May 2012 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.
Tuck, I., Carey, S. J., Kuznetsova, M. I., McCrocklin, C., Baxter, M. and Bennington, L. K. "Sacred healing stories told at the end of life." Journal of Holistic Nursing 30, no. 2 (June 2012): 69-80.
SUMMARY and COMMENT: The combination of kinship and divergence in the ways that nurses and chaplains approach spiritual care is apparent in this month's study, which engaged patients in the sacredness of their own life stories. The lead author, Inez Tuck, is well represented in the spirituality & health literature [--see Related Items of Interest, §II, below] as a nursing author, but she also holds an MDiv. At the heart of the present research is an intervention developed by Dr. Tuck that is faithful to patient-led pastoral care practice but systematized for nursing application.
The threefold purpose of the study is to (a) explore the acceptability and feasibility of implementing the
PATS© (Presence, Active Listening, Touch, Sacred Story) intervention, an approach to narrative storytelling developed by [Dr. Tuck], and the administration of Spiritual Health Inventory…in a sample
of people who have a terminal diagnosis of cancer; (b) explore the experience of living with a terminal illness as expressed in the narratives of the sacred stories of the study participants that results from PATS; and (c) analyze the sacred stories for the presence and nature of spirituality and healing. [p. 70]
A sample of 7 patients (out of a potential sample of 15, of which 13 originally agreed to participate) from a Palliative Care Unit at a large teaching hospital and a community hospice were given the Spiritual Health Inventory and then interviewed:
Each participant was asked to respond to the following focused research lead question:
Audiotapes were transcribed and analyzed by the investigators [--described on p. 73]. Among the findings, "The narrative analysis of the stories as told by the participants included three themes: finding out and struggling, discovering what it means, and living with the prognosis" [pp. 74 and 76]. These themes are conceptually explained [p. 76] and elaborately illustrated with extended excerpts [--see Table 2 on pp. 75-76]. Line-by-line analysis looked for indications of spirituality: "The stories included strong statements that indicated the search for meaning and purpose usually associated with spirituality…[and]…referenced a deep and often tumultuous relationship with God and connections with family" [pp. 76-77]. Moreover, the stories were classified according to four "categories of healing" [p. 77] explained in a table [--see Table 1 on p. 72]:
I would like for you to tell me about your experience of having cancer and finding out that there are no options available for future treatment or a cure. Your sharing the experience is very significant and for us becomes a sacred story. Please describe for me what this experience has been like for you and what impact it has had on you as a person today.
If at the conclusion of the story, the following topics have not been included, the interviewer will probe by asking further questions: What about spirituality? How would you describe spirituality or your spiritual journey? Was your sacred story a way to describe your spirituality? Was healing a part of your experience? How do you see yourself in terms of change or growth? [p. 73]
In short, the stories evidenced processes of spirituality-linked healing, and "[t]he results indicate the potential for a modest positive effect on the well-being of participants…" [p. 78]. Insufficient response to the Spiritual Health Inventory prevented an assessment of that instrument. However, the larger significance of the study may come from the piloting of the principal investigator's method of eliciting and honoring patients' spirituality thorough storytelling. Chaplains should be interested in the explication of the PATS method (or perhaps more properly approach), as a "spiritual intervention" involving "preparation by the interviewer prior to the session" and "activities intended to create a sacred space for the story to be told" [p. 71].
- Restorative healing --
- The return to one’s previous state of comfort; the strivings to recapture the known former sense of self
following an existential struggle or profound suffering.
- Integrative healing --
- The awareness of bringing together one’s physical, emotional, and spiritual self into a more balanced state of being and beyond the previous self following an existential struggle or profound suffering.
- Transformative healing --
- The emergence of a strongly changed sense of wholeness related to an epiphany or existential moment that transcends the previously known self following an existential struggle or profound suffering.
- Disintegrative healing --
- A decline in one’s condition or situation that is recognizable and troubling with wavering but failing
efforts to recover the former self following an existential struggle or profound suffering.
The theoretical basis of the four core elements of the PATS method are addressed at fair length [p. 71-72].
The Presence element is explained largely through the work of the nursing theorist Rosemarie Rizzo Parse [--see Related Items of Interest, §III, below], whose book, Illuminations: The Human Becoming Theory in Practice and Research (1995), "contends that true presence is a special way of being with the other that recognizes that the other’s values and priorities are what are most important" [p. 71].
To accomplish true presence, Parse…says that the nurse (provider) must center with the universe, prepare and approach the other, and attend intensely to the meaning of the moment being lived by that person. She believes that true presence is an invitation for the person to explore the depths of ideas, issues, or events in the way that he or she chooses. The process of being present focuses on the person’s thoughts and feelings about people, ideas, objects, or events in the moment of coming together with the nurse.... "The nurse takes what the person...says or does as the meaning of the situation and moves with the person...without judging, labeling, or specifying a nurse-generated change…." [p. 71]
Regarding the Active Listening element, Tuck and her colleagues say:
The human spirit is something sacred, to be respected and honored, and when the nurse listens sincerely, he or she affirms this fact. When listening to a patient, the nurse pays attention not only to the patient’s words but also to his or her voice tone and body language. The nurse strives to enter the patient’s world while listening with the eyes, heart, and spirit as well as mind and ears. [p. 71]
The Touch element is divided in to "contact" (skin-to-skin), and "non-contact" (eye contact or facial expressions). The emphasis here is on forms that would be considered "caring touch":
The outcomes of caring touch have been identified as comfort, security, enhancement of self-esteem, and reality orientation and also include creating a connection with the patient. Caring touch has primarily communicative functions. A nurse may gain permission to enter a patient’s personal space first by talking and then by talking and touching. Caring touch communicates acceptance of the patient as a unique person…. [p. 71]
Finally, the Sacred Story element, is "the essential feature of the intervention" [p. 71]. "PATS uses a qualitative narrative approach that fosters the sense of the sacred to solicit the participant’s stories" [p. 72]. Among the authors' comments here:
Stories provide a method for organizing and shaping human experience and thought. …Storytelling promotes spiritual well-being and allows the translation of distress into language that ultimately allows us to forget or to move beyond the experience…. …[I]t is a mechanism for achieving connectedness and intimacy. …[T]he act of storytelling itself becomes a spiritual intervention with possible healing effects even when a prognosis for physical recovery is poor. [p. 72]
Chaplains should recognize these elements in their own practice of engaging patients, though the nursing theory basis does present a somewhat different perspective (and language) than is usually found in pastoral circles. The article would seem to offer a productive meeting point for discussion between nurses and chaplains, and chaplain researchers may wish to consider how the methodology could be used or developed to describe pastoral encounters.
Suggestions for the Use of the Article for Discussion in CPE:
The nature of this article suggests the potential for discussion with one or more invited guests from Nursing, especially if a CPE program has access to nursing professors. Students could attempt to explain the PATS elements [--see esp. pp. 71-72] in their own words and begin to muse about potential differences and similarities between their pastoral perspective and a nursing perspective, even if only in the language they would use. Also, what do students think about the four "categories of healing" [p. 77, and Table 1 on p. 72]? Are these possibly useful to chaplains? The synopses of the study participants' stories [pp. 75-76] are rich descriptions in and of themselves for discussion. Do students agree with the "categories of healing" assigned to them by the researchers [--see p. 77]? Finally, students might want to look closely at the researchers' difficulty in conducting the interviews with patients, contending with interruptions and other practical impediments to concentrated interaction with patients [--see p. 74]. These difficulties speak to the challenges not only of research but of pastoral visitation.
Related Items of Interest:
I. Our featured study begins with a reference to a 2010 article on "Archetypal trajectories..." by Scott A. Murray, et al. The Research Network has previously noted this and other work of Professor Murray. See:
Murray, S. A. "Spiritual support in palliative care." Triple Helix (Easter 2009): 8-9. [This is a brief, popular article offering an overview of some of the author's research into trajectories. It is available freely online from the Christian Medical Fellowship (UK).]
Murray, S. A., Kendall, M., Boyd, K., Grant, L., Highet, G. and Sheikh, A. [Centre for Population Health Sciences, University of Edinburgh, Scotland]. "Archetypal trajectories of social, psychological, and spiritual wellbeing and distress in family care givers of patients with lung cancer: secondary analysis of serial qualitative interviews." BMJ [British Medical Journal] 340 (2010): c2581 [online journal]. [(Abstract:) OBJECTIVE: To assess if family care givers of patients with lung cancer experience the patterns of social, psychological, and spiritual wellbeing and distress typical of the patient, from diagnosis to death. DESIGN: Secondary analysis of serial qualitative interviews carried out every three months for up to a year or to bereavement. SETTING: South east Scotland. PARTICIPANTS: 19 patients with lung cancer and their 19 family carers, totaling 88 interviews (42 with patients and 46 with carers). RESULTS: Carers followed clear patterns of social, psychological, and spiritual wellbeing and distress that mirrored the experiences of those for whom they were caring, with some carers also experiencing deterioration in physical health that impacted on their ability to care. Psychological and spiritual distress were particularly dynamic and commonly experienced. In addition to the "Why us?" response, witnessing suffering triggered personal reflections in carers on the meaning and purpose of life. Certain key time points in the illness tended to be particularly problematic for both carers and patients: at diagnosis, at home after initial treatment, at recurrence, and during the terminal stage. CONCLUSIONS: Family carers witness and share much of the illness experience of the dying patient. The multidimensional experience of distress suffered by patients with lung cancer was reflected in the suffering of their carers in the social, psychological, and spiritual domains, with psychological and spiritual distress being most pronounced. Carers may need to be supported throughout the period of illness not just in the terminal phase and during bereavement, as currently tends to be the case.]
Murray, S. A., Kendall, M., Grant, E., Boyd, K., Barclay, S. and Sheikh, A. "Patterns of social, psychological, and spiritual decline toward the end of life in lung cancer and heart failure." Journal of Pain and Symptom Management 34, no. 4 (October 2007): 393-402. [(Abstract:) Typical trajectories of physical decline have been described for people with end-stage disease. It is possible that social, psychological, and spiritual levels of distress may also follow characteristic patterns. We sought to identify and compare changes in the psychological, social, and spiritual needs of people with end-stage disease during their last year of life by synthesizing data from two longitudinal, qualitative, in-depth interview studies investigating the experiences and needs of people with advanced illnesses. The subjects were 48 patients with advanced lung cancer (n=24) and heart failure (n=24) who gave a total of 112 in-depth interviews. Data were analyzed within individual case studies and then cross-sectionally according to the stage of physical illness. Characteristic social, psychological, and spiritual end-of-life trajectories were discernible. In lung cancer, the social trajectory mirrored physical decline, while psychological and spiritual well-being decreased together at four key transitions: diagnosis, discharge after treatment, disease progression, and the terminal stage. In advanced heart failure, social and psychological decline both tended to track the physical decline, while spiritual distress exhibited background fluctuations. Holistic end-of-life care needs to encompass all these dimensions. An appreciation of common patterns of social, psychological, and spiritual well-being may assist clinicians as they discuss the likely course of events with patients and carers and try to minimize distress as the disease progresses.]
II. For a sample of Inez Tuck's other work, see:
Baliko, B. and Tuck, I. "Perceptions of survivors of loss by homicide: opportunities for nursing practice." Journal of Psychosocial Nursing & Mental Health Services 46, no. 5 (May 2008): 26-34. [(Abstract:) Ten adult family members of homicide victims were recruited to participate in interviews describing their experiences related to the loss of their loved ones. A phenomenological approach was used to guide data collection and analysis, resulting in the identification of four major themes. Participants described intense emotional responses and grief complicated by the suddenness, violence, and intentionality of the homicide; engagement in activities that both buffered the emotional effects of the loss and helped them purposefully integrate it into their lives; the strengthening and dissolution of relationships; and a transformative, perpetually evolving post-homicide experience that was viewed as "healing" and that was influenced by many factors. Implications of these findings for research and nursing practice are discussed.]
McCain, N. L., Gray, P. D., Elswick, R. K. Jr., Robins, J. W., Tuck, I., Walter, J. M., Rausch, S. M. and Ketchum, J. M. "A randomized clinical trial of alternative stress management interventions in persons with HIV infection." Journal of Consulting & Clinical Psychology 76, no. 3 (June 2008): 431-441. [(Abstract:) Research in psychoneuroimmunology suggests that immunosuppression associated with perceived stress may contribute to disease progression in persons with HIV infection. While stress management interventions may enhance immune function, few alternative approaches have yet been tested. This randomized clinical trial was conducted to test effects of three 10-week stress management approaches-cognitive-behavioral relaxation training (RLXN), focused tai chi training (TCHI), and spiritual growth groups (SPRT)-in comparison to a wait-listed control group (CTRL) among 252 individuals with HIV infection. Using repeated measures mixed modeling, the authors found that in comparison to the CTRL group, (a) both the RLXN and TCHI groups used less emotion-focused coping, and (b) all treatment groups had augmented lymphocyte proliferative function. Despite modest effects of the interventions on psychosocial functioning, robust findings of improved immune function have important clinical implications, particularly for persons with immune-mediated illnesses.]
Tuck, I. "A critical review of a spirituality intervention." Western Journal of Nursing Research (2012): online ahead of print from the journal website, as of February 6, 2012. [(Abstract:) Although there is a growing interest in the topic of spirituality, there are few reports of spiritual interventions and limited empirical data to support their effectiveness. As health care practices become increasingly evidence based, the reliance on empirical data is critical. This article describes the spiritual intervention developed by the author and documents the testing of its effectiveness with clinical and nonclinical populations. The findings from a series of studies have been mixed. Preliminary studies reported that the intervention positively influenced patients’ outcomes, including overall quality of life and reduced selected stress responses. Significant positive trends were found that supported the potential effectiveness of the intervention for a variety of populations and clinical settings. However, subsequent testing in clinical trials indicated limited effect of the intervention although there were several noteworthy findings. The author discusses the implications of these findings for future investigations.]
Tuck, I. "Development of a spirituality intervention to promote healing." Journal of Theory Construction & Testing 8, no. 2 (Fall 2004): 67-71. [(Abstract:) Although there are a number of studies published on the topic of spirituality, few include a spiritual intervention. The literature is replete with descriptive studies often relating the presence or absence of spirituality with other study variables including healing. While a limited number of spiritual interventions are described in the literature, little is reported regarding their development. The article describes existing spiritual interventions and in greater depth the conceptual development of the group of intervention designed by this author. SPIRIT© is based on the theoretical and empirical literature on the topic of spirituality, the review of research findings related to existing spirituality interventions, and knowledge of principles of group process from the author's practice. The author describes the potential use of this spiritual intervention as a healing approach.]
Tuck, I., Alleyne, R. and Thinganjana, W. "Spirituality and stress management in healthy adults." Journal of Holistic Nursing 24, no. 4 (December 2006): 245-253. [(Abstract:) The purposes of this longitudinal, descriptive pilot study were to (a) test the acceptability and feasibility of a 6-week spiritual intervention; (b) determine the relationship between spirituality and stress; (c) explore the effects of the intervention on measures of perceived stress, spiritual perspective, and spiritual well-being; and (d) explore the meaning of spirituality. The sample consisted of 27 community-dwelling adults. Six categories emerged from the qualitative data as descriptors of the meaning and significance of spirituality. The survey data indicated that there were significant negative correlations between perceived stress and spiritual well-being at three time intervals, a significant decline in the levels of perceived stress, and a significant increase in spiritual perspective from the pretest to the 6-week follow-up. There were no significant changes in spiritual well-being. The intervention proved effective in reducing stress in this healthy adult sample.]
Tuck, I., McCain, N. L. and Elswick, R. K. Jr.
"Spirituality and psychosocial factors in persons living with HIV." Journal of Advanced Nursing 33, no. 6 (March 2001): 776-783. [(Abstract:) Spirituality and psychosocial factors in persons living with HIV: Aim of the study. This pilot study was designed to examine the relationships among spirituality and psychosocial factors in a sample of 52 adult males living with human immunodeficiency virus (HIV) disease and to determine the most reliable spirituality measure for a proposed longitudinal study. Background. HIV disease is among the most devastating of illnesses, having multiple and profound effects upon all aspects of the biopsychosocial and spiritual being. Although research has suggested relationships among various psychosocial and spiritual factors, symptomatology and physical health, much more research is needed to document their potential influences on immune function, as well as health status, disease progression, and quality of life among persons with HIV disease. Methods. This descriptive correlational study explored the relationships of spirituality and psychosocial measures. Spirituality was measured in terms of spiritual perspective, well-being and health using three tools: the Spiritual Perspective Scale, the Spiritual Well-Being Scale, and the Spiritual Health Inventory. Five psychosocial instruments were used to measure aspects of stress and coping: the Mishel Uncertainty in Illness Scale, Dealing with Illness Scale, Social Provisions Scale, Impact of Events Scale, and Functional Assessment of HIV Infection Scale. The sample was recruited as part of an ongoing funded study. The procedures from the larger study were well-defined and followed in this pilot study. Correlational analyses were done to determine the relationship between spirituality and the psychosocial measures. Findings. The findings indicate that spirituality as measured by the existential well-being (EWB) subscale of the Spiritual Well-Being Scale was positively related to quality of life, social support, effective coping strategies and negatively related to perceived stress, uncertainty, psychological distress and emotional-focused coping. The other spirituality measures had less significant or non significant relationships with the psychological measures. Conclusions. The study findings support the inclusion of spirituality as a variable for consideration when examining the psychosocial factors and the quality of life of persons living with HIV disease. The spiritual measure that best captures these relationships is the EWB subscale of the Spiritual Well-Being Scale.]
Tuck, I. and Thinganjana, W. "An exploration of the meaning of spirituality voiced by persons living with HIV disease and healthy adults." Issues Mental Health Nursing 28, no. 2 (February 2007): 151-166. [(Abstract:) Spirituality has been documented in several studies as having a positive effect on chronic disease progression and as being efficacious in improving quality of life and well being. In many studies, researchers have used predetermined definitions of spirituality and have proscribed the variable by the selection of measures. This study examines the meaning of spirituality as voiced by participants in two ongoing intervention studies, a sample of healthy adults and a sample of persons living with HIV disease. The findings resulted in six themes for each sample. Exhaustive statements were written depicting the summary relationships of themes. The findings support spirituality as an essential human dimension.]
Tuck, I., Wallace, D. and Pullen, L. "Spirituality and spiritual care provided by parish nurses." Western Journal of Nursing Research 23, no. 5 (August 2001): 441-453. [(Abstract:) The high level of religious participation in the United States provides a venue for parish nursing, a holistic nursing specialty that emphasizes the relationship between spirituality and health. This descriptive study measured two aspects of spirituality (spiritual perspective and spiritual well-being) in a national sample of parish nurses and described variables related to their practice. Furthermore, it qualitatively examined the provision of spiritual care to clients in this parish nurse sample. Parish nurses scored high in spiritual perspective and spiritual well-being and reported an emphasis on health promotion and education in their activities. Three views of spiritual interventions (ideal, general, and specific) were reported. Types of spiritual interventions typically fell into one of four categories: religious, interactional, relational, and professional.]
III. For more on Rosemarie Rizzo Parse's nursing theory, see the International Consortium of Parse Scholars. Presence is an important and often broadly implicit concept in Parse's theory of "Humanbecoming" (often written as one word).