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November 2008 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Witte, A. S.. van der Wal, D. M. and Steyn, H. C. "Mystical experience in the context of health care." Journal of Holistic Nursing 26, no. 2 (June 2008): 84-92.


SUMMARY and COMMENT: This month's study is of interest not just for its findings but for its perspective. It was "designed to explore mystical experience in the context of health care," [p. 84] --mystical experience being defined as a "subjective experience of transcendent phenomena that are apprehended directly in human consciousness and that are not mediated by normal cognitive or sensory perceptual faculties" [p. 85]. The researchers focus on "understanding and describing [emphasis added] mystical phenomena" [p. 84] rather than pathologizing or explaining away such phenomena, and they emphasize the importance of encouraging patients to share their experience and of supporting patients spirituality.

Interviews were conducted with 18 participants from two small hospitals and their surrounding rural Appalachian community. Inclusion criteria involved the question: "Have you ever had a mystical experience or unusual spiritual experience at a time of physical or mental stress or when you were receiving health care?" [pp. 85-86]. Of 48 hospital patients originally approached, 12 (25%) reported having had a mystical experience in the context of health care, though all participants marked their experiences from past treatments. "None of the participants reported a recent mystical experience, but three participants reported that their experiences were ongoing" [p. 87].

Participants described occurrences that were multifaceted and complex. They included interaction with the paranormal and the supernatural, visits to Heaven and Hell, interaction with living and dead family members, precognition, and incompletely described "spiritual feelings." Half of the participants used imagery reflecting a Christian orientation. The other participants described occurrences which were not associated with a particular faith tradition. [p. 87]
The authors discuss the meaning of the lived experience of such mystical phenomena [--see pp. 88-90] in terms of "[c]ommonalities in occurrence, maturation, and integration" [p. 88] that emerged in the interviews.
Most commonly, occurrence involved interaction with the supernatural and vivid sensory motor perceptions. Interaction with family members and emotional intensity were also prominent. Accompanying these were dynamic tension, a conviction of reality, and elements of cognition. ...[I]n this study, mystical experience is seen as a developing process which extends beyond the initial occurrence of the experience. Mystical experience goes through a maturation that is not time-limited, and the experience is ultimately incorporated into the individual’s life-world. This is not strictly linear but is a many-layered and complex process. ...Maturation incorporates processing, living with the experience, and sharing the story. ...The process of mystical experience culminates in integration into the participant’s life-world—affecting spiritual perspective, attitudes, and interactions with others. ...Participants described their mystical experiences as having profound impact on their lives. They reported developing self-confidence, better coping abilities, and appreciation of the spiritual. [pp. 89-90]
Points are illustrated by quotes from the participants. The analysis of the interviews is represented in a concept map [--see p. 88], which initially struck this reader as overwhelmingly labyrinthine and confusing in and of itself, but which does in fact show relationships between the many elements of the analysis.

The authors argue for nurses to support patients who share extraordinary experiences and, in making spiritual assessments, "incorporate understandable language, such as the phrase 'unusual spiritual experiences'" [p. 91]. It is significant, however, that referral to pastoral caregivers is recommended as a "secondary intervention" after nursing support, only upon validating that referral with the patient [--see p. 91].

It might seem that a pastoral referral would be indicated for individuals who express spiritual concerns, but this is not necessarily so. Several of the participants related experiences which they were unable to share with a pastoral caregiver but which they did share with the nurse researcher conducting the interviews. The nurse should attempt to listen first and to validate acceptability of pastoral care before suggesting pastoral referral. [p. 90]
One assertion made about nursing's support of patients may be contested by chaplains. The authors claim that the interventions of support and listening "do not require specialized expertise" [p. 91]. It would seem that the complexity of listening skills and supportive strategies is underestimated here --which should be apparent to chaplains, who spend a great deal of time in Clinical Pastoral Education exploring the subtleties and challenges of listening to and supporting patients in ways that truly follow the patient's lead. Nevertheless, it is conceivable that some nurses may more naturally capable than some pastoral caregivers in terms of listening and support, and that may be borne out by evidence from the interviews (cited above).

A final point: the study included observations from the nurse researcher who conducted the interviews, regarding the effect of sharing a patient's expression of mystical experience:

The responses of the nurse conducting the interviews included tension, a feeling of intimacy and empathy, and a sense of awe. Her reflective journal entries showed increasing awareness of the mystical. Ordinary activities seemed suffused by light and meaning. She developed increasing appreciation of mystical experience in everyday life, not only for the participants but also for herself. The participants’ experiences came to represent a manifestation of the rich complexity and reality of mystical experience in everyday life.... [p. 90]
This certainly suggests the potential for research in focusing not just on the patient but on caregivers and even researchers themselves.


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

This article would be an excellent one to discuss with nurses as guests to the CPE group. Nurses who use NANDA (North American Nursing Diagnosis Association) diagnoses, such as Readiness for Enhanced Spiritual Well-Being [--see pp. 84 and 90] would be particularly well-suited invitees. Actually, NANDA diagnoses may be an intriguing tangent for conversation [--see Related Items of Interest, III (below)]. One main line of discussion could focus on the potential role of skepticism in the process of supporting patients who report extraordinary experiences, in light of both the study's methodological approach (out of Husserl --see p. 85) and practical experience. Students could also be challenged to take seriously the finding that some participants in the study were apparently more open to sharing their experiences with nurses than with pastoral caregivers. In addition, students could explore how they are personally affected when they hear patients talk about mystical experiences, in comparison to how the interviewer was affected in the research.


Related Items of Interest:

I. Articles about spiritual encounters with "angels" and deceased relatives:

Arslanian-Engoren, C. and Scott, L. D. "The lived experience of survivors of prolonged mechanical ventilation: a phenomenological study." Heart and Lung: Journal of Acute and Critical Care 32, no. 5 (September-October 2003): 328-334. [In this small, qualitative study out of the University of Michigan School of Nursing, seven survivors of long-term mechanical ventilation were interviewed. All seven indicated that they derived reassurance from angelic encounters: "[s]eeing visions of 'angels' and receiving guidance and encouragement from 'deceased relatives'" (p. 332). This study was highlighted as our July 2004 Article-of-the-Month.]

Aylor, A. L. and Grimes, G. C. "End-of-life review." American Journal of Hospice and Palliative Medicine 25, no. 3 (June-July 2008): 233-36. [Among the findings of this study exploring the use of the term end-of-life review by hospice representatives from Texas and New Mexico Hospice organizations was that the term reflects hospice workers' familiarity with patients who indicated that they were being visited by "spirits (angels and God) reassuring and preparing them for the next life," being visited by "deceased friends and family members," and "[s]peaking aloud to departed friends and family members" (p. 234).]

Hufford, D. J. "Visionary spiritual experiences and cognitive aspects of spiritual transformation." The Global Spiral 9, no. 5 (September 2008): [This recent article in the online journal from the Metanexus Institute is by David J. Hufford, PhD, Penn State University Professor Emeritus and former Director of the Doctors Kienle Center for Humanistic Medicine at Penn State. Hufford addresses such phenomena as "visits" from deceased relatives, near-death experiences, and spiritual presences, examining research and academic debate on the subjects. Research indicates that such experiences are much more common than is often assumed.]

II. Near Death Experiences are obviously pertinent to the subject of extraordinary mystical phenomena for many patients. The subject was featured in our May 2006 Article-of-the-Month, which has been updated to include a number of recent articles.

III. The NANDA diagnostic classification of Readiness for Enhanced Spiritual Well-Being was adopted at North American Nursing Diagnosis Association annual meeting in 2002. The point person for the approval of the diagnosis was Lisa Burkhart (who is now an Assistant Professor at Loyola University, Chicago). For some background to this diagnosis, see the following by Burkhart:

Burkhart, L. "Report from the Spirituality and Religiousness Diagnosis Working Group." Nursing Diagnosis 12, no. 2 (April-June 2001): 61-62.

Burkhart, L. and Solari-Twadell, A. " Spirituality and religiousness: differentiating the diagnoses through a review of the nursing literature." Nursing Diagnosis (April-June 2001): 45-54.

NOTE: The diagnosis of Readiness for Enhanced Spiritual Well-Being is marked by the "ability to experience and integrate meaning and purpose in life through a person's connectedness with self, others art, music, literature, nature, or a power greater than oneself" [Nursing Diagnosis 13, no. 2 (April-June 2002): 68], and its defining characteristics are given as:

  • Connections to self
  • Desire for enhanced hope
  • Meaning and purpose in life
  • Peace / serenity acceptance
  • Surrender love
  • Forgiveness of self
  • Satisfying philosophy of life
  • Joy
  • Courage
  • Heightened coping
  • Meditation
  • Connections with others
  • Provides service to others
  • Requests interactions with spiritual leaders
  • Requests forgiveness of others
  • Requests interactions with friends, family
  • Connections with art, music, literature, nature
  • Displays creative energy (e.g., writing, poetry)
  • Sings / listens to music
  • Reads spiritual literature
  • Spends time outdoors
  • Connections with power greater then oneself
  • Prays
  • Reports mystical experiences
  • Participates in religious activities
  • Expresses reverence, awe
For more, NANDA International ( produces a number of resources, such as: Herdman, T. H., ed., Nursing Diagnoses: Definitions and Classifications, 2009-2011 (Oxford: Wiley-Blackwell, 2008).

[Lisa Burkhart has also recently published: Burkhart, L. and Hogan, N., "An experiential theory of spiritual care in nursing practice," Qualitative Health Research 18, no. 7 (July 2008): 928-938. This article does not address mystical experience or the NANDA diagnosis for Readiness for Enhanced Spiritual Well-Being, but it presents focus group research that offers insight into the process and experience of nurses offering spiritual care.]


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