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April 2003 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center - Presbyterian, Philadelphia PA.


Narayanasamy, A. [University of Nottingham, UK]. "Spiritual coping mechanisms in chronically ill patients." British Journal of Nursing 11, no. 22 (December 12, 2002 - January 8, 2003): 1461-1470.


SUMMARY: This recent qualitative study, using recorded interviews with 15 chronically ill patients, seeks to illuminate the "lived experience" of spiritual coping mechanisms in chronic illness. The author defines spirituality very broadly, though the themes which emerge in the analysis of the "unstructured" interviews involve a good deal of traditional religious language. The themes are: 1) reaching out to God in the belief and faith that help will be forthcoming, 2) feeling connected to God through prayer, 3) the search for meaning and purpose, 4) a strategy of keeping one's spiritual coping mechanism as a private and personal affair, and 5) connectedness with others who are seen as sources of spiritual support. The study is said particularly to explore this subject in a British population (instead of the North American population that dominates studies in the field) and to utilize a qualitative methodology to capture patients' "lived experience" (instead of the more common quantitative methods that focus on correlations between spirituality and health outcomes). The author concludes that "chronic illness may become a 'spiritual encounter' as well as a physical and emotional experience." There is emphasis placed upon the importance of "connectedness with God and others." Methodologically, the author notes that while patients in the study may have indicated some initial reticence, they became expressive on the subject of their spiritual experience in the presence of a supportive listener (i.e., the interviewer).

COMMENT: This is a study that should be of interest to CPE researchers, as well as to supervisors and students in general, for at least two reasons. First, it is centered on one of the most valuable discipline-bridging concepts in the area of spirituality and health: coping. While the concept of coping may be conceived and applied somewhat differently by chaplains, nurses, physicians, and psychologists; there is sufficient commonality here for good and clear communication across these disciplines, and studies of patients' religious coping can be prime opportunities for multidisciplinary research. Narayanasamy's study itself may be confined to nursing, but chaplains reading it will likely be stirred to think of how their pastoral insight could be complementary to such research pursuits. (Future Articles of the Month will address more fully the research on coping and religious coping, but a brief bibliography is provided below for a general introduction to the literature.)

A second notable aspect of this study is its focus on chronic illness. More and more, the literature of spirituality and health is looking beyond the circumstances of acute illness and end-of-life issues to a consideration of the day to day importance of spirituality in the lives of people with chronic illness. In part, this shift of attention to chronic illness is a function of how many illnesses once addressed only in acute forms may now often and largely be managed as chronic ailments on an outpatient basis (e.g., AIDS). The very quality of an illness' chronicity portends much for spirituality research, as patients have extended time to reflect upon their situation and to develop a rich sense of their lived experience of illness. Narayanasamy's preference for qualitative methodology fits well here, though that is not to say that quantitative methods couldn't be used productively. There is also usually increased opportunity for data collection from patients with chronic illnesses (in comparison to data collection from patients with single-episode acute illnesses), and Narayanasamy clearly takes advantage of this through an interview scheduling strategy.

An additional reason that this study should be of interest to chaplains is that Narayanasamy provides (no doubt unwittingly) yet another example of the insularity of clinical researchers' understandings of spiritual concepts, which have only recently been addressed in the health care literature but which have of course long been treated with depth and subtlety in the theological, pastoral, and philosophical literature. The study's ignorance or avoidance of the traditional religious and pastoral material suggests precisely why chaplains should keep abreast of the published knowledge base that allied health professions are developing on spirituality and health, because that is shaping the perspectives of those along side of whom we work; and chaplain researchers may contribute greatly to issues of concept validity regarding spirituality in studies and bring into play a sense of the broader religious literature. (For more on the definition of spirituality and its use by clinicians/researchers, see the September 2002 Article of the Month.)


Suggestions for the Use of the Article for Discussion in CPE: 

The article is clearly written, outlines well the methodology used, and contains good illustrations of the data in quotes from patients. It offers a brief but articulate description of the author's sense of the concept of spirituality and its relation to chronic illness, and the qualitative character of the study makes it easy for non-researchers to read. Discussion of it could follow several different lines. First, for students not familiar with the very broad definition of spirituality commonly found in the health care literature, a general discussion could center on the table of Descriptions of Spirituality (p. 1462), which gives a fair sample from the literature. Another line of discussion could focus on the subject of chronic illness and the role of spirituality. The article may be aimed at nurses, but it is likely that chaplains could easily relate Narayanasamy's characterization of patients' "spiritual encounter" through chronic illness to their own experiences in visiting with patients. In this way, the resultant themes of the study could provide the structure for discussion about chronically ill patients. Students might also be challenged to examine the concept of coping and think about how a patients' religious coping might be assessed, in clinical practice as well as in research (though, regarding research, some of the articles in the bibliography below may address this more fully). The various quotes from patients could be examined for coping dymanics in somewhat the manner of a CPE verbatim analysis, and thus students could bring their own insights to bear upon the material and compare their perspective to that of the author's. Another concept raised in the study is that of connection--a concept that often figures into CPE students' theory of pastoral care and a subject that could be explored generally. The qualitative methodology is nicely outlined in a table (p. 1465) that could be discussed in terms of the possibility of practical student projects. Finally, there could be some critical discussion of the character of the author's scientific outlook, especially in commenting on patients' feelings of "a presence" or "an awareness of God," specifically the sentence: "it would seem premature to speculate about this phenomenon in the absence of further empirical evidence [emphasis added] of this nature in the clinical context." Perhaps CPE students wouldn't feel so constrained to "speculate" here, and the discussion could turn to the question of why.


Related Items of Interest: 


Ai, A. L., Peterson, C., Bolling, S. F. and Koenig, H. "Private prayer and optimism in middle-aged and older patients awaiting cardiac surgery." Gerontologist 42, no. 1 (February 2002): 70-81. [The study looks particularly at private prayer as a coping strategy. See also the related earlier study: Ai, A. L., Dunkle, R. E., Peterson, C. and Bolling, S. F. "The role of private prayer in psychological recovery among midlife and aged patients following cardiac surgery." Gerontologist 38, no. 5 (October 1998): 591-601.] 

Baldacchino, D. and Draper, P. "Spiritual coping strategies: a review of the nursing research literature." Journal of Advanced Nursing 34, no. 6 (June 2001): 833-841. [This is a good overview of nursing perspectives.] 

Lazarus, R. S. "Coping theory and research: past, present, and future." Psychosomatic Medicine 55 (May-June 1993): 234-247. [Lazarus is the premier figure in psychological coping research, and while he does not focus on religious coping, this older article offers a good sense of the background against which religious coping research stands in some relief.] 

Meisenhelder, J. B. "Terrorism, posttraumatic stress, and religious coping." Issues in Mental Health Nursing 23, no. 8 (December 2002): 771-782. [This article speaks to the potential value of research into religious coping in a post-09/11/01 American context.] 

Pargament, K. "Religious/spiritual coping" In A Multidimensional Measurement of Religiousness/Spirituality for Use in Health Care Research: A Report of the Fetzer Institute/National Institute on Aging Working Group. Kalamazoo, Michigan: Fetzer Institute (October 1999): 43-56. [Pargament is the leading researcher today on religious coping. The Fetzer Institute's measure is available in the full print report. [Note that the document includes in the front matter the blanket permission (in bold type) that the document "may be used and reprinted without special permission."]

Pargament, K., Zinnbauer, B., Scott, A., Butter, E., Zerowin, J. and Stanik, P. "Red flags and religious coping: identifying some religious warning signs among people in crisis.." Journal of Clinical Psychology 54, no. 1 (January 1998): 77-89. [This article may be a difficult read for students who are not familiar with the coping literature, but it marks an important line of thinking for researchers.] 

Pargament, K. I., Koenig, H. G. and Perez, L. M. "The many methods of religious coping: development and initial validation of the RCOPE." Journal of Clinical Psychology 56, no. 4 (August 13-27, 2001): 519-543. [This thorough exposition on the RCOPE measure offers a great deal of information about how the concept of coping may be approached in research.] 

Pargament, K. I., Smith, B. W., Koenig, H. G. and Perez, L. "Patterns of positive and negative religious coping with major life stressors." Journal for the Scientific Study of Religion 37, no. 4 (December 1998): 710-724. [This article was also noted in George Fitchett's bibliography for Further Reading in the March 2003 Article of the Month.] 

Tix, A. T. and Frazier, P. A. "The use of religious coping during stressful life events: main effects, moderation, and mediation." Journal of Consulting and Clinical Psychology 66, no. 2 (April 1998): 411-422. 

[Added 11/1/04:]

Egbert, N., Mickley, J. and Coeling, H. "A review and application of social scientific measures of religiosity and spirituality: assessing a missing component in health communication research." Health Communication 16, no. 1 (2004): 7-27. [In their discussion of a number of instruments, the authors look at measures of religious coping, including the RCOPE and Brief RCOPE. See pp. 15-17. (This article is part of a theme issue on health communication and religion/spirituality.)]

Folkman, S. and Moskowitz, J. T. "Coping: pitfalls and promise." Annual Review of Psychology 55 (2003): 745-774. [This recent overview of coping contains a section specifically on religious coping. See pp. 759-761.]


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