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A Philosophical Analysis of Spiritual Coping

Dunn, Karen S. PhD, RN, FGSA; Robinson-Lane, Sheria G. PhD, RN

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doi: 10.1097/ANS.0000000000000323
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Abstract

THE DISCIPLINE of nursing has embraced the spiritual wellness of humanity as an essential component of holistic nursing practice and in the provision of both patient-centered and culturally responsive care.1–3 Although the meaning of spirituality has varied over time by cultural group and value system, its elemental definition has remained the same—the essential connections that provide meaning and purpose in life. Unlike religiosity, or the beliefs one practices that aligns with a religious or philosophical framework, spirituality necessitates no doctrine and has been recognized as an important quality-of-life indicator alongside other concepts such as autonomy, dignity, meaningful activities, and social relationships.4–6 For many patient populations however, health-related behaviors, such as dietary intake, medical treatment choices, disease management, and communication about health, have been linked to specific religious beliefs.7–10 Therefore, it stands to reason that spirituality, of which religion may be a component, can affect health outcomes. As an emergent area of research, scholars have begun to examine how spiritual coping strategies either positively or negatively influence the well-being of individuals. Evidence suggests that spiritual coping is a major mechanism of how spirituality is significantly associated with health.11–13 Still, questions remain regarding the scientific study of spirituality, and its relationship to health.14–16 Baldacchino and Draper17 defined spiritual coping as a response to illness and/or stressful situations that allow humans to find meaning and purpose in life, which results in an increased adaptive response. The authors argue that spiritual coping may engage religious and/or nonreligious strategies. While religious strategies, such as prayer, are derived from organized religions and are generally predicated upon the belief in a supreme being, or higher power, nonreligious strategies, such as self-reflection and social engagement for support and security, are equally important. Interestingly, older adults have historically been found to report using more religious coping strategies to help them deal with stress related to chronic illnesses, chronic pain, multiple losses, and normal aging-related changes. Generational or cohort differences in religious practices and beliefs have been cited as an explanation for why older adults use religious coping strategies more often than younger adults.18 Provided the inclination of older adults to engage in more religiously focused coping strategies, the operational definition of spiritual coping used in this analysis was taken from a concept analysis conducted by Cabaço and associates; it is a “set of spiritual rituals or practices, based on relation with God, Transcendent, and others, used by individuals in order to control and overcome stressful, illness, and suffering situations.”11(p162) The purpose of this philosophical analysis was to examine the relevance of spiritual coping to nursing science.

Statements of Significance

What is known and assumed to be true about this topic:

We recognize the study of spiritual coping as an emergent area of research where scholars have begun to examine how the use of spiritual coping can either positively or negatively influence the well-being of individuals. Still, scholars question the rigor and scientific study of spirituality and/or religiosity, and its relationship to health. We believe the continued development of science in nursing is con-tingent upon the careful philosophical analyses of complex concepts and their relevancy to the discipline. We chose to review research literature within the older adult population because they have historically been found to report using more religious coping strategies to help them deal with stress related to chronic illnesses, chronic pain, multiple losses, and normal aging-related changes.

What the article adds:

We found 3 recurrent themes within the research literature—international phenomenon that generates holistic well-being, resilience development, progression toward self-transcendence, and maladaptation. These themes were found to be in congruence with all 3 postmodern philosophy of science perspectives: postpositivist, interpretive, humanistic, or naturalistic, and critical or emancipatory. Metanarrative examination of the themes revealed spiritual coping is relevant to the holistic practice of nursing and multiple nursing theory perspectives.

ADVANCING NURSING SCIENCE THROUGH PHILOSOPHICAL ANALYSES

One of the hallmarks of disciplinary distinction is the presence of an identifiable philosophy, or lens for understanding the world. Nursing science is concerned with the ways in which humans experience health within the context of their environment and relationships to others, or as nursing theorist Rosemarie Rizzo Parse noted—the human-universe-health process.19 Advancing nursing knowledge, therefore, requires philosophical inquiry or topical evaluations using critical discussion to identify how complex concepts, such as spiritual coping, relate to nursing and may be studied further within the discipline. The philosophical analysis method outlined by Whall and associates20 provided the guidelines of this scientific inquiry into the relevance of spiritual coping to nursing. This method provides an examination of concepts of interest that have “metaphysical” questions that are difficult to answer with the usual scientific means.20,21 Whall and colleagues20 utilized a 3-step process that included: (1) a review of the research literature to identify recurring themes, (2) placement of selected themes into 3 postmodern philosophical approaches, and (3) a metanarrative examination. The following analysis examined spiritual coping within the context of postmodern philosophical approaches.

A BRIEF OVERVIEW OF POSTMODERNISM

According to Jacox et al,22 the 3 philosophical approaches in contemporary science are (1) postpositivist, (2) interpretive, humanistic, or naturalistic, and (3) critical or emancipatory. An adequate philosophical analysis requires the examination of the concept of interest, in this case spiritual coping, and how it may be studied within each of the 3 philosophical approaches.

The most dominant approach is postpositivist where the aims of science are to identify patterns and irregularities to describe, explain, and predict phenomenon. Findings are viewed as imperfect and probabilistic, the context of conditions where patterns are observed, are important, and environmental influences are controlled and understood. Research methods that are most acceptable for this approach are generally quantitative. The interpretive, humanistic, or naturalistic approach employs hermeneutic and dialectic methods to describe and explain phenomena from individual experiences within various environments. Theory building within this perspective is often inductive in nature, and research methods are typically qualitative. Finally, the critical or emancipatory approach encompasses (a) critical theory, (b) feminist research, (c) community-based participatory research, (d) action research, and (e) poststructuralists' investigations. These methods hold the same basic aims: reveal historical, structural, and cultural biases to seek emancipatory change for the participants and/or groups they represent as a part of the research process. The focus of research must also be on the structures or systems that prevent individuals and families from making changes. Researchers utilizing this approach can obtain data using quantitative, qualitative, or mixed-method designs.22,23

In the 1960s however, the discipline of nursing began to shift its philosophical approach from logical positivism/empiricism toward a more interpretive, postmodern, critical social theory, and feministic perspective. Nursing science within this postmodern perspective focused on holistic patient-centered care and the recognition of how the unique contributions of gender, culture, social status, and other human characteristics and experiences influence the ways in which humans interact with their internal and external environments to achieve optimal health. The inclusion of the role of culture and social context into disciplinary knowledge development required nurse scientists to begin using differing methods of scientific inquiry, thus adopting a more pluralistic philosophical approach.24

METHODS

Full-text, English, peer-reviewed articles published between 2014 and 2019 were reviewed following a general database search in CINAHL, PubMed (Medline), and PsycInfo using these key terms: religious coping, religious practices, religious beliefs, spiritual coping, spiritual well-being, spirituality, and older adults. Articles were selected that included participants at least 55 years of age. After evaluating 160 articles for topical relevance, we identified 24 articles to be included in the final review of the research literature. Content analyses of each article for key concepts and findings were then completed separately by the authors and documented in tables. Once all the tables were completed, comparative analyses of the recurrent key concepts and findings were done. The authors selected 3 recurrent themes of philosophical importance that emerged from the content analysis: (1) enhances physical, psychological, and social well-being, (2) promotes resilience, and (3) fosters self-transcendence. Literature supporting the 3 recurrent themes has been presented next.

Enhances physical, psychological, and social well-being

The first recurrent theme identified in the reviewed literature was that spiritual coping, when used to help deal with illnesses and/or stress, has been found to enhance physical, psychological, and social well-being among older adults across the globe. Whitehead and Bergeman25 found in a sample of 267 older adults living in the United States that spiritual coping decreased stress levels and acted as a buffer to improve glycemic and metabolic health. In a sample of 74 older adults living in the United States, McGowan and associates26 found that participants who reported higher levels of organized religiosity had lower levels of depressive symptoms than participants who reported lower levels of organized religiosity. Similarly, older adults living in Malta and Australia reported spiritual coping decreased their anxiety and depression.27 A secondary data analysis of the Wisconsin longitudinal study (n = 3146) by McDougle and colleagues28 revealed that older adult attendance at religious services was predictive of a lower mortality risk than those who attended religious services less often. A qualitative South African study (n = 16) found that older adults believed spiritual coping to be essential to health, well-being, and cured illnesses. Study participants also believed the mind and body were connected to God and their suffering, and that illness was viewed as a natural occurrence that could lead to purification and direct communing with God.29 Two-hundred community-dwelling older adults in Iran reported spiritual coping provided mental peace, improved mental health, and increased social functioning.30 Lee and Hwang31 reported that 246 Korean immigrants living in the United States attributed spiritual coping to vitality, energy, and mental health. Seventy-seven institutionalized older adults in Brazil who reported using positive spiritual coping had better overall quality of life (physical and psychological health, and environmental and social relationships).32 In a related study, 326 community-dwelling older adults in Brazil also reported a positive, significant association between the use of spiritual coping and quality of life.33 These findings provide evidence to support the theme that older adults across the globe use spiritual coping to maintain their physical, psychological, and social well-being.

Promotes resilience

The second identified recurrent theme was the ability of spiritual coping among older adults to promote resilience. Resilience, as defined by Van Kessel,34 is the ability to flourish while coping with adversity by using internal and external resources. Manning and colleagues35 interviewed 46 community-dwelling older adults and found that spiritual coping was vital to the management of hardships. Participants reported that spiritual belief structures that included specific values and practices were powerful tools and resources that promoted resilience and growth. Similarly, Stanko and associates,36 who interviewed 189 community-dwelling older adult victims of hurricane Katrina, found that belief in God, prayer, church attendance, and general reliance on faith communities were essential in dealing with multiple losses and devastation. A major theme cited by the Baldacchino and Draper37 qualitative study (n = 65) revealed that spiritual coping enhanced “self-empowerment through connections with self, others, nature, and God.”37(p843) For these participants, having a relationship with God was a means of support and strength that was manifested through prayer and church attendance. Conway-Phillips and Janusek38 studied the influence of (1) sense of coherence (having the confidence that life events are manageable, understandable, and have meaning), (2) social support (having at least one person nonjudgmentally listen to them), (3) spirituality (level of spiritual engagement), (4) health perceptions, and (5) motivation to perform breast cancer screening behaviors among 134 African American women and found higher levels of spirituality was a significant predictor of higher levels of motivation to perform breast cancer screening behaviors. A significant association between spirituality and a sense of coherence was also found; participants who reported increased levels of spiritual engagement also reported more confidence in managing, understanding, and finding meaning in life events. Finally, spiritual coping was found to be an essential strategy in the illness reframing processes used by older adults living with terminal cancer in Norway (n = 20)39 and Singapore (n = 81).31

Fosters self-transcendence

Finally, spiritual coping was described within the literature as an existential way to promote self-transcendence in late life. In Newman's Theory of Health and Expanding Consciousness,40 the transcendent nature of humanity is described as the ability of every person, whether in the state of health or illness, is a part of the universal process of expanding consciousness. This process allows people to develop and know who they are, find greater meaning in life, and achieve new dimensions of connectedness with others and the world. Parse41 conceptualized this process as co-transcending where emerging possibilities are lived rhythmical patterns that are limitless, free, liberating, and unexplainable in the Human Becoming Theory. According to Maslow,42 self-transcendence is the highest level of development that human beings can achieve by focusing on things that go beyond oneself (eg, becoming altruistic, having spiritual awakenings, and liberating oneself from egocentricity into a more unified being). Transcendence, as defined by Maslow, “is the very highest and most inclusive or holistic level of human consciousness, behaving and relating, as ends rather than means, to oneself, to significant others, to human beings in general, to other species, to nature, and to the cosmos.”42(p269)

Across 6 separate studies (n = 1794), older adults reported using spiritual coping strategies to (a) find meaning and purpose to their lives, (b) foster hope, and (c) go outside of the boundaries of what was happening to them physically, mentally, and socially amidst the suffering they were experiencing.30,33,37,39,43,44 Forty-six community-dwelling older adults in the United States reported that when dealing with adversity and hardships, religious beliefs and practices stimulated spiritual growth and transformation that led to a sense of well-being.35 Older adults in 3 studies (n = 1179) recognized religiosity as having sanctified, or legitimized, their lives as they searched for the divine in God, nature, friends, family, and religious communities.27,43,45 Finally, 599 older adult participants in 6 separate studies found religious beliefs helped them transcend and accept terminal illnesses, age-related changes, and multimorbidity by surrendering and trusting in God.29,31,37,39,46,47 In summary, characteristics of self-transcendence were reported in many of the articles reviewed as an outcome of spiritual coping.

Based on the review of the literature, it is apparent that spiritual coping is an internationally recognized phenomenon that is complex in nature. When considered within the context of aging, self-management of chronic disease, and/or adverse events, effective spiritual coping has been found to be generally beneficial in reducing negative biological and psychological outcomes such as depression, anxiety, and overall stress. The use of spiritual coping has also been found to increase social engagement and interactions that is indicative of a more positive quality of life. This seemingly moderating effect of spiritual coping also promotes resilience. Further, the feeling of connectedness, hope, purpose, meaning, and sanctification that individuals are able to experience as a result of their religious beliefs and practices also enables normal progression through older adult stages of growth and development, particularly reaching the level of self-transcendence and a greater sense of health and wellness.

Placement of themes within postmodern philosophy of science perspectives

The second step of this philosophical analysis is to identify linkages between the recurrent spiritual coping themes and 3 postmodern philosophy of science perspectives: (1) postpositivist, (2) interpretive, humanistic, or naturalistic, and (3) critical or emancipatory.

According to Newman et al,48 disciplinary knowledge can be developed from varying philosophical and scientific perspectives. Parse19 further noted that this discipline-specific knowledge, derived from varying schools of thought, may result in ontological, epistemological, and methodological processes that advance nursing science. The following evaluates the literature review findings from the postpositivist school of thought.

Postpositivist perspective

In the early 1990s, Newman et al48 described what we now refer to as the postpositivist philosophical approach in nursing. What the authors referenced as a “particulate-deterministic approach” allowed the phenomenon to be viewed as reducible entities that could be broken down into measurable parts. These measurable parts could then be linked to other phenomena where change was the result of antecedent conditions, which could be predicted and controlled. These relationships are viewed as linear and causal in nature. Only phenomena that are objective and observable in nature are studied within this approach.

Due to the seemingly intangible nature of the spirit, spirituality, and subsequently spiritual coping, it could be presumed that measurement would be infeasible. In fact, very few studies included within this review of literature objectively evaluated spiritual coping—although validated measures of spiritual coping exist.49 Most of the studies included within the analysis relied upon participant self-report rather than more objective measures of assessment. However, a clear recurrent theme that emerged from the review of literature was the positive effect of spiritual coping on physical, psychological, and social well-being. While some attributes of spiritual coping, such as church attendance, perhaps could be verified independently, measuring engagement with religious services, or how the use of prayer, meditation, or other religious rituals significantly affected health outcomes, was virtually nonexistent within the reviewed literature. Like many areas of nursing study, the variability involved in studying human experience can make prediction challenging; yet, scientists in a variety of disciplines have been able to successfully use postpositivist approaches to develop predictive models that explain the relationship between spiritual coping and particular psychosocial health outcomes.25,27,31,43,46,50–52 There is a significant opportunity for nurse scientists to use postpositivist methodologies to explain and predict the relationships between quality of life, health outcomes, and the use of spiritual coping strategies—particularly within older adult populations. Advancement of nursing science in this area has the highest potential for the development of new therapeutic practice approaches, standardized spiritual coping assessments, and the expansion of care models.

Interpretive, humanistic, or naturalistic perspective

The highly subjective nature of spiritual coping and the related concepts of quality of life and well-being make interpretive, humanistic, or naturalistic scientific approaches perhaps the most closely matched to current spiritual coping knowledge development in nursing science. This perspective, which has also been conceptualized as the simultaneity paradigm,19 is focused on the lived experiences of humans and asserts that reality is multidimensional and contextual—interrelationships are context dependent. Change is the result of multiple antecedents and probable relationships, which may be linear or reciprocal. Further, health here is a dynamic process rather than simply an outcome.

The theme, fostering of self-transcendence, fits well within this worldview. Four qualitative studies out of the 24 articles reviewed provided rich, lived experiences of how the use of spiritual coping provided a connection intrapersonally and interpersonally with God, family, friends, nature, and communities.37,39,43,45 Spiritual coping helped the older adults find purpose and meaning within their lives by reframing the suffering they were enduring. Beliefs in the afterlife and the ability to forgive and accept age-related changes, illnesses, and losses helped participants to transcend and adapt to the stressors that occur in later life. This sanctified view of life allowed the older adults to see God in all aspects of life including feeling and observing the sacred within themselves and others. Going outside the boundaries of quantitative methods by allowing participants to describe their own spiritual journeys can enhance nursing science, as these are natural, real-life stories that may be translated into evidence-based coping strategies that lead to positive health outcomes. Opportunities also exist within this perspective to use the study of spiritual coping to extend theories and conceptual models inclusive of health as the phenomena of interest. The final perspective considered as part of this analysis is the critical or emancipatory perspective.

Critical or emancipatory perspective

Within the critical or emancipatory worldview, human beings are unitary, evolving fields that are identified through patterns and interactions within a larger contextual whole. Change is unpredictable as systems move in stages from disorganization to more complex organization. Personal knowledge and pattern recognition are emphasized.53 According to Kagan et al,54 the emancipatory perspective is one that frees professional nursing from: (1) the dogma and constraints of powerful social and health care systems, (2) medical model and illness-cure frameworks that derive interventions from experiences with white, middle class, heterosexual, and patriarchs, and (3) society's misunderstanding and devaluing of nursing's disciplinary knowledge and expertise. Emancipation in this perspective views nursing science as critical, caring, and health promoting.

The use of spiritual coping among older adults to promote resilience can be viewed and studied within this postmodern perspective. Pesut and colleagues'55 discourse on the study of spirituality and religion suggest that nursing as a health care discipline must acknowledge the diverse perspectives of a global society that is inclusive of both Western and Eastern religious beliefs. Health care providers must not assume that, to be spiritually well, one must be free of pain and suffering indicative of Western beliefs. These authors postulated that by removing despair, anger, fear, and brokenness out of the spiritual aspect of the human suffering experience, one would lose the potential of growth, or in terms of this discussion, the promotion of resilience. Older adults reported using spiritual coping, as they struggled through hardships, hurricanes, and catastrophic events.35–37,39 These authors contend that without the struggle and a healthy spirit, resilience and/or growth would not occur. We believe that this is an area where nursing science is lacking and in need of growth. This shift in perspective from spiritual unwellness when individuals are suffering to having a healthy spirit when one is struggling to cope with hardships is not evident in the research literature. Further, the examination of spiritual coping from a critical or emancipatory perspective encourages the development of culturally responsive health care practices that integrate spirituality and the refinement of theoretical perspectives centered on persons and communities as units of care.

As evidenced by the preceding discussion, the study of spiritual coping may be examined from each postmodern philosophy of science perspective. Findings from the review of literature fit appropriately within each perspective and provide opportunities to further develop nursing practice and expand nursing theories. The final step of the philosophical analysis process, as outlined by Whall et al,20 is to provide an overarching interpretation of the concept of interest in ways that illuminate patterns and structures. This metanarrative examination further evidences the utility of concepts of interest to the discipline by outlining linkages to current nursing theories and conceptual models.

Metanarrative examination

According to Reed,56 nursing theoretical and conceptual models can be used as a method of interpreting metanarratives for nursing practice and knowledge development. Nursing conceptual models provide unified disciplinary perspectives and foundational philosophical assumptions that can evolve through nursing science and research evidence. The following metanarrative examines the concept of spiritual coping among older adults within the context of extant nursing theoretical and conceptual models. The nursing theoretical models selected for this metanarrative examination included: (1) the Roy Adaptation Model,57 (2) Neuman's Systems Model,58 (3) American Association of Critical-Care Nurses (AACN) Synergy Model for Patient Care,59 and (4) Reed's Theory of Self-Transcendence.60

Spiritual coping and well-being

The development of nursing knowledge began when Florence Nightingale61 wrote her worldview of what the role of nursing is and what it is not, and discussed the interconnections between the nature of humanity, disease, health, and the environment. From this landmark epistemology, nursing began an ontological journey to build the discipline with theory development and scientific inquiry. According to Fawcett,62 knowledge development in nursing must be guided by philosophical claims or paradigms regarding the nature of human beings and human-environmental relationships. One of the fundamental worldviews that has guided the development of nursing knowledge is the totality paradigm described by Parse.19 The primary philosophic claim of the totality paradigm is that humans are bio-psycho-social-spiritual beings in search of health by means of environmental manipulations.

Two conceptual models that have philosophical underpinnings derived from the totality paradigm are the Roy Adaptation Model (RAM)57 and Neuman's Systems Model.58 According to Roy,57 human beings are living systems made up of parts that have a common purpose related to their existence conceptualized as veritivity. Four underlying principles of veritivity are society driven and include (1) the purpose of human existence, (2) humanities' shared purpose, (3) creative actions toward a common good, and (4) the value and meaning of life. Human beings in this model share a common destiny and find purpose and meaning to their lives through reciprocal relationships with other people, the world, and God. Similarly, Neuman58 also views human beings as wholistic client systems composed of interdependent and interacting physiological-psychological-sociocultural-developmental-spiritual parts working dynamically together toward optimal wellness or highest level of system stability. Wellness in Neuman's view is achieved by taking into consideration the client system's perception of health, the nurse's perception of the client system's perception of health, the environment, and the client system's energy levels. Both the Roy and Neuman models include within their framework stimuli and/or stressors that evoke varying types of processes individuals need to adapt to in order to achieve system stability. Roy conceptualized the cognator and regulator subsystems as coping processes necessary for adaptation, while Neuman defines these processes as lines of defenses and resistance.

A recurrent theme that emerged from this analysis was that older adults across diverse cultures and locations reported using spiritual coping as a strategy to help them deal with various stressors. Further investigations found spiritual coping to be significantly associated with better physiological, psychological, and social health outcomes providing support for the philosophical underpinnings of the totality paradigm, the RAM, and Neuman's System Model. All conceptualize human beings as being comprised of bio-psycho-social-spiritual domains that strive for wholistic wellness. Further, each postulated that individuals have dynamic interactions with the environment to achieve well-being within the bio-psycho-social-spiritual domains. Therefore, the study of spiritual coping can easily be explored within Roy's and Neuman's nursing theoretical frameworks.

Spiritual coping and resilience

According to Walker and Avant,63 theory construction begins with clearly defined concepts that provide a distinct understanding of what is being described, explained, and/or predicted. The preceding review of literature described spiritual coping as an important means of resilience development. Interestingly, a concept analysis conducted by Gillespie et al64 found that self-efficacy, hope, and coping were defining attributes of resilience that could be engaged throughout the lifespan when dealing with hardships. An additional concept synthesis by Polk65 outlined the defining characteristics of resilience as patterns that are dispositional (physical and psychosocial factors), relational (roles and relationships), situational (cognitive appraisal skills, problem-solving ability, and capacity for action), and philosophical (personal beliefs in finding positive meanings in experiences). Polk further related these patterns to the simultaneity paradigm19 that posited human beings as more than and different from the sum of their parts, which are ever changing with the environment toward increasing complexity.

Resilience promotion has been identified as an important aspect of nursing care for many years. In fact, since 1996, the AACN Synergy Model for Patient Care has identified patient and family characteristics that drive the competencies nurses bring to the bedside.59 A major assumption of this model is the congruence between nurses' competencies and patient care needs that allow for the co-creation of synergy and fostering of optimal practice outcomes. Within this model, resilience has been conceptualized as one of 8 patient characteristics and has been defined as the individual's ability to return to a restorative level of functioning using compensatory or coping mechanisms. Restorative levels were operationalized as (1) minimal (unable to respond to compensatory/coping mech-anisms), (3) moderate (able to somewhat respond to compensatory/coping mechanisms), and (5) high (able to use intact compensatory/coping mechanisms). In 2006, Smith53 applied the AACN Synergy Model to spiritual care practices and identified that making appropriate spiritual care referrals and providing space and time for group and/or individual religious rituals and spiritual practices were important for effective coping that supported resiliency.

As reported in the research literature, the use of spiritual coping to deal with hardships has been found to promote resilience in older adult populations. Spiritual coping provided a mechanism older adults utilized to reframe hardships from multiple losses and devastation into more manageable experiences. The ability for nurses to reframe patient suffering into more meaningful and manageable levels is essential to this practice discipline. In addition, having awareness of resilient characteristics across all patient populations is vital to the discipline of nursing as conceptualized in the AACN Synergy Model. Nursing science may be expanded in this area by examining specific spiritual coping strategies and/or mechanisms that promote the growth and development of resilience in individuals and communities. Finally, intervention studies may be developed to determine the efficacy of specific spiritual coping strategies and build evidence-based nursing practice.

Fostering Self-transcendence

The final theme of self-transcendence as an outcome of religious/spiritual coping, and its relationships to holistic nursing practice, health, and healing, can be explained within the framework of Reed's Theory of Self-Transcendence.60 The transcendent outcomes of Reed's theory has 3 core concepts: (1) self-transcendence, (2) well-being, and (3) vulnerability. Self-transcendence is the intrapersonal ability to expand self-boundaries through self-acceptance and finding meaning in life, having the interpersonal capacity to connect with others, nature, and one's environment either upwardly (reaching out to a superior being or purpose) and temporally (integration of one's past and future into the present).66 Self-transcendence therefore is a characteristic of developmental maturity starting in adolescence through adulthood to the end of life where one becomes more aware of self-boundaries and dimensions greater than self. Well-being is defined as a sense of feeling whole and healthy that is congruent with one's own criteria for wholeness and health. Well-being is associated with positive health promotion experiences influenced by an individual's culture, values, and beliefs about health, and is an outcome of self-transcendence. Finally, vulnerability is defined as the awareness of one's personal mortality.66

In the case of older adult populations, many are vulnerable having to deal with multiple comorbidities, chronic pain, several losses, age-related changes, and the prospect of their own imminent death. Consistent with Reed's definition of self-transcendent, this thematic analysis found that reaching out to a superior being through prayer and religious ritualistic practices gave purpose and meaning to older adults and promoted feelings of connection and acceptance. Prayer is a multidimensional construct that can be categorized as a spiritual cognitive therapy (1) to reappraise or reevaluate stressful life events, (2) to minimize the negative effects of stress, and (3) to maintain optimum levels of health.67 Prayer can provide hope and a sense of universal connection with others, the environment, and religious deities, thus fostering self-transcendence. These connections and/or relationships can also be empirically tested to determine whether religious beliefs and practices are significantly associated with positive health outcomes.

CONCLUSIONS

The specific aim of this philosophical analysis was to present an argument for or against the relevance of spiritual coping to nursing science. The 3-step method used in this analysis provided a clear and logical method to address this specific aim and revealed the study of spiritual coping relevant to nursing science and important to holistic nursing practice. The 3 recurrent themes identified in the literature were found to share characteristics of all 3 postmodern philosophical approaches. These approaches can provide the philosophical diversity needed to develop comprehensive knowledge of the relationships between the use of spiritual coping and health outcomes. In addition, the 3 recurrent themes were also found to support concepts, propositions, and assumptions of many extant nursing theoretical and conceptual models that have been used to inform nursing practice. Since the writings of Nightingale, a core concept within the discipline of nursing has been to address how the spiritual nature of human beings influences health and well-being. Findings from this philosophical analysis support Nightingale's historical paradigm perspective.

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Keywords:

discipline; nursing; nursing knowledge; nursing models; nursing practice; paradigms; philosophy; spirituality; theoretical

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