthiness. It is the care nurses who spend most of the time with them; hence the trust as an aspect of ethics is critical in the treatment process. Presumably, trust would definitely be lost if other issues not related to patient’s wishes of complete wellbeing are given priority.

One of the most important “elements of trust is the respect of the patient as a person with spiritual wishes, desires and goals” (Ellis & Campbell, 2008, p.1161). A recent study suggests that the attitude of the patient is dominated by the feeling of respect from the healthcare professional (Ellis & Campbell, 2008). Respect involves the healthcare practitioner recognizing that the patient arrived with their own values, desires, and distinct goals to achieve during and after treatment. It must be noted that these values and beliefs may be completely different from those of care givers in virtually all aspects. In his review of respectful care for critically ill patients, Landis (2007) notes, “respectful care starts with the intention to learn about needs and resources of the patients as a whole person” (p.219). This means that the patient’s physical, psychological and mental health must be learnt in an integrated manner to accomplish the treatment goals complete health. This provides the ethical guideline for ethical treatment of the patient through spiritual practice recognition. Cohen, Wheeler & Scott (2007) gives the following ethical guidelines as the benchmark for understanding and respecting patient’s spiritual and religious beliefs:

1. “Healthcare professionals should seek a basic of understanding of patients’ spiritual needs, resources, and preferences;
2. healthcare professionals need to follow the patient’s expressed wishes regarding spiritual care;
3. healthcare professionals should never prescribe spiritual practices nor urge patients to relinquish religious beliefs or practices as this would mean lack of professional integrity;
4. professionals who are in charge of care such as nurses should seek to understand their own spirituality;
5. And finally, any participation in spiritual care should be consonant with professional integrity” (p.45).

Human Rights and Legal Dimensions of Spirituality in Chronic Illness Treatment

It is acknowledged that a person’s role in healthcare cannot be complete by only focusing on the physician-patient relationship. In fact, a patient’s whole health is completed by the environmental and social environment.

At the core of every aspect of spiritual dimension in treatment care is the legal provisions that are designed to accomplish the rights of individual patient in critical care. Recognizing that health is a process through which one can gain “physical, mental, social, emotional or spiritual wellbeing”, there is normally regular checkup that is provided by healthcare professionals in their daily routine. Guiding these healthcare provisions are legal and policy provisions needed to accomplish the rights of the patient at all levels and period of care. According to World Health Organization, “”promoting and protecting health and respecting, protecting and fulfilling human rights are inextricably linked” (Ellis & Campbell, 2008, p.1160).

The guiding policy and legal principle is based on the fact that a patient must be protected from any professional negligence that may occur within the professional practice. It is noted that any violation or little attention to human rights may be detrimental to the life of the individual patient in many ways. Such aspects as harmful traditional practices, forcing healthcare issues to the patient, and violating treatment procedures may lead to a lot of strain and worsen the already grave situation of complicated health status of the critically ill. In fact, health policies are known to either “promote or violate human rights in the design or implementation”; hence the need to observe and acknowledge freedom of expression from discrimination, rights of the patient to participate in the process, and right to his or her privacy and information (Ellis & Campbell, 2008, p.1163).

In many healthcare practices, legal issues in critical care, including end-of-life care are grouped together under the broad heading of advance care planning. For instance, healthcare practice in the United States suggests that involve advance care planning involve the completion of personal advanced directive. Turner (2006) defines advanced directive as “instructions given by a capable person, often in written form, about their wishes for healthcare (treatment) and/or personal care in the event that they become incapable of giving informed consent” (p.487).

In spite of the fact that traditional intent of advance directives was to ensure that patients’ wishes were honored, several studies within the United States indicate that only a minority of adults (20-30%) have actually completed an advanced directive (Stefano & Esch, 2007). Consequently, this tool has had limited effects on treatment decisions near end of life or patients under chronic illness (Stefano & Esch, 2007). The DNP-prepared nurses cannot achieve the intended goal due to this inconsistency and lack of legal provision to accomplish the healthcare goals for specific cases. Wilber (2008a) acknowledges that advanced directives are not as successful as initially intended for a number of reasons: “the lack of discussions regarding underlying goals and values, lack of discussion regarding preferences for care, the failure to address cultural issues, poor communication between patients and healthcare professionals, difficulty in getting resources to effectively develop healthcare plans, and the absence of system to support advanced care plan.”

Various programs have been designed to facilitate the implementation of advanced care planning. One such very successful program is “The Respecting Choices Advance Care Planning Program”, developed by the Gundersen Lutheran Medical Center. This program has proven very successful in the United States, Canada, and Australia (Wilber, 2008a, p.79).

Development of conceptual model

The concept of spirituality has developed within healthcare and this implies that the person should be viewed as a single entity comprised of many individual facets. While the social implication and policy guidelines provided by the relevant authorities suggest the need to carry out individual assessment, it is clear that the need to develop the concept of whole healthcare provision is necessary. In fact, Turner (2006) sees the term spirituality as a little-understood phenomenon in the conventional healthcare. He states that individual human beings are people in “a balanced interaction” of all biopsychological and spiritual components. Basically, it is possible to develop a conceptual framework to understand the four main domains of spirituality such as religion, religious coping and support, spiritual wellbeing and spiritual need.

There is need for a conceptual model that can explore how individuals may make sense from chronic illness so as to facilitate the ultimate goal of coping strategies for the patients. It is acknowledged that spiritual aspect of self should be explained by making efforts to find the meaning of suffering experienced by critically ill individual. Subsequently, this helps to develop the source of hope that can help the patient face the challenges they go through during the pain process. A whole model would incorporate culture as the basis that guide the interpretation of the significance of critical ill health at an individual, familial, and societal levels so as to increase and facilitate healthcare provisions.

Application of model to and understanding or response to the issues

Making sense of critical illness is model will facilitate life transitions in an individual’s overall life standards and care so as to incorporate the spiritual as well as cultural perspectives of the healthcare provisions and care. The effective coping can be well achieved through incorporation of coping skills gained through the understanding of how patients make sense of their circumstances and thus supports nurses in efforts to help patient’s practice effective coping during times of cure.

In order to effectively implement this model, it must be always remembered that clinicians’ reluctance to discuss issues of religion and spirituality may emerge from their own anxieties about death as well as misconceptions about how much the patient wants to know about his or her illness. Certain studies have revealed that healthcare professionals avoid discussions that relates to the patient’s health status by assuming that they would discover by themselves (Monroe, Bynum & Susi, 2008; Wachholtz & Pearce, 2009). Basically, there’s a need to develop awareness among the professionals on how to understand how a patient make sense of himself or herself in the general treatment of the people. The implementation of the model would incorporate the patient-physician, family, and other healthcare professionals’ awareness of the patient’s status as well as recognition of each other’s awareness.

Recommendations

It is critical to note that there are several issues that have emerged from this analysis. The provision of meaning and hope in the chronic illness care needs a qualified healthcare professional. The availability of resource includes appropriate skills to help the patient cope with the stressing situations in chronic illness. The general principle is that the more external and internal resources available among the patients and the healthcare professionals, the more likely one is able to cope with the demands of life. It therefore follows that an emphasis should be put on the coping resources which help to shift focus from reacting to stressful situations such as pain to preventive and transformative coping. Basically, when one is well equipped with adequate resources to cope with pain and other stressful situations, he or she is not likely to term certain situations or feelings as life threatening or harmful to life.

To support this idea, it is important for the healthcare professional to be adequately trained in all dimensions of spirituality so as to develop an understanding of the patient’s understanding of self. If a patient has developed connection with spiritual belief through prayer, it is possible to help the patient develop relationship with other individuals who acknowledges or practices the same spiritual belief. To ensure that this happens, it must be noted that the medical practitioner’s spirituality will help the patient develop a bond with him or her hence facilitate psychological healing.

The consequences of chronic illness are likely to strengthen the patient’s spiritual belief. In this case, family members will have their belief and faith as the backbone of the patients support. The significant others form a critical part of a complete healthcare provision. It is therefore important to include family members in the planning and development of healthcare provision mechanism. Since the patient’s lifetime environment has been all along occupied by his or her significant others, the union between them will remain strengthened through the development of emotional connections during the performances of such spiritual rituals like prayer. Moreover, studies have reveled that faith and family support are two single most important part of treatment for critically ill patient (Ellis & Campbell, 2008). Additionally, it is acknowledged that faith and belief in the existence of “The Most High’ is what leads many to belief that some happenings in life have a purpose in life, hence they should be embraced rather than frowned.

At the level of care provisions, physicians and other healthcare professionals have a duty to develop standards of care at individual level, putting in mind the need to understand that the patient needs closer people more closely due to limited social activities. Establishing the relationship with other people is part of the healing process. In a study to establish the role of other people like family friends, it was revealed that family members are most critical in establishing psychological support through relating with others in the social cycle.

Lastly, it must be recognized that self-restructuring or self-awareness depends on several factors in the coping strategies of a patient. The success or failure of coping largely depends on the skills of the individual. For example, if one strategy is used to assist two critically ill people with identical situations, it may not work effectively due to lack of similarity in coping strategies. The difference is normally created due to different attitudes and personalities of these individuals. According to, Fitchett (2009), a resilient person is not necessarily someone with a lot of coping skills but must be someone with right stuff such as endurance, determination, optimism, flexibility, creativity, wisdom, humility, faith, integrity and equanimity” (p.99). How these positive factors mediate the whole process provide some attributes that can help frontier a new investigation through research.

Conclusion

Chronic illness is a challenging situation for both the patient and the clinicians. Additionally, patient’s significant others such family members and friends do play big roles in the whole treatment of the patient. The universal concept of spirituality helps us understand the variations that exist among the minds of the stakeholders in the critical care setting. The understanding of the universal concept of spirituality helps us appreciate rather than taunt other religions or spiritual beliefs. The theoretical concept underlined above helps to explicitly understand patient’s needs and aspirations as far as treatment is concerned. To optimally implement the multidisciplinary actions on chronic illness treatment, it is critical to develop a system that incorporates all aspects of spirituality as prescribed in the contemporary literature of nursing. Finally, the setting of attitude should also play an important process as it is known to influence the overall acceptance of the treatment process.

Reference List

Cohen, C.B., & Wheeler, S.E., & Scott, D.A. (2007). Prayer as therapy. A challenge to both religious belief and professional ethics. The Anglican Working Group in Bioethics. Hastings Cent Rep, 30: 40-47.

Ellis, M.R., & Campbell, J.D. (2008). Patients’ views about discussing spiritual issues with primary care physicians. South Med J, 97: 1158-1164.

Fitchett, G. (2009). Assessing Spiritual Needs: A Guide for Caregivers. Lima, OH: Academic Renewal Press.

Kendrick K., & Robinson, S. (2008). Spirituality: its relevance and purpose for clinical nursing in a new millennium. J Clin Nurs, 9: 701-706.

Koenig, H.G. (2009). Religion, spirituality, and medicine: research findings and implications for clinical practice. South Med J, 97: 1194-1200.

Landis, B. J. (2007). Uncertainty, spiritual well-being and psychosocial adjustment to chronic illness. Issues in Mental Health Nursing, 17 (3), 217-231.

Monroe, M.N., Bynum, D., & Susi, B. (2008). Primary care physician preferences regarding spiritual behavior in medical practice. Arch Intern Med, 163: 2751-2756.

Purdy, M., & Dupey, P.A. (2009). Holistic flow model of spiritual wellness. Couns Values, 49(2):95–106.

Stefano, G.B., & Esch, T. (2007). Integrative medical therapy: examination of meditation’s therapeutic and global medical outcomes via nitric oxide [review]. Int J Mol Med, 16(4):621–630.

Turner, D. (2006). Just another drug? A philosophical assessment of randomized controlled studies on intercessory prayer. J Med Ethics, 32(8):487–490.

Wachholtz, A., & Pearce, M. (2009). Does spirituality as a coping mechanism help or hinder coping with chronic pain? Journal of Current Pain and Headache Reports, Vol. 13, Number 2, pp. 1531-3443.

Wilber, K. (2008a). Integral Psychology: Consciousness, Spirit, Psychology, Therapy. Boston, MA: Shambhala Publications; 2000.

Wilber K. (2008b). Waves, Streams, States and Self: A Summary of My Psychological Model. Boston, MA: Shambhala Publications.