Abstract
This systematic literature review analyzed the construct of spirituality as perceived by people who have experienced or are experiencing a major life event or transition. The researchers investigated studies that used narrative analysis or a phenomenological methodology related to the topic. Thematic analysis resulted in three major themes: (1) avenues to and through spirituality, (2) the experience of spirituality, and (3) the meaning of spirituality. The results provide insights into the intersection of spirituality, meaning, and occupational engagement as understood by people experiencing a major life event or transition and suggest further research that addresses spirituality in occupational therapy and interdisciplinary intervention.
Within occupational therapy, there have been three major, but distinct, research foci related to spirituality. The first highlights the use of spirituality when dealing with a major life event (Morris, Johnson, Losier, Pierce, & Sridhar, 2013; Pillay, Girdler, Collins, & Leonard, 2012). Second, the benefits of spirituality have been studied in association with the engagement in select occupations (Tzanidaki & Reynolds, 2011; Unruh & Hutchinson, 2011). Third, researchers have investigated the meaning of lived experiences in which spirituality is identified as an integral part of that experience (Boswell, Hamea, Knight, Glacoff, & McChesney, 2007).
Recently, the occupational therapy literature has shifted to examining the intersection of engagement in spirituality within a life circumstance or transition, engagement in select occupations, and the meaning of the lived experience (Beagan, Etowa, & Bernard, 2012; Smith & Suto, 2012). Although the results provide valuable insights, the studies have been limited in number.
The purpose of this systematic literature review was to elucidate how people dealing with a major life event or transition use spirituality and make meaning of their experiences and to see whether spirituality would have any association, direct or indirect, with occupational engagement. A major life event or transition may be characterized as any situation or circumstance that alters a person’s life in a substantial way, implying some level of role change or adaptation. A major life event entails a sudden and dramatic change, and a transition implies an ongoing adjustment.
Method
Design
A systematic literature review allows researchers to analyze the applicable literature with the intention of adding to the existing data on a particular topic (Portney & Watkins, 2009). Descriptive, thematic analysis, with themes purposefully selected for this broad literature review, allowed a collective synthesis with a low level of interpretation (Bearman & Dawson, 2013; Vaismoradi, Turunen, & Bondas, 2013).
Procedures
The researchers searched the EBSCOhost, Academic Search Premier, CINAHL with Full Text, Medline, ATLA Religion, PsycARTICLES, and PsycINFO databases, beginning with the term spirituality and then the type of methodology (phenomenology or narrative analysis) and a specific term pertinent to major life change: life change, disability, illness, death, crisis, conflict, rehabilitation, stress, trauma, substance abuse, abuse, mental health, marriage, or children. The abstract of each article was then reviewed to assess whether it met the following inclusion criteria: (1) empirical and peer reviewed, (2) published from January 2011 through January 2014, (3) published in English, (4) used narrative analysis or a phenomenological methodology, and (5) addressed the concept of spirituality and major life events or transitions.
After 60 applicable articles were retrieved, the researchers discontinued the search process and systematically extracted 15 articles to further analyze. On the basis of this review, the following research questions were further clarified and became the foundation of the coding sheet: (1) What are the avenues to and through spirituality? (2) What is the experience (outcome)? (3) What is the meaning of spirituality to people dealing with a major life event or transition?
The 60 articles were then randomly assigned to the researchers, and each article was thoroughly reviewed to determine whether it met the inclusion criteria, including whether the methodology and results were congruent with the research question (Joanna Briggs Institute, 2014). Each article was coded independently by two of the researchers. One article was ultimately eliminated from the review because it did not meet the inclusion criteria.
Data Analysis
To situate this review and assess the diversity of the 59 articles, demographic information related to the participants’ religious affiliation, if any; gender and age; and country was collected. The authors’ disciplines were determined to be academia (n = 8), art therapy (n = 1), business (n = 1), counseling (n = 2), nursing (n = 18), occupational therapy (n = 5), medicine (n = 7), psychology (n = 9), social work (n = 11), and undetermined (n = 7).
Descriptive coding—words and phrases capturing the preliminary themes—was completed for all 59 articles (Saldaña, 2013). Focused coding and thematic analysis were then completed on the collective data. Categories were established with relevant definitions and descriptions, and thematic analysis among and within articles was conducted, highlighting major themes and establishing subthemes and preliminary interconnections between themes (Saldaña, 2013; Vaismoradi et al., 2013).
Results
Demographic Information
The articles spanned the types of major life events and transitions reported, religious affiliations represented in the studies, geographical locations where participants lived, and participant demographics in age and gender. Although the demographic information the articles provided was diverse, the majority of the articles focused on medical- and health-related events, end-of-life concerns, and related caregiving (n = 35 articles). Participants were predominantly adults ages 18–60 yr (n = 33 articles), Christian (n = 32 articles), and from North America (n = 26 articles).
Overarching Themes
Three major themes arose from the analysis: avenues to and through spirituality, the experience of spirituality, and the meaning of spirituality.
Avenues to and Through Spirituality.
The theme of avenues to and through spirituality represents the actions, mechanisms, and activities that people used to cope with their current situation or life challenge; subthemes include spirituality affiliated with religion, coping mechanisms and activities, and relationships. Some of the avenues identified had a direct connection to spirituality, whereas other avenues either supported spirituality or were interconnected with it.
Avenues related to spirituality affiliated with religion include speaking with religious authorities and engaging in prayer and other religious rituals and routines. The overarching belief of Faith and God grounded these activities and were associated with a general but highly valued and life-sustaining trust in God regardless of the hardship or situation (Hong & Welch, 2013).
Additional avenues to and through spirituality were identified beyond religious activities. Participants in the reviewed studies articulated that engaging in coping mechanisms and activities fostered some sense of emotional or physical release (Rehnsfeldt & Arman, 2012) or increased self-identity and awareness (Mihalache, 2012; Smith & Suto, 2012) that ultimately influenced spiritual well-being. Coping mechanisms could include actions that may have been considered big steps or acts of desperation (Hong & Welch, 2013; Sharpe, Joe, & Taylor, 2013); ignoring problems or distancing oneself from the event (Hutchinson, Hersch, Davidson, Chu, & Mastel-Smith, 2011); and time-fillers that brought temporary relief from the uncertainty and anxiety associated with life challenges (Sharpe et al., 2013; Teti et al., 2012).
Relationships entailed connecting with others as a beneficial way to experience spiritual wellness (Tan, Wilson, Olver, & Barton, 2011), undergo personal transformation (Saeteren, Lindström, & Nåden, 2011), and have an opportunity to fulfill a spiritual quest to give back to others (Humbert, Bess, & Mowery, 2013).
Experience of Spirituality.
The theme of experience of spirituality highlights the expressed and observable outcomes or results of engaging in spirituality and is represented by the subthemes of embracing acceptance; dealing with suffering, fear, and guilt; finding hope and the will to fight; growing or moving forward or away; and developing resilience.
Acceptance, a newly found recognition or validation of the self, comes from an internal, renewed, or redefined self-identity or through others, a higher being, or both (Allen & Brooks, 2012; Bong, 2011). Acceptance from family, friends, and groups enabled participants to find purpose and meaning (Tan et al., 2011), endure the challenge (de Guzman et al., 2011), or accept unconditional care (Hertz, Addaad, & Ronel, 2012). Acceptance from a higher power reflected a belief in a higher power’s authority and ability to heal, help, and guide (Dittman, 2012; Wade, 2013).
As part of the spiritual experience, participants frequently needed to deal with suffering, fear, and guilt specifically related to the life transition or event. Participants' spirituality either helped them diminish or resolve these feelings or provided them with the strength to endure or face them (Bong, 2011; Denney, Aten, & Leavell, 2011).
Finding hope, described as a spiritual belief that enables people to trust that “things are going to work out somehow” (Wade, 2013, p. 1143), was expressed in reference to a better future, as a way to live, as recognition of God’s support, and as a mantra to overcome hardship (de Guzman et al., 2011). Finding the will to fight results in direct action to deal with the life circumstance as a result of finding hope (Hong & Welch, 2013).
Multiple authors described participants’ experiences of growing as they moved forward in dealing with the major life event (de Castella & Simmonds, 2012; Fallah, Keshmir, Kashani, Azargashb, & Akbari, 2012). One author described participants’ experiences of moving away from failure and suffering toward a more positive future after finding some hope and growing through the experience (Humbert et al., 2013).
Developing resilience was depicted as an important quality to have or acquire to enhance one’s abilities, overcome illness, and accept change. It was influenced or heightened through participants’ ongoing engagement in spirituality and working through challenging life events (Fallah et al., 2012; Price, Kinghorn, Patrick, & Cardell, 2012).
Meaning of Spirituality.
The theme of the meaning of spirituality represents how people make sense of what has happened to them or family members in the larger context of life. Subthemes include purpose and life meaning, trust in a higher power, positivity and acceptance, connectedness, questioning of God or reality, and critical thoughts and questions.
The subtheme of purpose and life meaning encompasses a sense of direct and divine purpose for one’s life (Denney et al., 2011), with the idea that experiencing a challenging life event is part of some larger scheme, often outside of the person’s control. The person may not necessarily attribute this plan to a higher being or power. In addition, the person may or may not fully understand the event’s purpose and life meaning but still acknowledges it as being part of or important in providing something better to others or life in general (Unruh & Hutchinson, 2011).
The subtheme of positivity and acceptance involves being able to find some sense of beauty or gift within the experience of suffering or in daily life. Despite the life circumstances and pain suffered, people may still find a sense of personal strength through the ability to see beauty in life (Price et al., 2012), and the intricate web of personal encounters and relationships (Bornsheuer, Henriksen, & Irby, 2012).
Life challenges were the impetus behind participants’ questioning of God or reality to further their understanding about God or a higher power (Collin, 2012; Hattie & Beagan, 2013) and led them to seek something beyond themselves (Gottheil & Groth-Marnat, 2011). The discovery of those answers or insights, when clarity was gained from the questioning, included increased self-awareness or perspectives that participants had not previously considered (Bong, 2011), some enlightenment that provided them reassurance (Mitchell, Silver, & Ross, 2012), hope (Mitchell et al., 2012), or a new image of God (Kim & Pak, 2013).
Critical thoughts and questions (i.e., the reason for our existence) may have been directed to others or to God or a higher power, but they may also have been directed to no one in particular (Rehnsfeldt & Arman, 2012; Van Lith, 2014). Making sense of a challenging life event frequently evoked these questions, and although participants may not have received a tangible answer or response, some found meaning in the discovery of life purpose, the acceptance of mystery or the beauty of not knowing, and the possibility that insight into these questions might one day be realized (Mihalache, 2012; Saeteren et al., 2011).
Discussion
The studies reviewed did not use the terms occupations or occupational engagement, but the theme of avenues to and through spirituality best reflects this potential construct. This theme emphasized multiple aspects of doing, such as speaking with religious leaders and engaging in prayer, religious rituals, and actions. Aspects related to doing, along with being, becoming, centeredness, and connectedness (Kang, 2003), were also reflected in both the relationships and the coping mechanisms and activities subthemes. The wide range of activities to and through spirituality suggests a variety of occupations that are not reflected in the description of spirituality in the Occupational Therapy Practice Framework: Domain and Process (Framework; American Occupational Therapy Association [AOTA], 2014).
The Framework identifies spirituality as a client factor and notes its relationship to instrumental activities of daily living (religious and spiritual occupations) and rituals. However, the results of this literature review suggest that people engage in spirituality in diverse and complex ways that are interconnected within occupations, client factors, contexts, and rituals.
Significance of Findings
What appears to be missing from the current professional definition and description of spirituality (AOTA, 2014) and the occupational therapy literature is how people actually deal with suffering, fear, and guilt; how these feelings influence self-identity; and how occupations may be used to cope. This interrelated relationship with spirituality appears diminished because the complexity and significance of suffering, pain, and guilt are not clearly articulated in the occupational therapy literature beyond some knowledge or general recognition of the experience. Although researchers have some understanding of the interconnection of occupations, the experience of spirituality, and the meaning of spirituality, the occupational therapy literature lacks an understanding of the turning point of acceptance, the process or evolutionary journey of spirituality over time, and how spirituality affects adaptation and vice versa. All the studies reviewed, as well as the studies in the occupational therapy literature that intersect with occupational engagement, spirituality, and meaning making (Beagan et al., 2012; Smith & Suto, 2012), entailed a retrospective snapshot or current perspective of the participants. These two perspectives may not fully capture the subtle details of an ongoing spiritual journey.
Review Limitations
The limitations of this review include the article retrieval method within a select time frame and restriction to available databases, and the descriptive terms chosen by the researchers may not have reflected all major life events. The collective perspective used in formulating the study and reporting the results suggests a positive constructivist and optimistic stance, which may not give attention to the unique social–cultural–political differences within the analysis (Savin-Baden & Howell Major, 2013).
Implications for Occupational Therapy Practice
An interdisciplinary approach to address and support clients in their own meaning of spirituality is recommended (McSherry, 2006). Referring clients to professionals who have the education, training, resources, and prescribed role to engage in philosophical and theological conversations related to meaning and spirituality is advised (Galek, Flannelly, Koenig, & Fogg, 2007). However, occupational therapy’s unique role in and contribution to the team approach in addressing spirituality, particularly the influence of occupations on the experience of spirituality, and even potentially the meaning of spirituality as it relates directly to occupational engagement, also warrants ongoing study.
This review has the following implications for occupational therapy practice:
• An interdisciplinary approach in using spirituality in practice is recommended.
• The use of occupations within intervention may be used to elicit meaning and facilitate the experience of spirituality.
• Occupational therapy practitioners should be sensitive to the unique needs and desires of clients when using spirituality to deal with major life events.
Conclusion
This literature review helps validate the importance of understanding the occupations in which people engage with spirituality during a major life event or transition. Our results indicate that the experience of spirituality is associated with internal experiences related to embracing acceptance and dealing with suffering, fear, and guilt and may be interconnected with the subthemes of growing and moving forward or away and finding hope and the will to fight.
This review of the current literature suggests that people who have experienced or are experiencing a major life event or transition frequently attempt to make sense of it. The questions of why, for what purpose, and what the event signifies imply questioning reality, the presence of a life force or higher being, and human nature and existence. For some people, questioning and searching provide greater commitment to and reassurance regarding life views and life purpose, and for others, critical thoughts and questions may lead to acceptance of mystery. In any case, the meaning gained, or the ongoing wrestling with ideas, provides people with motivation to move forward in the spiritual experience and engage in avenues to and through spirituality.
Footnotes
*
Indicates studies that were reviewed for this article.