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July 2007 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Tinley, S. T. and Kinney, A. Y. [School of Nursing, Creighton University, Omaha, NE;]. "Three philosophical approaches to the study of spirituality." Advances in Nursing Science 30, no. 1 (January-March 2007): 71-80.


SUMMARY and COMMENT: This is a straightforward, relatively brief, and very thoughtful presentation of empiricism, interpretivism, and poststructuralism as approaches to the study of spirituality & health. Though written for a nursing audience, the article should be quite useful for chaplain researchers and students, especially those new to the field. Its principal charge to researchers is to consider how each philosophical approach offers advantages for different kinds of inquiries.

The authors begin with a short note about spirituality in nursing research and the "lack of conceptual clarity about the term 'spirituality'" [p. 72]. They also reference a few of the "nursing theorists who have identified spirituality as a central concept in their theories" [p. 71]: Betty Neuman's "The Neuman systems model in research and practice" [Nursing Science Quarterly 9, no. 2 (1996) : 67-70], Rosemarie Rizzo Parse's "Human becoming: Parse's theory of nursing" [Nursing Science Quarterly 5, no. 1 (1992): 35-42], and Jean Watson & Roxie Foster's "The Attending Nurse Caring Model: integrating theory, evidence and advanced caring-healing therapeutics for transforming professional practice" [Journal of Clinical Nursing 12, no. 3 (May 2003): 360-365].

The bulk of the paper is the presentation of the three philosophical approaches, and they are first given brief overviews for the sake of clarity and context, and then analyzed in light of exemplar articles from the nursing literature [see: Related Items of Interest, below]. For each exemplar, Tinley and Kinney look at the "problem and purpose" of the article, the "authors' assumptions," the "object of inquiry," "data analysis," "outcomes," and "strengths and limitations." Examination of the Strengths & Limitations of each exemplar/approach goes to the heart of the overall analysis, but students may be especially struck by the Authors' Assumptions --an often-overlooked element of article criticism.

In sum, Tinley and Kinney hold:

Poststructuralism can provide a very important contribution by illuminating the often obscured impact of political and social forces that construct the meaning and interpretations of words such as spirit and soul, spiritual and religious, spirituality and religiosity. ...Interpretivism provides each research participant the freedom to define spirituality and honors and preserves his or her very personal experiences. It provides detailed descriptions on which to base interpretations and theory related to spirituality. Its contribution to nursing knowledge and practice is in the appreciation of how spirituality impacts individuals in a myriad of ways. ...[And]...Empiricism provides the capacity for testing the commonalities and associations with larger groups of people. It allows for controls to be set in place so that findings can be generalized to even larger groups. It will be with empirical research that nursing will be able to test assessment tools and evaluate interventions for the spiritual health of patients. [p. 78]

The article concludes with an exhortation for researchers to consider how the "merit of each philosophical paradigm lies in its appropriateness to answer a specific type of question" [p. 79]. For this reader, the fundamental challenge of the article is the call for every a researcher to be as consciously agile in philosophical approach as in the identification research questions. Chaplains new to the field often seem to favor interpretivism, and for them this may be a call especially to explore empiricism.


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

This month's article is well suited either for early in a CPE residency, when students might gain a broad view of research approaches, or later in preparation for student research projects. General discussion might focus on the idea of the fit between a research question and the research approach, as a way of backing into the issue of methodology. The subject of authors' assumptions, as pointed out in the analysis of exemplar articles [see: Related Items of Interest, below] may be quite intriguing and productive for many students, and one or more of the exemplar articles could be assigned as complementary reading. Discussion could even lead to a general interest in research methodology that could be pursued in a series of sessions. The Authors' Assumptions section of the analysis of the empirical exemplar article [pp. 73-74], dealing with the Spiritual Well Being Scale, could be an entree to a further discussion of that specific instrument, about which resources have been explored in the March 2004 Article-of-the-Month. Other resources from among past Article-of-the-Month pages include: in relation to the poststructuralist exemplar on the conceptualization of spirituality, the September 2002 page on the various definitions and uses of spirituality in the health care literature and, in relation to the discussion of interpretivism, the March 2003 page's Related Items of Interest section on qualitative research. Some students may be interested in the idea of the Patient-Generated Index (mentioned on p. 79) --a new review of that tool has been recently published [see: Related Items of Interest, below], and it may make for a good follow-up article for discussion with more advanced students.


Related Items of Interest:

I. Tinley and Kinney provide good profiles of the three "exemplar" studies (i.e., Fernsler, et al. for empiricism; Halstead & Hull for interpretivism; and Henery for poststructuralism), but their abstracts are as follows:

Fernsler, J. I., Klemm, P. and Miller, M. A. "Spiritual well-being and demands of illness in people with colorectal cancer." Cancer Nursing 22, no. 2 (April 1999): 134-140 (and quiz pp. 141-142). [(Abstract:) The purpose of this descriptive correlational study was to identify the relationship between subjects' spiritual well-being and the demands of illness (DOI) imposed by colorectal cancer. Potential subjects were notified about the study through computer networks. Those who met the criteria and wished to participate in the study used e-mail to request a study packet, which included an explanation of the study, the Demands of Illness Inventory (DOII), the Spiritual Well-Being Scale (SWBS), a demographic form, and a stamped return-reply envelope. Of the 170 packets requested, 121 (71%) were returned complete. More than half of the respondents were men and were of a Christian faith. Most respondents reported physical symptoms, but were able to carry on normal activity. Demands of illness were greater among men, the youngest subjects, those who received treatment in the previous 2 months, and those who reported decreased activity, metastatic disease, and/or terminal status. Women reported significantly greater spiritual well-being than men. Subjects who reported higher levels of spiritual well-being indicated significantly lower DOI related to physical symptoms, monitoring symptoms, and treatment issues. Findings indicate that a greater degree of spiritual well-being may help to mitigate the DOI imposed by colorectal cancer.]

Halstead, M. T. and Hull, M. "Struggling with paradoxes: the process of spiritual development in women with cancer." Oncology Nursing Forum 28, no. 10 (November-December 2001): 1534-1544. [PURPOSE/OBJECTIVES: To examine the process of spiritual development in women diagnosed with cancer within five years of initial treatment. DESIGN: Exploratory, qualitative. SETTING: Outpatients in the mid-central and southwestern United States. SAMPLE: 10 Caucasian women, ages 45-70, who completed initial treatment, were not undergoing treatment for recurrence, and were within five years of diagnosis for breast or ovarian cancer or non-Hodgkin's lymphoma. METHODS: Data collected during two semistructured interviews, coded and analyzed using grounded theory techniques. Frame of reference--symbolic interactionism. MAIN RESEARCH VARIABLES: Developmental processes of spirituality; responses to diagnosis, treatment, and survival of cancer. FINDINGS: Diagnosis of cancer threatened the meaning of the women's lives, resulting in a sense of disintegration. This problem was resolved through the basic social psychological process of Struggling With Paradoxes, a three-phase process of Deciphering the Meaning of Cancer for Me, Recognizing Human Limitations, and Learning to Live with Uncertainty. In phase I, the paradoxes focused on the possibility of death, distress, vulnerability, and maintaining connection. In phase II, the paradoxes involved confronting death, asking difficult questions, and letting go of ultimate control of their lives. In phase III, the paradoxes centered on uncertainty, redefining meaning, and identifying spiritual growth. Reintegration occurred over time, although when threatened by the possibility of recurrence, disintegration resurfaced for a time. CONCLUSIONS: Findings emphasize not only the importance of spirituality, but also that spiritual experience is individualized and developmental in nature. Spiritual growth occurs over time following the diagnosis of cancer and is not necessarily related to age. IMPLICATIONS FOR NURSING PRACTICE: Spiritual concerns may be painful for patients to address; spiritual caregiving requires an acknowledgment of need by the woman with cancer and a caring, sensitive caregiver. Nurses should be aware of the phases of spiritual development so that interventions can be designed to address individual needs that may vary over time.]

Henery, N. "Constructions of spirituality in contemporary nursing theory." Journal of Advanced Nursing 42, no. 6 (June 2003): 550-557. [BACKGROUND: The nursing literature on spirituality tends to agree that modern science is relatively powerless to address the loss of personal meaning experienced by people facing death, suffering and loss. As a remedy, the literature recommends addressing patients' spirituality. The typical analytical move is to distinguish spirituality from religion and consider it a part, dimension or property of the patient. AIM AND METHOD: This paper uses discourse analysis to identify the formal properties of scientific and religious discourses and their social and political implications. The nursing literature is then investigated to detect the use of such discourses in constructing the object spirituality and to consider any implications for nursing as a social practice. FINDINGS: Far from escaping science and religion, the literature constructs spirituality by means of scientific and religious discourses. These discourses have characteristic strengths and weaknesses that the nursing literature seems to miss. Accordingly, its use of religious discourse lacks coherence and depth, and risks merging human with transcendent authority. Its use of scientific discourse lacks precision and clarity and risks intensifying those features of modernity which contribute to a loss of personal meaning in the face of death, suffering and loss. CONCLUSION: Nursing literature on spirituality raises important questions but is limited in its capacity to address them. This paper provides an alternative perspective. First, it draws on an analysis of the modern institutional environment and its existential dimension. Secondly, it applies discourse analysis to the task of helping people experiencing illness and injury. This approach respects the strengths and limitations of both scientific and religious discourses.]

II. For general resources about research methodology, see the following that are cited by Tinley and Kinney:

Allen, D., Benner, P. and Diekelmann, N. L. "Three paradigms for nursing research: methodological implications." Pp. 23-38 in: Chinn, P. L. Nursing Research Methodology: Issues and Implementation. Rockville, MD: Aspen Publishers, 1986. [Note: Tinley and Kinney's bibliography gives only partial book information.]

Creswell, J. W. Research Design: Qualitative, Quantitative, and Mixed Method Approaches. 2nd ed. Lincoln, NE: Sage Publications, 2003.

Grant, B. M. and Giddings, L. S. "Making sense of methodologies: a paradigm framework for the novice researcher." Contemporary Nurse 13, no. 1 (August 2002): 10-28.

LoBiondo-Wood G. and Haber, J. Nursing Research: Methods, Critical Appraisal and Utilization. 6th ed. St. Louis, MO: Mosby, 2005. [Note: Tinley and Kinney's bibliography list this as a 2006 imprint, but Books-in-Print has it as October 2005.]

III. Regarding methodology, all chaplain researchers should be familiar with:

VandeCreek, L., Bender, H. E. and Jordan, M. R. Research in Pastoral Care and Counseling: Quantitative and Qualitative Approaches. Decatur, GA: Journal of Pastoral Care Publications, 1994.

IV. For further reading about the idea of the Patient-Generated Index (mentioned on p. 79), the following review of that tool has been recently published:

Martin, F., Camfield, L., Rodham, K., Kliempt, P. and Ruta, D. "Twelve years' experience with the Patient Generated Index (PGI) of quality of life: a graded structured review." Quality of Life Research 16, no. 4 (May 2007): 705-715. [(Abstract:) The Patient Generated Index (PGI) is an individualized quality of life (QoL) measure that has been in use since 1994. Various adaptations have been made to suit a variety of client groups. The PGI's psychometric properties have been studied but their review is necessary to inform instrument choice. This article provides a structured review, using grading criteria adapted from those developed to aid outcome measure selection for use with older people. These criteria grade quality of evidence and strength of findings for psychometric validity, providing a useful model for future reviews. All published articles providing data addressing validity, reliability and/or responsiveness were included in the review. Eighteen relevant articles were identified and analysed using the grading criteria. Variable results and quality of investigation were seen. Generally the measure was found to be adequately reliable for group comparisons. The PGI appeared valid but evidence for responsiveness was unclear. Those versions of the measure using fewer points in their Likert scales may have higher reliability. Cognitions involved in QoL judgments remain little understood and investigations of psychometric properties may be enhanced by examination of appraisal processes. --47 refs.]


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