The lived experiences of spiritual suffering and the healing process ...

PATIENT EXPERIENCE

The lived experiences of spiritual suffering and the healing process among Taiwanese patients with terminal cancer Chung-Ching Chio

MD

Vice Superintendent, Department of Neurosurgery, Chi-Mei Medical Center, Yung Kang City, Tainan, Taiwan

Fu-Jin Shih

DNSC, RN

Professor, Academic Deputy Dean, School of Nursing, National Yang-Ming University, Peitou Taipei, Taiwan

Jeng-Fong Chiou

MD, MHA

Director of Cancer Center, Assistant Professor of Medical School, Taipei Medical University Hospital, Taipei, Taiwan

Hsiao-Wei Lin

RN, BSN

Physician Assistant, Cancer center, Taipei Medical University Hospital, Taipei, Taiwan

Fei-Hsiu Hsiao

PHD, RN

Assistant Professor, College of Nursing, Taipei, Taiwan

Yu-Ting Chen

RN, MSN

Instructor, Graduate Institute of Nursing, Chang Gung University, Tao-Yuan, Taiwan

Submitted for publication: 23 May 2006 Accepted for publication: 21 September 2006

Correspondence: Fei-Hsiu Hsiao Assistant Professor College of Nursing 250 Wu-Hsing St Taipei Taiwan Telephone: 886 2 27361661 ext. 6317 E-mail: hsiaofei@tmu.edu.tw

CHIO C-C, SHIH F-J, CHIOU J-F, LIN H-W, HSIAO F-H & CHEN Y-T

Journal of Clinical Nursing 17, 735–743 The lived experiences of spiritual suffering and the healing process among Taiwanese patients with terminal cancer Aims and objectives. The purposes of this study were to explore the lived experiences of spiritual suffering and the change mechanism in healing processes among Taiwanese patients with terminal cancer. Methods. The approach to this study was phenomenological-hermeneutic. Twentyone patients with terminal cancer were invited to participate in a semi-structured interview that dealt with their experiences of spiritual suffering and the healing process. This study was conducted in the inpatient unit of the oncology department in two general hospitals. The interviews were recorded, transcribed and later analysed using the approach of narrative analysis. Results. According to the results of case narration, the causes of spiritual suffering included cancer, known as a life-threatening illness, physical pain, treatment complications, uncertain illness progression, disability problems and lack of support. Patients turned to internal resources (including regarding the suffering as a life challenge, volunteering to help other cancer patients and searching for life wisdoms) and external resources (including peer support groups and family support) as they (2008)

2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd doi: 10.1111/j.1365-2702.2006.01854.x

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endured spiritual suffering. Taiwanese patients turned to Eastern and Western philosophies of Taoism, Confucianism, Buddhism and Christianity as methods to interpret their spiritual suffering. Conclusion. Patients’ positive views of misfortune because of cancer and sufficient social supports were the key elements of the healing process to alleviate spiritual suffering. Relevance to clinical practice. Nurses who learn to participate in suffering assessment are better able to understand spiritual needs of cancer patients. Cancer patients’ views on the change mechanism in healing processes could provide essential information for nurses in developing an effective intervention programme. If nurses consider cultural factors that shape patients’ experiences of spiritual suffering and the healing process, they could learn how to meet the needs of patients better from different cultural backgrounds. Key words: cancer, change, healing, nursing, spirituality, suffering

Introduction Cancer, when perceived by patients as a life-threatening illness, contributes to spiritual suffering. McGrath (2002) conceptualized spiritual suffering as spiritual pain, meaning that individuals experience conflict and disharmony between their positive belief systems and the reality of their current situation. Spiritual suffering influenced patients’ abilities to cope with terminal cancer effectively because it contributed to impairments in patients’ connectedness, faith and religious belief systems, value systems, meaning and purpose in life, self-transcendence, inner peace, harmony, inner strength and energy (McMillan & Weitzner 2000, Villagomeza 2005). Previous studies have examined how to enhance patients’ spiritual well-being, the causes of spiritual suffering and strategies to heal suffering. Villagomeza’s study (2005) found that the causes of spiritual suffering among cancer patients included disease-related dilemmas (e.g. confronting one’s own mortality, enduring unbearable physical pain, feeling guilty for unhealthy behaviours in the past, experiencing the worsening effects of illness progression and enduring the complications of treatment). Other causes of spiritual suffering were patients’ interpretations of stressors (e.g. perceiving stressors as problems) and ineffective spiritual coping (e.g. lack of social support). A review study by Lin and Bauer-Wu (2003) reported that the following factors could enhance spiritual well-being among cancer patients: awareness of illness progression, social network supports, a sense of control and hope and a sense of a meaningful life. Previous studies focused on examining factors related to spiritual suffering and healing strategies. Very few studies have explored the process of what led patients to encounter spiritual suffering and, subsequently, how patients adopted 736

strategies to transform their suffering into healing. In addition, existent studies do not adequately explain patients’ experiences of the change mechanisms involved in the healing process to achieve spiritual well-being. There is also a lack of studies exploring the impact of cultural factors on spiritual suffering and the healing process. Hwang (2001) reported that, because of the influence of Confucian thought, shame in traditional Chinese culture was related to a failure to fulfil positive duties and obligations. As the disabilities caused by cancer may lead patients not to fulfil their family responsibilities, they may accordingly suffer from spiritual distress caused by their frustration at not understanding the meaning of their lives. This cultural attribution of a sense of guilt illustrates that Chinese patients may not only feel guilt for unhealthy behaviours in the past, as indicated in the Western study of Villagomeza (2005), but also for a current failure to fulfil family roles as required by Chinese cultural values. An example of a cultural pattern of healing strategies is the traditional Chinese interpretation of life misfortune as applied by Chinese culture. For example, the indigenous concept of ‘yuan’ (predestination) that remains widespread in Chinese society is based on the Buddhist belief in predestination. This concept indicates that the relationship between people and situations is determined by fate (Leung 1996). Yang (1982) argues that yuan serves as a defence mechanism, helping people attribute difficulties to external factors. As a result, a person could avoid negative emotions that might have emerged from self-blame for negative situation outcomes. The current studies do not provide evidence on how the Chinese belief in predestination helps cancer patients to accept their illness. Limited understanding about spiritual suffering and a lack of available training programmes on providing spiritual care

2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd

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(Villagomeza 2005) constitute two main reasons for the neglect of spiritual care within nursing. Moreover, few studies examine the issue of how cultural values influence cancer patients’ experiences of spiritual suffering and how the healing process may influence nurses to provide culturalsensitive spiritual care for cancer patients of different cultural backgrounds. Therefore, this study aimed to examine terminally ill cancer patients’ experiences of spiritual suffering, understand their views of the change mechanism in the healing process and explore the role of Chinese cultures in shaping such experiences.

Method This research used a phenomenological-hermeneutic approach, based on reading response theory, to analyse cancer patients’ experiences of spiritual suffering and the healing process. The study was informed by Ricoeur (1981), who observed that reading response theorists have elaborated on the chronological and social discourse qualities of all narrative by paying special attention to the ‘phenomenology of the act of following a story’ (p. 277). In the current study, the researcher applied this method to examine the interview transcripts to identify the narrative structures and explore the experiences of suffering and healing among patients with terminal cancer.

Participants Twenty-one inpatients who were diagnosed as having terminal cancer by physicians and who were over 18 years of age were recruited to participate in a semi-structured interview. Those who were unwilling to be interviewed and/or felt too uncomfortable to talk were excluded. The average age of the patients was 55, with an age range from 37–76 years. Thirty-seven percent of patients were male, while 63 percent were female. Most patients (88Æ9%) were married. The distribution of educational levels was 10Æ5% who were illiterate, 21% who attended or finished primary school, 42Æ1% who achieved junior and senior levels in high school and 26Æ4% who were college/university graduates. Only 5Æ6% of patients were not religious. The rest practised different religions: 22Æ2% Buddhism, 27Æ8% Taoism, 5Æ6% ‘Yit-Kuan Tao’ (integrated Eastern Buddhism, Taoism and Western Christianity), 22Æ2% folk religion (combined with Buddhism and Taoism) and 16Æ7% Christian. These patients suffered from colon cancer (17Æ6%), lung cancer (23Æ5%), breast cancer (23Æ5%), oesophageal cancer (11Æ8%), cervical cancer (5Æ9%), gastric

Spiritual suffering and healing process

cancer (5Æ9%), malignant neoplasm of the brain (5Æ9%) and multiple melanoma (5Æ9%).

Data collection The institutional review board approved this study before the researcher approached the patients to enter the study. The potential subjects obtained information about this study from nurses or physician’s assistants. All participants gave their written consent to participate in the study after nurses or physician’s assistants had explained the study’s purpose, content and possible benefits. They were also informed of the procedures to be taken to protect the confidentiality of the data they provided. The qualitative data were collected through a semi-structured interview with patients by nurses and physical assistants in the inpatient unit in the oncology department in two general hospitals. Interviews lasted for an average of 40–90 minutes. Open-ended questions were used in an interview guide (Table 1) to explore the lived experiences of spiritual suffering and the healing processes among patients.

Data analysis The researcher used Ricoeur’s reader response theory as applied by Good (1994) to analyse the interviews. This method involves three analytic elements: emplotting, subjunctivizing and positioning of suffering. Emplotting refers to the process of identifying prototypical plot types as forming the underlying structure to a case story. Subjunctivizing refers to the process of identifying multiple perspectives and potential outcomes in narrative stories. Positioning of suffering refers to the process of examining the meanings of suffering in everyday life experience. According to Good, the following steps allow for an acceptably reliable interpretation of interviewees’ stories: (1) reveal the story structure and

Table 1 Interview guide 1. After you became ill, what aspects of life, such as interpersonal relationship changes, economic changes and so on, have changed? 2. How have these changes influenced your view of life? For example, what are the meanings of living? What do people come to this world for? 3. In the process of suffering from illness, what factors have influenced your view of life, such as the words provided by your family, friends, a book, or religious belief? 4. How do you cope with suffering from illness? 5. What do you think is the power which provides you with support to go on with your life?


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identify the prototypical plot types, (2) identify domains and themes associated with each plot type and (3) establish the validity of meanings carried by the observed themes. The third step can be accomplished by replicating the meaning using cross-situational, respondent, or narrator approaches.

Results The identified prototypical plot types, domains and themes are shown in Table 2. The details of the results are presented in accord with the steps of the analytic method as follows:

Reveal the story structure and identify the prototypical plot types As indicated in Table 2, analysis yields three prototypical plot types. All types share the common story structure organized by the sequential ordering of events and the relationships that link them to one another: having been diagnosed as a cancer patient, encountering spiritual suffering, receiving treatments, experiencing disability problems and using different coping strategies. Under the common story structure, three prototypical plot types could be identified among 21 case stories according to who was mainly relied on patients’ experiences

Table 2 Plots and themes identified from the narrative interviews Structures of the Narrative Interviews Plot I (2 patients)

Plot II (4 patients)

Plot III (13 patients)

Rely on self Domain: suffering Theme 1 Feeling distressful because of physical pain Theme 2 Pessimistic thoughts about wanting to die Theme 3 Lack of support

Rely on others Domain: suffering Theme 1 Feeling a fear of death

Rely on self and others Domain: suffering Theme 1 Feeling a fear of death

Theme 2 Feeling distressed because of physical pain

Theme 2 Feeling distressed because of physical pain

Theme 3 Feeling sad and hopeless because of disability problems Theme 4 Sense of guilt for being the family’s burden Theme 5 Pessimistic thoughts about wanting to die

Theme 3 Feeling sad and hopeless because of disability problems Theme 4 Sense of guilt for being the family’s burden Theme 5 Pessimistic thoughts about wanting to die

Domain: healing Theme 1 Passive attitudes towards life meanings

Domain: healing Theme 1 Being empowered and having a better feelings through encouragement from family, friends and/or other cancer patients Theme 2 Sense of being protected through practising religious worship

Theme 6 Self-blame for doing wrong things Theme 7 Feeling sad and hopeless because of lack of support from some family members or friends

Domain: healing Theme 1 Being empowered through encouragements from, family members, friends and/or other cancer patients Theme 2 Feeling released through patients practising beliefs of letting go and living in the moment Theme 3 Gaining positive view of life meanings through searching for religious and other explanations Theme 4 Being self-transcendent through helping other cancer patients

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of suffering and the healing process. Accordingly, all case stories fell into three plot types: Plot I, rely on self; Plot II, rely on others; and Plot III, rely on self and others. Of the patients studied, two fell into Plot I, four fell into Plot II and 15 fell into Plot III.

Identify domains and themes under each plot type As shown in Table 2, the domains and the themes under each prototypical plot type emerged in this study. Two domains were identified in all plots: suffering and healing. Under domains, emerged themes were causally related. For example, for Plot I, under domain of suffering, three themes demonstrated that physical pain caused by cancer and chemotherapy resulted in patients’ feeling distressed and having pessimistic thoughts about wanting to die early. Lack of support enhanced patients’ pessimistic view of spiritual suffering. Under the domain of healing, patients held passive attitudes towards life meanings. For Plot II, the domain of suffering indicated that cancer patients perceived their disease as life threatening. Pain and disability problems caused by the symptoms of cancer and chemotherapy led them to feel fear, distress, sadness and hopelessness. Their negative feelings influenced them to view life meanings pessimistically and to wish to die. The healing domain demonstrated that support from family members, friends and other cancer patients empowered the patients mentally. As a result, patients’ distressful feelings were improved. Moreover, through practising religious worship, patients’ felt calm because they had a sense of being protected by a supernatural power. For Plot III, in addition to the common experiences of suffering indicated in the results of Plot II, patients appeared to have self-blame for doing wrong things that in turn caused their illness. Traditional Chinese culture emphasizes the value of filial piety, which reinforced a patient’s sense of guilt for being a family burden and not being able to fulfil his/her roles. The negative feelings influenced them to view their lives as worthless. In the domain of healing, in addition to relying on help from others as indicated in Plot II, patients themselves tried to renew their efforts to search for life meanings. Through patients practising the beliefs of leting go and living in the moments, their feelings of uncertainty, tension and fear were released. Thus, the positive views of life meanings arose. Self-transcendence was discovered among patients who were volunteers and provided care for other cancer patients. Not only relying on protection from a supernatural power, but also these patients searched for the meaning of their suffering. In turn, they gained a positive view of life.


Establish the validity of meanings carried by the observed themes In this study, an independent reviewer and the researcher (the correspondent author) verified the validity and reliability of the analysis. Validity was achieved by verifying the meanings of people’s interpretations of their experiences related to the local world (Kleinman 1994). Through reviewing all verbatim transcripts, the researchers first identified the structure of narrative stories. The prototypical plot types were verified for distinctive meanings of the experiences among all stories. Themes under the domains of suffering and healing were verified after the researchers examined the meanings of patients’ interpretations in relation to context, process and the patients’ social and cultural contexts. All emerging themes were determined when agreement was reached. For example, various meanings of spiritual suffering given by subjects were identified in terms of the causes of distress such as symptoms of cancer, disability problems, or feelings of inadequacy for not fulfilling their roles in the family. Concerning the impact of the researcher’s subjective interpretations of the meanings of subjects’ stories in the analytic process, Kleinman (1994) argued, ‘What the anthropologist seeks to achieve is not objectivity of observation, but controlled interpositionality of interpretation in an academic discourse’ (p. 132). The results of case narration that emerged from the analytic process are presented below.

Plot I: rely on self Mr Wu had suffered from liver cancer for over one year. Persistent physical pain from cancer and chemotherapy made him feel angry and view the world pessimistically. He said, ‘I have been tolerating pain for a long time. In this torturing process, I with this tortured body have been through a difficult time. I feel very painful. If I could die early, I would not experience the torture anymore’. He complained that his children took his money but did not take a good care of him. Lack of support from family members contributed to his passive attitudes towards life and death. He described, ‘They took my money. But they do not take care of me. It is impossible for them to pay for my medical fee. This is the reason why I feel painful in my mind. I wish they could take good care of us [his wife and him]. But when we do anything which makes them feel upset, they talks to us loudly… I feel nothing about death. There is nothing I cherish in this world’.


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Plot II: rely on others

Buddha’s mercy in order to change bad cells in the body into good

Mr Lin had suffered from oesophageal cancer for over a year. His disease resulted in his uncomfortable feelings. He reported, ‘I cannot tell you to what extent this illness caused me pain because it is too painful to tell you exactly. My body is not well. My mind is not well either’. His children taking good care of him led to feelings of guilt because he thought that he had become a burden in the family. His pessimistic thoughts about wanting to die early came out. He described: ‘I think I may feel happier and feel free if I die early. I do not want to be tortured any more. I am very tired of having this kind of life. My children are very kind. But I wish to die early so as not to be their burden’. Religious belief was the main source he relied on for his suffering. Practising religious worship made him feel protected and cared for by God. Another patient, Mr Yu, had suffered from lung cancer for two years. His spiritual suffering was related to his fear of death, there being no medication to cure his illness and the pain he suffered because of complications in his chemical therapy. In his view, supports from family members, friends and other cancer patients were the main resources to keep him up. He said ‘If you deal with this illness alone, no one encourages you. It will be very lonely so that you will give hope up easily. Receiving chemical therapy influences your appetite. My wife and my sister keep asking me to eat some. If I do not eat, I feel that I will let them down’. He also reported on help from other cancer patients: ‘We met in the hospital. Then, we encouraged each other and made fun of each other, which made us feel better. When you feel better, you feel less pain’.

cells. Moreover, when you lived happily everyday, you would make cancer cells become good cells. If you were not happy, it would make your bad cells worse. I tried to practise what the books suggested. When my physical condition was not very bad, I practised this method and then felt more relaxed.

She read books about how other cancer patients survived with their strong will. She mentioned: ‘I often talked to myself and said that I wanted to be tough and to live with a strong will. I wanted to live happily everyday. For this reason, my suffering mind was transformed’. Her belief in living for the day and in this moment also helped improve spiritual suffering. She relates, ‘At that time, I had a dream where I could move my legs and could go somewhere. But when I woke up, I found I still could not move my legs. I felt depressed. But I thought living happily or not happily was a one-day-at-a-time process. What was the point of being depressed?’ Now she finds herself caring about family members and others more than before when she focused only on her own enjoyment. She wants to be a volunteer helping others in the hospital. Now she thinks that the purpose of life is to experience and deal with many stresses and challenges. Mrs Wang is the only patient who reports receiving counselling provided by a psychologist in the hospital. She says: A psychologist often came to see me. I could release the pressure suppressed in my mind through talking and communicating with him. For example, a while ago, one patient who was my roommate in the hospital died. Two days later, another one died. I felt so scared. He took me to the living room and talked to me. After talking with him, I felt better. At that time, I felt scared to hear about their family

Plot III: rely on self and others

members crying. The crying reminded me of the time when my

Mrs Wang had suffered from malignant haemangiopericytoma for two years. She recalled when she firstly learned that her problems had been diagnosed as cancer. She could not accept the diagnosis and felt angry. She asked, ‘Why me?’ She blamed herself and felt guilty for not exercising and for eating meat. She believed these practices caused her cancer. Disability problems caused by the immobility of her legs led her to feel despair and hopelessness. She thought about ending her own life because it was too painful to be alive. She commented, ‘People coming into this world, not for enjoying it but for experiencing suffering’. Reading books about how to survive from cancer transformed her experiences. She commented: At that time I read a book about how to change cancer cells into good

mother died. He wanted to help me find the cause of my fear. But we still could not find the reason.

While the psychologist provided counselling, in her view doctors and nurses helped her deal with physical pain. For another patient, Ms. Wu, her breast cancer, which could become life threatening, influenced her life in that she might not to be able to take care of her parents in the future. As a result, she felt guilty for not being a good daughter who should be alive when her parents needed her care in accord with the traditional Chinese cultural value of filial piety. She said, ‘I am still young and my parents are alive. If my life is going to be taken away, my leaving this world shows that I am not fulfilling my duty of filial piety to my parents’. Her relapse led her to learn to let go not to put all responsibilities on herself. As a result, the sense of guilty was released.

cells. In this book, they suggested that you think often about

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Moreover, her belief in religion helped her accept her death because she said, ‘Religion makes me know where I will go when I die’. For the other patient, Mrs Wong, the religious belief in karma (wrongdoing in one’s previous life resulting in an obstacle in her current life) influenced her to attribute suffering from cancer to her wrongdoing in a past life. She described, ‘Suffering from this illness may be related to karma. This explains why not others but I suffered from this illness. People say the fortune in the present life comes from doing good things in the past life. For me, probably I did something that I should not have performed in the past life, so I got this illness….’ Her searching for life meanings contributed to her positive view of her present life. In thinking about life meanings, she said, ‘I have been making contributions to society for seventeen years, so my life is not meaningless. I have performed enough for my life’. Traditional Chinese cultural belief in fate helped her accept the fact that her husband had an affair with another woman and did not provide care for her. She described, ‘For the relationship with him, I believe it is my fate. The only thing I can do is to accept it as my fate… I think that the environment can make a person to be strong. Hardship has its own meanings. It can make a person reach achievement’. For Mrs Wu, the Chinese belief in yuan (predestination) helped her appreciate what she had in life and to accept what would happen in the future. She said: Belief in yuan is the strength keeping me up. We do not have children, so our worry is different from others. To me, what I have is enough because I always take everything seriously, no matter how big or small it is…The meaning of my life is worthwhile because of the many things I have performed with my best effort…For death, everyone will go through this process finally. Cancer patients just meet with the issue of death earlier than healthy people.

Discussion Spiritual suffering This study and other studies (Lin & Bauer-Wu 2003, Villagomeza 2005) found that cancer patients experienced spiritual suffering because their perceptions of suffering from cancer as a death sentence threatened the meanings and purposes of their existence. More reasons for spiritual suffering included physical pain, treatment complications, uncertain illness progression, disability problems and lack of support. The manifestations of spiritual suffering included emotional aspects (feelings of fear, sadness and hopelessness) and thought aspects (pessimistic feelings of wanting to die


early and negative thoughts about self). This study demonstrated that cultural factors played an important role in shaping patients’ experiences of spiritual suffering. Cultural values influenced their interpretations of the stress arising from suffering from cancer. For example, Chinese cultural values, which emphasize filial piety, influenced cancer patients to have a sense of guilt. This was a fear of not being able to fulfil obligations of taking care of parents in accord with the value of filial piety as cancer would take their lives away from their parents. Their self-blame contributed to a negative view of self and pessimistic thoughts about the meaning of life. This result supported Bedford and Hwang’s study (2003), which suggested that the personal identities of Chinese people are dependent upon their performance of responsibilities in their social role. Because of the influence of Buddhism belief and a belief in ‘karma’ (wrongdoing in one’s previous life resulting in obstacles in the current life), one patient attributed her suffering from cancer to doing wrong things in the past life. This casual interpretation of illness resulted in the patients’ self-blame.

Change mechanisms in healing process This study and a number of studies (Koopman et al. 1998, Giese-Davis et al. 2000, Sherwood 2000, Narayanasamy 2002) illustrated that cancer patients’ connections to support systems were positively related to coping effectively with spiritual suffering. The encouragement from social networks, including family members, friends and other cancer patients, contributed to a patient’s desire to live. Patients perceived that empathy from other cancer patients strengthened their belief that only those who had similar problems could understand what it is like to suffer from cancer. Support from other cancer patients, including providing related information about illness and treatment, sharing feelings and providing coping strategies, helped patients have a sense of calm and hope. Moreover, patients learned from other cancer patients that helping others with cancer was important to the meanings of life’s purpose; through this knowledge, patients developed confidence in their own self-existence. Cancer patients considered the assistance and care they received from their families as the most important resource in their healing process. Trust and reassurance were also evident in the behaviour of family members as they provided social support to patients. These family members applied religious meanings and beliefs in life meanings to interpret patients’ suffering. Their reinterpretation helped patients reduce the sense of anxiety, fear and hopelessness. Consistent with previous studies (Narayanasamy 2002), for patients, searching meanings for spiritual suffering was an


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essential coping strategy when meanings of the patients’ existence was threatened by suffering from cancer. The meanings emerged from reinterpretations of suffering contribute to healing (Kleinman 1988). This study and the study by Benzein et al. (2001) suggested that the emerging positive meanings of purposes of life could help cancer patients in coping effectively with spiritual suffering. For example, for some patients, emphasizing their current contributions of serving as a volunteer and of completing the responsibilities of taking care of children helped relieve their sense of guilt caused by the cultural belief in karma (wrongdoing in one’s previous life resulting in obstacles in the current life). Through self-affirmation, cancer patients viewed positively what they had performed with their best efforts in the current life; thus, they achieved peace of mind. This study revealed that a number of factors enhanced cancer patients’ feelings of self-transcendence: patients providing support for other patients, perceiving suffering from cancer as a life challenge, possessing a will to live and changing attitudes towards family members. Being a volunteer and providing care for other cancer patients caused patients to view their own existences positively because they were not only patients but also helpers. Perceptions of suffering from cancer as a life challenge helped patients not only to view their suffering positively but also to regard solving challenges as self-achievement. The will to live strategy led cancer patients to be proud of their strength to overcome suffering. The change of attitude towards and caring for family members transformed their suffering to a healing status of self-transcendence because these patients appreciated their ability to establish intimate relationships. This study illustrated that a belief in living for the day and in the moment and a Chinese belief in yuan (predestination) influenced cancer patients’ cognitive appraisals of their situations and, subsequently, transformed their negative emotions into peaceful states of mind. The attitude of living for the day and in the moment was commonly used by cancer patients. This attitude influenced them to appreciate their existence and emphasized joy and contentment in the current life. Buddhist belief in yuan (predestination) is commonly used by Chinese people to cope with the distress emerging from life problems (Huang et al. 1983). In this study, patients applied this belief in coping with marital problems and with anxiety about the progression of their illness in the future. This study and the studies (Huang et al. 1983) found that yuan was believed by Chinese people to explain that fate was changeable, unpredictable and uncontrollable. When Chinese people attributed negative situations to yuan, they were more likely to recover from emotional distress. This belief in fatalism helped them accept troublesome situations. Cancer 742

patients accepted that things could not be controlled and were determined by fate which resulted in patients suffering from cancer, treatment outcomes, illness progression and completion of responsibilities to take care of parents according to the Chinese value of filial piety. Subsequently, patients practised letting go and forgiveness to release their feelings of guilt, tension and fear. This study and the previous studies (Fitchett 1995, Sherwood 2000, Narayanasamy 2002) revealed that cancer patients perceived religious belief as an important source when they went through spiritual suffering. Through patients’ practising religious worship, patients believed that they were protected by a supernational power and that they could turn their difficulties to God. This belief influenced them to perceive their situations as less threatening and frustrating. The elements of religious healing also included relieving unpleasant emotions, engaging in social activities, achieving a peaceful mind and life and achieving a positive prospect. A previous study also supported these same findings (Herth & Cutcliffe 2002).

Limitations and implications The small sample size of 21 patients may limit generalizing the results to the majority of patients with terminal cancer. Because there were few patients under the age of 30 in this study, the researchers were not able to make assertions about the impact of belief in traditional Chinese cultures on the patient’s life experiences of spiritual suffering and the healing process. Nevertheless, the results of this study suggested that the patients over age 30 were influenced by traditional Chinese cultures in their interpretations of life meanings and purposes. The study indicated that, while encouragement from other cancer patients, family members and friends were the main sources of patients’ receiving psychological and spiritual support, nurses mainly provided management for physical pain. This suggested a lack of involvement by nurses in providing spiritual care for patients with terminal cancer. The implications of this study for the nursing practice include understanding spiritual needs through conducting spiritual and healing assessments to elicit the complexity of spiritual suffering and developing an intervention programme based on the view of cancer patients on the change mechanisms of healing process. The contents of assessment may include assessing the changes of life as patients have been diagnosed with cancer, the impacts of the changes on the views of life meanings, other factors influencing their views on life meanings, the strategies used to cope with spiritual suffering and the strength that protects them from spiritual suffering.


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Developing an intervention based on patients’ views of the elements of healing process may enhance internal and external resources. External resources include peer support groups and family support. Internal resources include empowerment strategies, such as helping patients to regard suffering as life challenge, serving as volunteers helping other cancer patients and reinforcing life wisdoms based on Eastern and Western philosophies of traditional Taoism, Confucianism, Buddhism and Christianity. Understanding the impacts of cultural factors on shaping lived experiences of spiritual suffering and the healing process may help develop culturally sensitive spiritual care for patients with different cultural backgrounds

Acknowledgements This study was supported by a grant from the Chi-Mei Medical Center-Taipei Medical University (94CM-TMU-07). I would like to express my particular appreciation to the cancer patients for generously sharing their stories for this study.

Contributions Study design: FHH, FJS; data collection: CCC, JFC, HWL; data analysis: FHH, YTC and manuscript preparation: FHH.

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