Leadership

DIMENSION

Spirituality as a Coping
Mechanism
Jacinta Kelly

Spirituality as a coping mechanism can be observed to be a powerful resource in the

provision of comfort, peace, and resolution for patients confronted with critical ill-
ness. While the exact machinery of spirituality in adaptation and adjustment to ill-
ness is enigmatic, the complementary benefits are clearly illustrated in the analysis
of recounted personal experiences. Analysis of interactions with patients living the
experience of coping with critical illness provides nurses with a means of reflection
and transformational learning which improves and preserves the spiritual heritage
of nursing care. Key word: Spirituality. [DIMENS CRIT CARE NURS. 2004;23(04):162-168]

Espousing to holism, nurses are philosophically disin-
clined to be wholly responsible for a part or partly
responsible for a whole, but rather view the person as
an integration of mind, body, and soul (Figure1). Wat-
son1 affirmed that health is unity and harmony of these
three spheres and disharmony can extend to become
disease. Florence Nightingale2 emphasised that the
needs of the spirit are as critical to health as those indi-
vidual organs, which make up the body. Regrettably, in
nursing practice the spiritual needs of the patient are
often neglected.3 However, spirituality is returning to
healthcare because people believe in it and seek it as
part of their treatment.4 Reflecting on a series of per-
sonal interactions, this article analyzes the triad of spir-
ituality and the nurse-patient relationship in the context
of coping mechanisms in adaptation and adjustment to
illness. The anonymity of the persons subsequently
described is rigorously preserved.
CRITICAL INCIDENT
Critical incident analysis enables practitioners to use an
incident from practice, reflect upon it, and analyze it.5
It is thought that critical reflection may promote trans-
formational learning and ultimately improve the qual-
ity of patient care. Williams6 suggested that self-con-
sciousness (reflection) and continual self-critique (criti-
cal reflection) are crucial to competence.
DEFINITION OF SPIRITUALITY
The nebulous and complex nature of the concept of spir-
ituality has made an agreed definition of the spiritual
dimension of care elusive.7 McSherry4 conveyed spiritual-
ity as subjective, unique, universal, and mysterious. Caw-
ley8 deemed it impossible to devise a standard definition
due to the plethora of individual perceptions and inter-
pretations. Wright9 affirmed that spirituality is not an
intellectual exercise; but a lived experience.
MEANING
McSherry4 described spirituality as the desire to identify
some meaning and purpose in our lives and existence that
will assist us in generating motivation or purpose, which
will lead to a sense of fulfilment. Others10 have embraced
a liberated view of spirituality as whatever a person takes
to be the highest value in life. Consequently, a dislocation
or disconnection from one’s source of meaning in life can
result in a state of spiritual distress. Burnhard11 postulated
that spiritual distress will possibly result from an inabil-

162 Dimensions of Critical Care Nursing Vol. 23 / No. 4


Figure 1. Integration of mind, body,
and soul.
ity to invest life with meaning; it can be demotivating and
painful.
An elderly man hemorrhaged tears unashamedly
when I asked him if he was married. Struggling in his
anguish to be coherent he replied, “My wife died
recently of a heart attack in the car as I took her to the
hospital.” He described his life as empty, pointless.
Concerned with aggravating his angina I encouraged
him to be calm; I skilfully changed the subject. I thought
it was the safest option. Not wanting to impose, he obe-
diently tidied his tears.
SPIRITUAL DISTRESS
Greenstreet7 described spiritual pain as manifested by a
deep sense of hurt stemming from feelings of loss, or sep-
aration from the individual’s source of spiritual suste-
nance. The intense torment exhibited by the patient
recalling the loss of his soul mate, summoned a need for
his spiritual dismay to be addressed. Fry12 lists the neces-
sary skills for delivering spiritual care as including active
listening, attentiveness, genuineness, and comprehending
the experience. Instead, I chose to distract the subject.
SPIRITUAL IMMATURITY
Excusing my course of action with a barrier of medical
rationale I engaged an inauthentic and procedural
mode. Narayanasamy and Owens presented studies
Spirituality
demonstrating that nurses on identification of patient’s
spiritual needs, adopted a procedural and logical step
taking approach.3 Prioritizing the concern of his angina
I was secure in viewing his care in a reductionist man-
ner; all the while undermining the equal merits of his
spiritual needs. Nicholls and Warner advised that work-
ing with people as unique individuals rules out the pos-
sibility of hiding behind uniforms and diagnostic
labels.13 Clearly the patient sensed my lack of spiritual
‘where with all’ and retreated demurely. Existentialists
described spirituality as a universal phenomenon and
suggested that the capacity for spirituality belongs to all
of us. I needed to develop skills to help patients in spiri-
tual “dis-ease.” Waldfogl14 maintained that nurses need
personal and spiritual maturity to help patients engage
in the spiritual realm so that they provide better and
richer support to patients.
SPIRITUAL AWARENESS
Neuman15 stated that spirituality permeates all aspects of
a person, regardless of whether spirituality is acknowl-
edged or developed. Spiritual awareness may be sup-
pressed, remain underdeveloped, or lay dormant.16-18
Thoresen19 believed that spirituality is inherent to the
human condition and as such is an inescapable part of
our identity. Govier20 espoused the importance for nurses
to understand their own spirituality in order to assist oth-
July/August 2004 163
 Spirituality
Figure 2. Observing boundaries (Adapted from Sheets, 2001).
ers. McSherry4 recommended methods to generate self-
awareness such as reflection, critical analysis and
appraisal of oneself and experiences.
CONNECTEDNESS
Burkhardt found that spirituality is experienced
through caring connectedness with self and others.21
Others have suggested that meaning can be found
through relationships with other people.10
Overwhelmed by the exhaustive nature of heart fail-
ure the patient slumped defeated into her chair. She was
a farmer’s wife and scorned the title as it implied it
earned her no recognition. I wondered at her wisdom.
She smiled at my obvious grasp. I returned the senti-
ment. Feeling the trials of the morning wash she was too
weary to talk; she reposed. I lingered, sitting silently by
her. It was momentary and rich.
TRUST
Brown and Pedder22 stated that seeking help from a
stranger is bound to arouse anxieties. Relinquishing the
privacy of tending to independent personal hygiene dic-
tated the need for a trusting relationship between this
patient and her nurse. This trust was not implicit.
McSherry4 observed that trust will only be established if
the nurse is both reliable and dependable. I established
trust and connectedness by making time for this indi-
vidual and engaging in simple exchanges. Spiritual com-
fort gained by sharing with others, harmonious rela-
tionships, touch, security, and love can prevent isolation
and loneliness.23 Due to the extent of her illness I knew
the most potent medicine available to her was hope.
Dyson, Cobb, and Forman10 stressed that developing
relationships of trust and mutuality can promote hope
and inner strength.
MINISTRY OF PRESENCE
I recognized that through a spirit of understanding the
ubiquitous service of intimate care culminated in com-
panionship. Wright24 concurred that ministering to
patients’ spiritual needs is not about performing rituals
with them, but learning to understand their belief sys-
tems so that you can say or do the right thing at the
right time.24 I acknowledged an unstilted silence, an
opportunity simply to “be there,” to minister presence.
McSherry4 observed that it only takes a minute to sow
the seeds of trust and respect.
164 Dimensions of Critical Care Nursing Vol. 23 / No. 4
VULNERABILITY
Relishing this experience, I regretted the many missed
opportunities of connectedness that I prohibited into
my consciousness. Caring for the spirit implies relying
on the ability to stay with all that is weak and vulnera-
ble in the other-self and in oneself. I observed that by
giving more of myself I actually received much more.
The therapeutic essence of caregiving is not a restricted,
one-way dynamic; quite simply, in giving, nurses also
receive.25 Nonetheless, I was conscious of the need to
maintain a healthy distance. While the therapeutic rela-
tionship between nurse and patient creates an opportu-
nity for nurses to connect, it also creates potential for
misuse, abuse, or taking advantage of the patient.26
Observing situational boundaries I entered the patient’s
zone of helplessness moderately right of centre on the
underinvolvement/overinvolment continuum (Figure 2).
Crossing a boundary to meet patient needs can be ther-
apeutic.
DEATH AND DYING
The severity of this patient’s illness hastened the need to
address her fears of death and dying. McClement27
believed that caregivers need to risk involvement with
dying patients and their family, even if they are not sure
what to say or do. I associated a patient’s impending
death as a professional defeat. Intensive care units are
designed to maintain life and it may be difficult for
nurses who equate the inability to cure with profes-
sional failure. Nonetheless, I felt that avoidance behav-
ior would result in neglect. I was encouraged to view
her demise as a life event that is mutually inevitable.
The harmonious connectedness that I experienced
with this patient provided an informal bond that could
surmount the vicissitudes of life. More critically, care-
giver failure to drop the mask of professionalism has
been characterised as tantamount to inhumane treat-
ment of the dying.28 Endeavoring to further enrich her
spiritual support I offered the patient the services of the
chaplain. Kuuppelomaki29 recommended that the chap-
lain’s services are of crucial importance with respect to
a dying patient’s spiritual needs and responding to those
needs.
TRANSCENDENCE
Tanyi30 clarified the benefits of spirituality/religion as
an awareness and acceptance of hardship and mortal-

ity, a heightened sense of physical well-being, and the
ability to transcend beyond the infirmities of existence.
In adopting a transcendent approach, spirituality could
be argued to provide a mental attitude that promotes
health.31 Spiritual coping strategies such as relationship
with friends, family, God/nature may help the individ-
ual to transcend beyond the self to reach a higher
power, resulting in self-empowerment and ability to
cope with the stressful situation.32
The nebulous and complex nature of the
concept of spirituality has made an
agreed definition of the spiritual
dimension of care elusive.
SPIRITUAL CRISIS
Wilkinson33 affirmed that nursing is not just technical
rationality. However, the emphasis of this patient’s care
was placed on the task of repositioning.33 Mitchell
argued that to provide spiritual care, nurses need to be
less mechanical and more compassionate.34 A dearth of
empathy was clearly evident to me. Wright documented
high levels of stress and burnout among healthcare pro-
fessionals, especially nurses.24 Turner attributed com-
passion fatigue to the constant exposure to tragedy and
human frailty that desensitises us and we become emo-
tionally anaesthetised.35 Alternatively, I considered com-
passion fatigue to be a spiritual crisis. Wright illustrated
spiritual crisis in our work as a crisis of meaning where
so many values seem to be turned on their heads, such
as throughput and cost effectiveness, overtaking, car-
ing, and compassion.9 In a high-tech environment atten-
tion to machines and alarms often takes precedence.
McSherry23 observed that with the numerous advances
in scientific and medical technology nursing has become
more complex and the relevance of spirituality has
tended to be diluted and sometimes lost. McSherry
observed that the technological aspects of care some-
times overshadow the concerns for spiritual and
humanitarian need. Of course I accepted that nurses
must have the technical skills to care for their patients,
but others have implied that if they go beyond simply
performing tasks and make an effort to recognize the
individuality and value of each patient, the spirituality
of both will be enhanced.18
COMMUNICATION
Greenstreet contended that it is through communica-
tion skills that nurses will access their patients’ spiritual
needs.7 However, Allan added that we live in a culture
Spirituality
in which language is regarded as the highest form of
communication.36 I sensed that the spoken form of com-
munication, though physically possible, was not avail-
able to the patient in this uncaring environment. To
transcend her spiritual vulnerability the patient sang.
Evans suggested that while the evidence is limited music
appears to improve mood and tolerance and it may act
as a distracter during unpleasant procedures.37 My will-
ingness to allay her fears was vocalized as we chanted.
Miller38 stated that nurses need to be self-aware and to
identify our own style of communication and under-
stand how to modify it for our interactions with
patients when necessary.
Religion
Matthews defined religious commitment as the partici-
pation in, or endorsement of practices, beliefs, attitudes,
or sentiments that are associated with an organized
community of faith.39 The secularization of Western
society has contributed to a view that sees any signs of
religious belief as purely and simply symptomatic of
madness.13 Florence Nightingale believed that spiritual-
ity is intrinsic to the human experience, in contrast to
psychiatrists such as Freud who viewed religion as
pathological.40 Nonetheless, intrinsic belief-related
aspects of religion and the extrinsic participatory and
social aspects, might be important elements of people’s
lives.41 Religious belief or spirituality can be part of find-
ing that “center” of calmness and peace which is vital
to recovery.13
Having sustained multiple injuries a young Jehovah
witness refused blood products and complicated the
course of his illness. Though his illness was protracted,
his mood was never somber or subdued. His resilience
to pain was remarkable; his complacency arresting. His
family prayed with him at his bedside. Although both
his legs were amputated, he felt fortunate that he could
still join his hands in prayer. A psychiatric review was
obtained.
PRAYER
Due to the extent of his injuries I had a rational expec-
tation that this patient would experience pain. How-
ever, Neuman explained that spirituality controls the
mind and the mind controls the body.15 Because of his
disfigurement I expected the patient to be depressed
and angry. Yet, despite his suffering due to his disfig-
urement he showed more resolve in his religious con-
victions. I viewed his response as inappropriate. Alter-
natively, Hilton proposed that religious beliefs might
influence one’s perception of their illness and their abil-
ity to cope with it.42 As I observed his community
prayer at his bedside, like Holt-Ashley and Lindquist, I
July/August 2004 165
 Spirituality
Figure 3. Spiritual journey to self-actualization.
had to concede that prayer as a complimentary prac-
tice was healing and comforting.43 Prayer can offer
solace, inner strength, and resolution to deal with chal-
lenging situations. Wright stated that upward of 60%
of the population pray regularly to worship, to request
and most commonly to move closer to God.24 I was
concerned that the other patients might view this pray-
ing as proselytizing. Holt-Ashley and Linquist argued
that spirituality should not be relegated to churches,
temples, and mosques but should be an integral part of
the work environment.43 The International Code of
Ethics (ICN) agreed that in providing care, the nurse
should promote an environment in which human
rights, values, customs, and spiritual beliefs of the indi-
vidual, family, and community are respected.44 I
motioned his family and friends to pray with the
patient. McSherry affirmed that nurses feel inade-
quately prepared to address the spiritual concerns of
166 Dimensions of Critical Care Nursing Vol. 23 / No. 4
their patient.23 By contrast, the family took my hand in
gratitude and I knew that indirectly I had given spiri-
tual support.
FAITH AND HOPE
Nurses are fairly good at dealing with the ritualistic
aspects of religions. I respected his wish not to receive
blood products. However, Ameling and Povilonis high-
lighted the point that to know a person’s religion does
not necessarily reveal all there is to know about their
spiritual selves or how they find meaning in life.45 While
I viewed his rigid religious beliefs as self-destructive, I
appreciated his faith as a means of self-actualization
(Figure 3). McSherry contended that it is the nurse’s role
to assist individuals to make sense and find meaning in
times of crisis.4 I was assured that his strong family sup-
port reinforced his faith. Kuuppelomaki argued that not
all patients want to receive spiritual support from the

nursing staff.29 Nonetheless, it was evident that I needed
a daily measure of his and his family’s faith to ensure
that hope was sustained. Although hope has long been
recognized as a significant factor in patient recovery and
survival, the phenomenon receives little attention until
the patient becomes hopeless. Faith is the inseparable
companion of hope, without faith there is no hope and
where there is no hope, faith disintegrates.46
IMPLICATIONS FOR PRACTICE
• Understanding the spiritual dimension of human
experience is paramount to nursing, because nursing
is a practice-based discipline interested in human con-
cerns.
• Spiritual needs should be assessed, directly, through
questioning, and indirectly, through observation.
• Spiritual assessment must be an ongoing, continuous
process.
• While spiritual care is not an added extra, rather an
essential part of care; it also has to be respected that
not all patients need or want spiritual care.
• Patients may be self-sufficient, or may have called on
friends and family for help with their concerns.
• A greater appreciation of the diversity of religious
beliefs is required to interact positively with patients.
• Stereotyping of patients in terms of religious and cul-
tural needs may lead to the rigid application of reli-
gious practices. Therefore, there is a move away from
emphasis on religiosity to increased awareness of
individuality in spiritual care.
• There is a need for multidisciplinary involvement
between chaplains, doctors, and allied health profes-
sionals.
• The challenge of burnout is to treat it for what it is—
a spiritual crisis. The effective treatment may call for
spiritual renewal or awakening of the soul.
CONCLUSION
While complexities regarding the concept of spirituality
were acknowledged, the complimentary benefit of spiri-
tuality in adaptation and adjustment to illness was
shown to be irrefutable. Analysis of the issues indicated
that spiritual distress was devastating and required
deliberate and insightful attention from a spiritually
mature practitioner. The evidence clearly suggested that
harmonious connectedness achieved through trust
building, presencing, and effective communication for-
tified the patient’s personal coping reserves.
Realization that nurses and patients possessed the
common predisposition to vulnerability and mortality
lent a deeper sense of empathy to the patient’s experi-
ence. Transcendence was described as a means to over-
come discordant encounters. Spiritual aridity in nurses
Spirituality
was exemplified by the disportionate attention dedi-
cated to the technical aspects of patient care, cascading
in a spiritual crisis for both patient and nurse. Religion
and prayer were expressed as formal spiritual resources
and were shown to be instrumental in providing the
family with a means to petition and intercede for their
loved one. Faith in a higher God or divine power was
demonstrated to culminate in the patient and family’s
self-actualization of hope.
In this article, reflection provided a means of
achieving a patient-centered approach by improving
and developing the synergistic relationship between
nurse and patient. Furthermore, it was demonstrated
that interactional analysis can weave theory to practice
effecting transformational learning; ensuring the
integrity of nursing’s spiritual and holistic heritage, and
ultimately improving the quality of patient care.
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ABOUT THE AUTHOR
Jacinta Kelly is presently completing a post-graduate course in criti-
cal care studies at Waterford Regional Hospital in Waterford, Ireland.
Address correspondence and reprint requests to: Jacinta Kelly, Bridge
Street, Cahir Co, Tipperary, Ireland (Amnesia104@hotmail.com).

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168 Dimensions of Critical Care Nursing Vol. 23 / No. 4