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Spiritual Distress in Adult Cancer Patients

Toward Conceptual Clarity
Liwliwa R. Villagomeza, BSN, RN
Spiritual distress is conceptualized as impairments in 7 constructs of a person's sense of spirituality:
(1) connectedness, (2) faith and religious belief system, (3) value system, (4) meaning and purpose in life,
(5) self-transcendence, (6) inner peace and harmony, and (7) inner strength and energy This article clarifies
spiritual distress through concept analysis and provides nurses with cues fcr its recognition in adult patients with
cancer. KEY WORDS: spiritual chaos, spiritual crisis, spiritual disequilibrium, spiritual disintegration, spiritual pain,
spiritual struggie. spiritual suffering, spiritual turmoii. spirituality HoiisiNurs Pract 20()5:i9(6):285-294
Cancer robs people of their hopes and dreams and
not only threatens the physical body but also the spirit.
People with cancer experience disbelief, fear.
isolation, shock, spiritual distress, and uncertainty.'"-^
When perceiving cancer as a death sentence, fear may
be overwhelming."^ In addition, disease and
treatment-related symptoms are emotionally,
psychologically, physically, and spiritually distressing.
Fu et al^ identified a constellation of symptoms,
including anorexia, dysphagia. dyspnea, fatigue, loss
of concentration, mucositis, nausea, pain, paresis,
pruritus, sleep deprivation, vomiting, and weakness.
Spiritual distress is strikingly omitted from Fu's list,
which parallels the limited use of spiritual distress as a
nursing diagnosis by oncology nurses. In a study by
McHolm/' only 28.9% of participants indicated using
spiritual distress as a nursing diagnosis when planning
patient care.
Although nurses are obligated to provide spiritual
care to patients.^ many omit spiritual care for both
intrinsic and extrinsic reasons. Intrinsic reasons
include anxiety and discomfort discussing subject
matter often considered highly personal and
pseudoscientific.*^ Anxiety and discomfort emanate
from uncertainty about spiritual beliefs'*; lack of
understanding of spirituality and spiritual distress; and
From the University of South Florida. Tampa.
The auihor thanks Elaine Slocumh. PhD. RN.BC. for guidance in ihc
preparalicm of ihis manuscript and Nikki Smith for assisiance with
Fijiure I.
Corresponding author: Liwliwa R. Vlllagoineza. BSN. RN. 1119 Dockside
Dr. Lutz. FL 33559 (e-mail: lvillago(p!hsc.usf.edu).
perceived lack of education, training, and skill
providing spiritual care. Extrinsic reasons include the
inherent precedence of biophysical care priorities that
often limit provision of holistic care and lack of
theoretical nursing models to assist nurses with this
responsibility.^ Another barrier to spiritual care
implementation is lack of a standardized tool for
measuring spiritual distress in the clinical setting.
To help patients awaken to their spirituality, it is
crucial to recognize spiritual distress. This article
clarifies spiritual distress through concept analysis,
using Walker and Avant's method.'*' and provides
nurses with cues for recognizing spiritual distress in
adult patients with cancer. Spiritual distress may be
found in the literature using the following search
terms: spiritual disequilibrium.' spiritual
disintegration,^ ^ spiritual struggle." spiritual
turmoil.'- spiritual suffering,'-' spiritual pain,'"^
spiritual chaos.''' and spiritual crisis."' "
TOWARD CLARITY: CONCEPT ANALYSIS
Concept analysis, an important process in advancing
nursing knowledge and practice, generates and
clarifies the meaning of a concept through highly
creative, intuitive, and rigorous processes.'^ Walker
and Avant's 8-step concept analysis method with 8
steps as listed, was used for this article;
1. Select concept
2. Identify aims of analysis
3. Identify uses of concept
4. Determine defining attributes
285
286 HOLISTIC NURSING PRACTICE NOVEMBER/DECEMBER 2005
5. Construct model case
6. Construct borderline, related, contrary, invented.
and illegitimate cases
7. Identify antecedents and consequences
8. Define empirical referents
SPIRITUAL DISTRESS SUBCONCEPTS
The abstract and complex concept of spiritual distress
consists of 2 distinct subconcepts: spirit and
distress. Subconcepts are identified in the context of
original meaning and in the context of nursing and
healthcare language. Conceptualization begins by
examining the etymology of the terms spirit and
distress.
Spirit
Spirit is typically traced to Latin (spiritu.s; soul,
courage, vigor, breath, or vital principle). The noun
form means "animating" or "vital principle in humans
and animals"; the verb form means to "make more
active or energetic" and "an act to carry off away
secretly and swiftly as though by the act of
supernatural powers." Derivatives have significant
meanings linked to how the concepts are used today
(Table 1). Spirituality (Latin, spiritualitatem). an
all-encompassing term referring to a person's being or
essetice, is a nonsectarian recognition of spirit or
divinity in the hearts of human
Spirit and spirituality in nursing and healthcare
Spirit is the life principlethe soul, will, and thought.
The vital life force in humans, spirit is the pervading
animating principle or characteristic. This life force is
manifested in love, passion, and inspiration, which
motivates and connects people with the world and one
another.'^'" Spirit also refers to disposition or mood
(eg. brave spirit, high spirits) and to supernatural
beings (eg. ghosts or angels).-'
In nursing and healthcare, spirit takes on the
concept of spirituality. Heightened interest among
TABLE 1. Derivations of spirit
Term Original Origin
Meaning
Spirit (n)
Spirit (V)
Spiritual (adj)
Spirituality (n)
Spiritualism
Spiritualist (n)
Spirituals (n)
Spirited (adj)
Spiritless (adj)
Spirits/Spirituous
Spirit level
espirif
pneuma
prajna
ruah
spirare
pisto
spirituel
spiritualis
spiritualite
spiritualitalem
spiritualty
Old French
Greek
Sanskrit
Hebrew
Classical
Latin
Old Slavian
Old French
Classical Latin
Middle French
Late Latin
Early form (1377)
Animating or vital principle
Breath, spirit
Breath, spirit
Wind, breath, exhalation
Breathe
To play the flute
"Of or concerning the spirit," especially in religious aspects
Breath, wind, air or "of breathing, of the spirit" and "of or concerning
the church"
Originally, a nonsectarian recognition of spirit or divinity in the hearts
of all beings
A person's being or essence
[In religious philosophy] teaches the existence of being or reality as
distinct from matter. This being may be referred to as the mind or
the spirit; also the belief that spirits of the dead communicate with
the living
Someone who believes in the ability of the living to communicate with
the dead via a medium; believes that an individual's existence and
personal identity continue after death
African American religious songs in southern United States; first
recorded in 1866; emotional, with strong rhythms
Lively, energetic, animated
Duli, apathetic, unconcerned
Volatile substance or strong alcoholic liquor
Glass tube filled with alcohol and an air bubble used by carpenters
and masons to determine level surfaces
Spirinuil Distres.'i hi Adull Cancer Palienis 287
researchers in exploring the relationship of .spirituality
and health has recently generated a significant number
ot studies; however, the healthcare community has not
reached consensus regarding a universal definition of
spirituality, in spite of available empirical data.
McSherry and Ross-^"^ contend that spirituality has no
set of defining attributes and that lack of a definition is
the "greatest dilemma associated with spiritual
assessment."
Because spirituality is the lens through which
spiritual distress can be viewed, a clear definition of
spirituality is needed. Common themes have emerged
in the literature' -' -^"' ^-"" that led to the
conceptualization of spirituality as a phenomenon
wilh 7 distinct but overlapping constructs, as
follows:
1. Connectedness. Manifested in meaningful and
healthy relationships. Encompasses connected-
ness to self (intrapersonal); others (personal); na-
ture and environment (ecological): and to God.
Supreme Being, or Transcendent Power (transper-
sonal).
2. Faith and religious belief system. Although used
interchangeably, religion and spirituality are not
the same concepts. Religion is part of a person's
spiritual makeup; religious rituals are how peo-
ple manifest their religiosity and religious beliefs.
Dombeck'*" states. "Religion is defined as an orga-
nized body of thought and experience concerning
fundamental problems of existence; it is an orga-
nized body of faith." Most often associated with
religion and religious beliefs, faith is belief in God
or a power not necessarily identified as God.^^
3. Vfl/^.sv5rem. A person's cherished standards; hav-
ing to do with truth; beauty: and worth of thoughts.
objects, or behaviors.'^
4. Sense of meaning and purpo.se in everyday life
and amidst suffering. The significance of life; the
ability to make sense of life situations, whether
desirable or undesirable; and being able to derive
purpose m existence.- ' ^
5. Sense of self-transcendence. Defined as "an expan-
sion of personal boundaries beyond the immediate
or constricted views of oneself and the world""^"
that results in self-empowerment and the ability to
cope with stressful situations.-^
6. Sense of inner peace and harmony amidst the
chaos of life and fear and uncertainty when experi-
encing life-altering or life-threatening illnessesp
Spirituality fosters a positive, calm, peaceful, and
harmonious state of ^*'
7. Sense of inner strength and energy that is inte-
grative and unifying beyond the physical realm. It
is the dynamic, creative, and vital life force that
instills hope and motivation.*^-^
Distress
Distress {Latin, districtu and di.stringere; to draw apart
or hinder)'*^ is defined as causing misery, pain, or
suffering,-^ and is related to the terms strain and
stress. The noun form of strain refers to injury caused
by straining, as in "putting undue stress upon"; the
verb form refers to "bind, stretch, or draw tightly";
"clasp"; or "squeeze."'"^ Strain also describes injury
by overexertion (eg, muscle strain) or being stretched
beyond normal limits.-*
Stress (Middle French, destresse\ hardship,
adversity, force, or pressure; and Old French, estrece\
narrowness or oppression) can also be used
figuratively to mean "put emphasis on" (stress a point
of argument).''' Today, stress, defined as a specific
force tbat strains or deforms, a mental or physical
tension, and an urgency or pressure.-^^ is synonymous
with strain, emphasize, and importance.
Distress in nursing and healthcare
Ridner"^' and Armstrong"*- conceptualized distress in
their work on psychological distress and symptom
experience, respectively. Distress is defined as "a
nonspecific, biological or emotional response to a
demand or stressor that is harmtui to the individual.""^'
Distress is used to describe the discomfort associated
with unpleasant symptoms of an illness. Nurses are
familiar with clinical phenomena (eg. symptom or
respiratory distress) that indicate that patients need
help and use symptom distress to assess the impact of
cancer-associated symptoms. McCorklc and Young"*-^
define distress as "the degree of discomfort reported
by patients in relation to their perceptions of the
symptom being experienced."
Strain is used in nursing in phenomenon such as
role strain (eg, women who have multiple roles)."^"^
Stress, more closely related to distress, began
appearing in nursing journals in 1956. 10 years after
Hans Selye identified the biologic syndrome of .stress.
In the 1970s, stress became recognized as a construct
by nurse researchers.''-'' In 1984, Lazarus and Folkman,
as cited in Rice."*^ conceptualized stress as a "rubric
for a complex series of subjective phenomena,
including cognitive appraisals (eg, threat, harm, and
288 HOLISTIC NURSING PRACTICE NOVEMBER/DECEMBER 2005
challenge), stress emotions, coping responses, and
reappraisals. Stress is experienced when the demands
of a situation tax or exceed a person's resources and
some type of harm or loss is anticipated."
CONCEPT OF SPIRITUAL DISTRESS
State of disharmony
Conceptualization of spiritual distress reveals 2
opposing concepts: spirit, spiritual, and spirituality,
which denote positivity; and distress, strain, and
stress, which denote negativity. Spiritual takes a
different meaning when combined with the concept of
distressone that rids spirit of its positive virtues.
Distress also takes a different meaning. Generally
denoting physical distress (concrete concept), it
becomes abstract when combined with spiritual.
McGrath'^ refers to spiritual distress as spiritual pain.
"a state of conflict between one's belief system and
current reality. Spiritual pain is the experience of
conflict and disharmony between a person's hopes,
values, and beliefs and their existential experience
with life."
The North American Nursing Diagnosis
Association defines spiritual distress as "the disruption
in the life principle that pervades a person's entire
being and that integrates and transcends one's
biological and psychosocial nature.'"*^
Gulanick et al"''' defines .spiritual distress as "[...]
an experience of profound disharmony in the person's
belief or value system tbat threatens the meaning of
[...] life. During spiritual distress, the patient looses
hope, questions his or her belief system, or feels
separated from his or her personal source of comfort
and strength. Pain, chronic terminal illness, impending
surgery, or death or illness of a loved one are crises
that may cause spiritual distress. Being physically
separated from family and familiar culture contributes
to feeling alone and abandoned."
Clinical picture: Could it be depression?
Spiritual distress and depression present a similar
clinical picture. It is a challenge for nurses to
differentiate between spiritual distress and depression
in their patients. Diagnosis of depression is beyond the
scope of bedside nursing; however. Diagnostic and
Statistical Manual of Menial Disorders. Fourth Edition
(Text Revision)"*^ criteria provide an unambiguous
definition of depression. Diagnosis is made when 5 or
more of the following criteria are experienced almost
daily for at least 2 weeks, with I of 5 symptoms being
depressed mood or loss of interest or pleasure;
Depressed or irritable mood
Markedly diminished interest or pleasure in all or al-
most all activities
Significant weight loss or gain
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or excessive or inappropri-
ate guilt
Diminished ability to think or concentrate, or indeci-
sive ness
Recurrent thoughts of death or suicide
Examination reveals that symptoms of spiritual
distress are specific and manifest as impairments in
spiritual makeup; depression symptoms are more
generalized. This is a key point to consider when
differentiating between the concepts. In the
perspective of cause-and-effect, spiritual distress can
be viewed as a cause of depression. Therefore,
omission of spiritual intervention in patients
experiencing spiritual distress can cause prolonged
and profound sadness, irritability, difficulty sleeping,
feelings of guilt, and other symptoms indicative of
depression.
DEFINING ATTRIBUTES AND
EMPIRICAL REFERENTS
Walker and Avant'" considers identification of
empirical referents as the final step in concept
analysis. In this article, the sequencing of steps is
adjusted to accommodate the simultaneous discussion
of the defining attributes and empirical referents of
.spiritual distress.
Tbe defining attributes of spiritual distress are
conceptualized as clusters of impairments in any
combination of spirituality constructs. Some degree of
spiritual distress is present when a situation has a
cluster consisting of 3 or more impairments; for
example, a cluster may be formed when impairments
in connectedness, faith and religious belief system,
and sense of meaning and purpose in life coexist at
any given time.
Spiritual distress cannot be an "all or nothing"
phenomenon. Spiritual distress may be incrementally
Spiritual Distress in Adull Cancer Patients 289
present and. as such, perceived by patients in varying
degrees of intensity. The conceptualized incremental
nature of spiritual distress may be associated with
either the number of impairments present or the degree
of impairment severity as perceived by the patient.
Table 2 outlines the defining attributes of spiritual
distress and the corresponding empirical referents.
Walker and Avant'*' caution analysts that "an analysis
cannot be completed until there are no overlapping
attributes [.. .J between the defining attributes and the
model case"; however, in the analysis of spiritual
distress, it is difficult to achieve because of the
inherent, overlapping nature of its defining attributes
and empirical referents.
The empirical referent "expresses feelings of
disconnection from God" is used as an example. This
may represent impairment in transpersonal
connectedness, faith and religious belief system, and
self-transcendence. In Figure 1, the circles
representing impairments overlap partially at the
periphery but converge completely at the core. When
all 7 defining attributes converge, a person is in a state
of intense spiritual distress, as depicted by the person
encased in the chaotic-.shaped shell in Figure 1. This
occurs when at least one empirical referent from each
defining attribute is present and experienced.
MODEL CASE
Louise, a 49-year-old pholojournalist and poet, felt a
lump on her left breast while away on field
assignment. She felt powerless to do anything at that
time and described the days and nights that followed
as tormcnting^filled with profound fear and intrusive
thoughts. Diagnosed with breast cancer with lymph
node involvement, Louise was admitted to the hospital
following a syncopal episode at her physician's office
while discussing treatment options.
Louise found comfort by replaying life events of
the past year. It was a good year for her family.
Following a rift with her son days before his wedding.
Louise had made amends with him. Her joy at soon
becoming a grandmother was overwhelming, but in a
positive way. Although Louise's career brought
worldwide travel, it also caused her to skip annual
physician visits. "Why didn't I go for that
mammogram last year!" she exclaimed.
Louise considers herself spiritual, not religious.
Spirituality helped her cope with her mother's illness a
few years ago; however, now she says, "I feel so down.
I can't draw strength from my own reserves." When
Louise called her minister on the day of her biopsy, he
was not available. She lamented. "He's never there
when I need him most!" She has since avoided talking
to her minister, ignoring his phone calls and declining
his visits. Instead. Louise called a friend and claimed
that she cannot get support from people when she
needs it most.
During the admission process. Louise
expressed her feelings through her sobs. "Where are
you God? Why did you do this to me? I've been a
good person. This is not fair. I do not deserve to
suffer!" Throughout the day. she was in and out of bed
and pacing in her room, repeatedly sorting aimlessly
through pictures from a recent assignment. She
expressed ambivalence about the treatment plan,
saying, "Well, I've lived a full life, so be it. 1 don't
think I can live without a breast or without hair. How
will ! look? I'll no longer be the person I used to be.
It'll feel like 1 never existed. Moreover. I don't think
I'll be able to withstand the side effects of treatment."
Louise also had episodes of quietness, staring at the
window as if looking for answers on the horizon. She
wrote on her pillowcase: "Beyond the physical pain
that comes with cancer is a more profound pain... A
pain that permeates one's whole being. This is pain of
the spirit.. .my spirit!"
Louise was experiencing every defining attribute of
the concept of spiritual distress. She was clearly
experiencing impairments in sense of connectedness
{to herself, others, and God); faith and religious belief
system ("Where are you God?"); value system
(ambivalence regarding treatment plan); meaning and
purpose in life ("It'll feel like I never existed");
self-transcendence (inability to see beyond her
suffering); inner peace and harmony (profound fear
and intrusive thoughts); and inner strength and energy
("I'm so down, I can't draw strength").
BORDERLINE CASE
Franco, a 58-year-old Hispanic man. was admitted to
the hospital because of dehydration secondary to
uncontrolled diarrhea. He had just completed a course
of oral chemotherapy and radiation ihcrapy for colon
cancer, as well as a course of antibiotics for upper
respiratory tract infection. His main support was his
family, whose love and caring and daily prayers
sustained his spirits. Never prayerful until his illness.
Franco discovered solace with prayer during sleepless
nights, when the discomfort of internal burning
290 HOLISTIC NURSING PRACTICE NOVEMBER/DECEMBER 2005
TABLE 2. Defining attributes and empirical referents of spiritual distress
Defining attributes
(constructs ot spirituality)
Empiricai referents {patient manifestations or ciinician cues)
1. Impairments in sense of
connectedness to self, to
others, to the environment,
and to God or a Supreme
being/Transcendent power
2. Impairments in faith and
religious belief system
3. Impairments in value system
4. Impairments in sense of life's
meaning and purpose
5. Impairments in sense of
self-transcendence
6. Impairments in sense of inner
peace and harmony
7. Impairments in sense of inner
strength and energy
Exhibits alienation
Engages in self-blame
Expresses inability to accept self
Demonstrates anger, frustration, and despair to others
Expresses being separated from usual support system
Exhibits paradoxical attitude: refuses interactions with friends and family, or may reach out
to others for solace
Feels separated trom personal source of comfcrt and strength
Expresses feelings of disconnection from important others
Demonstrates disinterest in nature and music
Demonstrates inability to experience previous state of creativity
Expresses feelings of disconnection from God
Verbalizes concerns about relationships with God/Supreme
Being/inspiring Power/deity
Verbalizes loss of faith
Verbalizes inner conflicts about beliefs
Expresses anger toward God or Supreme beingATranscendent power
Demonstrates sudden changes in religious and spiritual practices (eg, disinterest in usual
religious activities [reading religious and spiritual literature] and inability to pray)
Expresses feelings of being abandoned by God, Supreme being or Transcendent power
Displaces anger toward religious representatives
Exhibits paradoxical attitude: refuses interactions with spiritual leaders or may verbalize
intense need to see a priest, rabbi, or religious leader for spiritual assistance
Does not experience that God is forgiving
Does not experience that God is loving
Regards illness as punishment
Questions if predicament is a punishment from God
Asks "What did I do to deserve this?"
Seeks answers to "why" questions (eg, "Why did this happen to me? "Why would God allow
me to suffer this way?")
Questions moral and ethical implications of therapeutic regimen
Denies responsibilities for problems
Gallows humor (inappropriate humor in a grave situation)
Questions meaning of own existence
Questions meaning of suffering
Expresses concern with meaning of life and death and/or belief systems
Demonstrates inability to experience and integrate meaning and purpose in life
Expresses inability to find meaning in the midst of suffering expressed as crying and
expressing a sense of hopelessness
Demonstrates inability to be introspective and reflective
Demonstrates inability to love, apologize, and forgive
Inability to feel indebted to a power greater than self
Inability to reconcile with others
Expresses fear, discouragement
Verbalizes profound disharmony
Expresses nonspecific feelings of anger
Verbalizes inner restlessness and feelings of chaos
Describes nightmares or sleep disturbances
Altered behavior or mood evidenced by anger, crying, withdrawal, preoccupation, anxiety,
hostility, or apathy
Expresses guilt
Exhibits pessimism and hopelessness
Describes somatic complaints
Demonstrates inward turning by withdrawing
Expresses profound inner pain and suffering
Expresses feelings such as "spirits are down" or "broken-hearted"
Spiritual D/.v/rcv.v in Adult Cancer Faiienls 291
Impairments in
connectedness
Impairments in
faith iinJ religious
belief system
Impairments in
sense ot" meaning
and purpose
impairments in
value system
Impairments in
sense of self-
transcendence
Impairments in
sense of inner
peace and harmony
Impairments in
inner strength and
energy
FIGURE 1. Defining attributes of spiritual distress.
prevailed. Praying is now a source of strength for him:
his day is not complete until he prays.
On his second day at the hospital, he started to feel
isolated. He was placed on isolation precautions while
waiting for results of a stool examination. Concerned
that his family members could be exposed to his
'new" illness, he suggested that they phone rather than
visit. Although this was his choice, it made him lonely
and weaker. Franco slept most of the day and stopped
praying, attributing this to increasing lack of energy
secondary to diarrhea. On hospital day 5, his primary
physician noted this change in his behavior and
ordered a psychosocial consult to rule out depression.
Franco's primary nurse that day was aware of Franco's
past use of prayer and consulted the chaplain. The
chaplain visited Franco, spending a considerable
amount of time listening to his concerns and fears.
Before the chaplain left, he held Franco's hands and
they prayed together. When the psychosocial
as.sessment consultant visited the next day. Franco
stated that although he still felt weak, he also felt an
unexplained, renewed vigor.
Franco exhibited some but not all defining
attributes of the concept of spiritual distress.
Loneliness and lack of energy hindered his prayer
practice, and the inability to pray impaired his inner
peace and harmony. He did not, however, disconnect
from his support system and people important to him.
His openness to the chaplain also indicated his intact
sense of connectedness.
RELATED CASE
Alma, a 37-year-old patient with head and neck
cancer, was found febrile and admitted to the Head
and Neck Clinic. Outgoing, outspoken, jolly, and
optimi.stic. Alma previously worked as a ride operator
at a local amusement park during the day and as a
singer at a local club at night.
Prior to Alma's cancer diagnosis, she experienced
vertigo, nausea, and recurrent hoarseness, forcing her
to find other jobs. Because there was no suitable job
opening at the amusement park, she took a leave of
absence. And, she also gave up her night job because
singing was a strain on her health. Her relationship
with her common-law husband had become so
unstable that it just naturally dissolved. Isolation and
292 HOLISTIC NURSING PRACTICE NOVEMBER/DECEMBER 2005
withdrawal and other psychological and emotional
manifestations were outcomes of Alma's experiences.
Alma's case initially appeared to be a ca.se of
spiritual distress because of isolation atid withdrawal
cues: however, with appropriate psychiatric
assessment. Alma's case was appropriately diagnosed
as clinical depression.
CONTRARY CASE
Nora, a 45-year-old woman, momentarily lost
consciousness, fell, and fractured her left elbow while
getting her home ready for guests. Two months prior
to admittance as a 24-hour observation patient, Nora
had undergone total abdominal hysterectomy with
bilateral oophorectomy for uterine cancer. She did not
seem to be bothered by pain or immobility and did not
exhibit signs of anxiety over the treatment plan.
Appearing serene, Nora said. "I've been through
worse. I'm sure I can handle this." Admission data
gathering identified that Nora turns to spirituality in
times of stress. Her bout with cancer had taught her
that drawing strength from within helps the healing
process. She nurtures her spirit by helping others,
praying, attending church .services, meeting weekly
with her spiritual leader, playing with her dogs,
gardening, listening to music, painting, and regularly
chatting with friends in a Web-based cancer support
group. Describing herself as an optimist, Nora
expressed hope that the cancer will not recur.
Nora's case portrays a contrary case of spiritual
distress. Positive attitude, hopefulness, serenity, and
optimism are virtues contrary to the defining attributes
of spiritual distress.
ANTFXEDENTS AND CONSEQUENCES
Antecedents and consequences are analogous to cause
and eftect. Antecedents, events that must occur or
conditions that must exist prior to the occurrence of
the concept, must be present before spiritual distress
occurs. Table 3 outlines antecedents of spiritual
distress in adult patients with cancer.
Consequences are events and conditions that occur
as a result of the concept having occurred.
TABLE 3. Antecedents of spiritual distress in adult patients with cancer
Antecedent
Events or patient experiences
^ Stressors
Patient appraisal that the stressor
constitutes a major life problem
Ineffective spiritual coping
Disease-related
Fear of the unknown
Initial diagnosis of cancer
Cancer recurrence
Impending surgery
Loss of self-identity
Unrelieved physical pain
Onset of treatment complications
Cancer unresponsive to treatment
Disfigurement secondary to surgery or other form of treatment
Prolonged hospitalizations or frequent rehospitalizations
Preexisting comorbid conditions
Physical separation from family or familiar culture
Regret about unhealthy behaviors of past (feeling guilty)
Facing own mortality (end-of-life issues)
Social support-related
Illness of a family member
Death of a family member
Loss of something of value, like a job or a pef
Loss of material belongings, for example, house, car
Family conflicts secondary to family stress brought on by cancer
Cognizance ot the existence of a stressor
Self-aware ness that stressor causes problems
Perception that family members/significant others are not empathic with patient's
critical situation
Preexisting low levels of spirituality (ie, undeveloped or dormant spirituality)
Lack or absence of social support (church or other organizations)
Spirinml Distress in Adull Cancer Patients 293
TABLE 4. Consequences of spiritual distress in
adult patients with cancer
Consequence Events or patient experiences
Negative: result of
ineffective
spiritual coping
strategies
Positive: result of
effective spiritual
coping strategies
False sense of hope regarding cancer
outcome
Increased somatic complaints
Increased perception of physical
symptom distress
Superimposed illnesses (eg,
hypertension, myocardial infarction)
Harm to self (eg, substance abuse)
Suicide is the extreme negative
consequence
Reawakening of spirit
Increased sense of well-being
Self-reorganization
Spiritual growfh or transformation
Consequences of spiritual distress in adult patients
with cancer are categorized as positive or negative
(Table 4). The most positive consequence of spiritual
distress is spiritual awakening; the most extreme
consequence is the desire to die or commit suicide.
overcome this shortcoming. Nurses comfortable with
their spirituality and possessing skills and experience
in spiritual caregiving should be mentors and role
models in the art of spiritual caregiving. The author
proposes a model of spiritual caregiving with 7 foci of
care (FOC) drawn from the 7 defining attributes of
spiritual distress as follows:
FOC I: Sense of connectedness. Develop an ongoing
trusting relationship with the patient.
FOC 2: Faith and religious belief system. Respect and
support patient's faith and religious belief system and
make appropriate referrals.
FOC 3: Value system. Assist patient to sort out ethical
dilemmas in healthcare decision making.
FOC 4: Sen.se of meaning and purpose in life amidst
suffering. Show compassion; be aware of patient's
suffering and act to ease such suffering.
FOC 5: Sense of self-transcendence. Encourage re-
flective prayer.
FOC 6: Sense of inner peace and harmony. Allow
patient to verbalize fears and listen.
FOC 7: Sense of inner strength and energy. Help pa-
tient deal with feelings of guilt and instill hope.
IMPLICATIONS FOR NURSING PRACTICE
Assessment is the first step in recognizing
spiritual distress; however, no current study identified
a standardized assessment tool used by nurses in
inpatient clinical areas. Exploring spiritual assessment
by drawing on international literature, McSherry
and Ross""^ identified various assessment tools
and categorized them as (1) direct patient questioning.
(2) indicator-based tools, and (3) audit tools.
Knowledge about spiritual distress discovered
through this concept analysis can fill the gaps created
by the lack of standardized tools for measuring
spiritual distress in the inpatient setting. Nurses are
encouraged to use the information in Table 2 as a
reference tool and use empirical referents as checklist
items for a quick assessment of spiritual distress.
Assessment does not necessarily involve direct patient
questioning; guided by checklists, casually observing
patient behavior, and listening to patients' everyday
stories often reveal more about a patient's spiritual
needs than do direct questioning.
Nurses may omit spiritual care for many reasons;
however, with scientific evidence supporting the
benefit of spirituality on health, nursing must
IMPLICATIONS FOR NURSING
RESEARCH
The conceptualization of spiritual distress in this
analysis generated certain questions that can
potentially be answered by conducting empirical
studies. Nurse scientists whose interests are in the
domain of spirituality, religion, and health are
encouraged to explore these questions:
1. If weights are assigned to each construct of spir-
ituality, would all be weighted the same? Or, are
some constructs more essential than others and,
hence, weighted more?
2. What are the essential differences between spiritu-
ality and religion or religiosity? What implications
do these differences have for assessing and inter-
vening in spiritual distress?
3. With spiritual distress conceptualized as clusters
of impairments in any combination of the 7 con-
structs of spirituality, how many impairments must
be present before a nursing diagnosis of .spiritual
distress can be made?
4. Can .spiritual distress be quantified by using visual
analogue scales as assessment tools in the clinical
setting?
294 HoLisric NURSING PRACTICE NOVEMBER/DECEMBHR 2005
5. What contribution to clinical practice would the
development of a midrange theory of spiritual dis-
tress provide?
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