Spiritualty and HIV Disease: An Integrated Perspective

JANAC Vol. 12, No. 3, May/June 2001 McCormick et al. / Spirituality and HIV Disease

Spiritualty and HIV Disease: An Integrated Perspective Douglas P. McCormick, MS, RNCS, FNP Barbara Holder, RN, PhD, FAAN Margaret A. Wetsel, RN, CS, PhD Tony W. Cawthon, PhD Spirituality is an important resource that individuals use to cope with a chronic illness such as HIV disease. Spirituality has both a religious and an existential component that share the concepts of meaning in life, hope, self-transcendence, and rituals. An integrated perspective utilizing these shared concepts is proposed to assist HIV-positive individuals in coping with the challenges of their disease. Nursing interventions include promoting hope, teaching, sharing information, and creating a sense of empowerment in people with HIV to address spiritual issues. The article concludes with a case study that emphasizes application of the integrated perspective of spirituality with an HIV-positive person. Key words: spirituality, HIV/AIDS, nursing, coping

S

pirituality is a resource that chronically ill individuals, including those infected with HIV disease, use to cope with the physiological and psychosocial challenges of illness (Carson & Green, 1992; Carson, Soeken, Shanty, & Terry, 1990; Coleman & Holzemer, 1999; Fryback & Reinart, 1999; Hall, 1998; Harrison, 1997; Kendall, 1994; Landis, 1996; Matthews et al., 1998; O’Neill & Kenny, 1998; Peri, 1995; Relf, 1997; Soeken & Carson, 1987; Sowell et al., 2000). Although new drug therapies have helped persons with HIV disease live longer (Brashers, Neideg, Reynolds, & Haas, 1998), many of these people still face significant disruptions in their quality of life. Most HIV-infected individuals experience some degree of fear, anxiety, and frustration as they confront and manage pain, uncertainty, and changes in body image (Fryback &

Reinart, 1999; Harrison, 1997; Landis, 1996; Nunes, Raymond, Nicholas, Leuner, & Webster, 1995; O’Neill & Kenny, 1998; Peri, 1995; Soeken & Carson, 1987). Information about the effects of spirituality on the health and well-being of persons infected with HIV disease is limited. The research and anecdotal information that exists generally presents spirituality from either a religious or an existential perspective. This dichotomous view of spirituality limits the options available to advanced practice nurses in the provision of holistic health care to patients infected with HIV disease (Hickey, Ouimette, & Venegoni, 2000). In contrast, an integrated perspective of spirituality that includes the components of religion and existentialism has the potential of serving as a framework for developing comprehensive and effective nursing strategies that more fully address the spiritual needs of HIV-infected patients (Soeken & Carson, 1987). An integrated view of spirituality and the effects of spirituality on the health and well-being of HIV-infected persons will be presented, followed by a discussion of implications for advanced nursing practice and research. Douglas P. McCormick, MS, RNCS, FNP, is a family nurse practitioner in the Infectious Disease Clinic of the Greenville Hospital System, Greenvile, SC. Barbara Holder, RN, PhD, FAAN, is an associate professor, and Margaret A. Wetsel, RN, CS, PhD, is an assistant professor at Clemson University School of Nursing. Tony W. Cawthon, PhD, is an assistant professor at Clemson University School of Education, Clemson, SC.

JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 12, No. 3, May/June 2001, 58-65 Copyright © 2001 Association of Nurses in AIDS Care

McCormick et al. / Spirituality and HIV Disease

59

Spirituality: An Integrated Perspective Spirituality is an intrinsic energy source that has a basis in both religion and existentialism (Fryback & Reinert, 1999; Kendall, 1994; Landis, 1996; Relf, 1997). Religion is a system of organized religious beliefs and practices related to a higher power (Fryback & Reinert, 1999; Landis, 1996; O’Neill & Kenny, 1998). The religious perspective advocates the belief that a divine influence operates within a person and serves as a guide for behavior (Landis, 1996; Peri, 1995; Soeken & Carson, 1987). In contrast, existentialism focuses on individual concerns and finding meaning in life and is expressed as a person’s knowledge of self, interaction with others, and sense of purpose (Carson & Green, 1992; Kendall, 1994; Landis, 1996; O’Neill & Kenny, 1998). Spirituality is an abstract concept that defies scientific definitions (Harrison, 1997). A review of the related literature on spirituality revealed the lack of an integrated perspective. Some researchers describe spirituality as a sense of hope and self-transcendence, which in turn provides purpose in life (Hall, 1998; Harrison, 1997; Landis, 1996; Peri, 1995). Others describe spirituality as providing a sense of purpose from which feelings of hope and self-transcendence emerge (Carson & Green, 1992; O’Neill & Kenny, 1998). There is little information about the interactive effects of religion and existentialism. However, there are indications that the most successful strategy in using spirituality to cope with chronic illness combines aspects of both religion and existentialism (Carson & Green, 1992; Hall, 1997; Landis, 1996; O’Neill & Kenny, 1998; Peri, 1995; Sowell et al., 2000). This integrated perspective of spirituality suggests that all individuals have needs for meaning in life, hope, and self-transcendence and that these needs are met by utilizing aspects of both religion and existentialism (see Figure 1). Hope and self-transcendence are characteristics of religion and existentialism that result in a person discovering meaning in life along with periodical reevaluation of life priorities (Carson & Green, 1992; Carson et al., 1990; Coward & Reed, 1996; Fryback & Reinert, 1999; Kendall, 1994; Landis, 1996; O’Neill &

Figure 1. Spirituality: An Integrated Perspective

Kenny, 1998; Peri, 1995; Relf, 1997; Sowell et al., 2000). Hope instills a belief that being connected to a higher power or other people allows a person to have some influence on his or her future (Barroso, 1999; Harrison, 1997; Kylma & Vehvilainen-Julkunen, 1997; O’Neill & Kenny, 1998; Soeken & Carson, 1987). Self-transcendence increases self-awareness, involvement with others, and the ability to look beyond one’s problems (Coward & Reed, 1996; O’Neill & Kenny, 1998). Hope and self-transcendence are both evident in religious and existential beliefs and behaviors (Carson & Green, 1992; Carson et al., 1990; Coward & Reed, 1996; Fryback & Reinert, 1999; Kendall, 1994; Landis, 1996; O’Neill & Kenny, 1998; Peri, 1995; Relf, 1997). Individuals with HIV typically use coping strategies related to the two basic components of spirituality. Individuals for whom religion is important will connect to a higher power and cope with problems by praying, worshiping, reading religious material, asking for forgiveness from a higher power, and discussing concerns with family and friends who have similar religious beliefs. Other individuals use an existential approach to cope with their problems. These people establish meaningful interpersonal relationships and routinely use meditation, guided imagery, and/or visualization for relaxation and reflection. They gather information about their problems and discuss them with similarly affected individuals (Barroso, 1999; Carson et al., 1990; Carson & Green, 1992; Greene et al., 1999; Hall, 1998; Harrison, 1997; Kendall,

60

JANAC Vol. 12, No. 3, May/June 2001

1994; Landis, 1996; O’Neill & Kenny, 1998; Relf, 1997; Soeken & Carson, 1987).

The Integrated Perspective and HIV Disease HIV is a progressive chronic illness with debilitating symptoms that result in significant lifestyle changes. The uncertainty of the illness over time results in fear and anxiety related to body image changes, pain, and confronting one’s own mortality. Individuals infected with HIV must give meaning to their disease within the context of their lives (Barroso, 1997; O’Neill & Kenny, 1998; Soeken & Carson, 1987). The challenge of living with a life-threatening illness such as HIV disease often leads to spiritual questions and is reflected in how HIV-infected persons cope with their illness (Carson et al., 1990; Fryback & Reinart, 1999; Kendall, 1994; Landis, 1996; O’Neill & Kenny, 1998; Peri, 1995; Soeken & Carson, 1987). Individuals who are HIV positive are faced with numerous challenges to their personal resources: HIV disease progression, access to quality healthcare, compliance with prescribed health regimens, educational level, financial status, and psychosocial support (Brashers et al., 1998; Heckman, Somlai, Sikkema, Kelly, & Franzoi, 1997; Landis, 1996; O’ Neill & Kenny, 1998). Spiritual Resources The ability to cope with living with HIV depends on a person’s available resources and his or her capacity to utilize them (Landis, 1996). Spirituality serves as a support for some HIV-infected persons who experience fear, prejudice, and other unique challenges such as the inability to give life meaning, hopelessness, isolation, and low self-esteem (Carson et al., 1990; Harrison, 1997; O’Neill & Kenny, 1998; Peri, 1995; Relf, 1997). The integrated perspective suggests a means for identifying and strengthening the spirit and resiliency of chronically ill persons living with HIV (Kendall, 1994; O’Neill & Kenny, 1998). By recognizing the existing and shared spiritual resources within the religious and existential perspectives, the practitioner is better prepared to facilitate comprehensive utilization of these resources by patients with HIV

disease. These shared resources include meaning in life, hope, self-transcendence, and rituals. Establishing meaning or purpose in life for people with HIV can be viewed as a type of self-actualization where emphasis is placed on meeting or exceeding one’s full potential (Fryback & Reinert, 1999; Kendall, 1994). The challenge of finding meaning in life when faced with a serious illness involves the ability to take stock of the current situation and then look forward with hope. If successful, these individuals are able to focus on what can be rather than on what has been (Peri, 1995). HIV-positive individuals can find meaning in their lives by getting in touch with a higher power, focusing on self-improvement, assisting others infected with HIV, establishing closer ties with family and friends, becoming less materialistic, and becoming knowledgeable about their HIV disease (Barroso, 1997; Carson & Green, 1992; Fryback & Reinert, 1999; Kendall, 1994). Social support is also an important resource used to give life meaning for persons who live with the daily challenges of HIV (Barroso, 1997; Carson et al., 1990; Landis, 1996). Social support involves meaningful interactions between two or more individuals who share mutual obligations (Barroso, 1997; Nunes et al., 1995). Kendall (1994) and Barroso (1997) found that individuals with HIV believed meaningful relationships contributed the most to their physical and psychological health. A feeling of connectedness is central to the concept of social support. Kendall describes human connectedness as an intense need for closer association and kinship with others. Kendall found that HIV-infected individuals who felt connected to other persons were able to transcend personal suffering and consequently better connect with family and friends. The reciprocal nature of social support increases self-esteem and psychological health, promotes immune function, and decreases stress and isolation in people with HIV disease (Barroso, 1997; Heckman et al., 1997; Kylma & VehvilainenJulkunen, 1997; Nunes et al., 1995; O’ Neill & Kenny, 1998). Nunes et al. (1995) described the social support network of HIV-infected persons as including family, friends, self-help and peer support groups, and clergy. Hope is a fundamental resource for individuals coping with HIV. Mutually supportive relationships,

McCormick et al. / Spirituality and HIV Disease

religion, miracles, and work all provide a sense of hope that promotes coping skills, positive lifestyle choices, and self-esteem in people with HIV (Hall, 1994). Hall (1994) stated that for HIV-positive individuals, hope is a function of daily living and is affected by both religious and existential factors. Hope emphasizes optimism and self-determination and is essential for establishing satisfaction and meaning in life (Barroso, 1997; Hall, 1994; Harrison, 1997; Kylma & Vehvilainen-Julkunen, 1997; O’Neill & Kenny, 1998; Soeken & Carson, 1987). A sense of hope and self-transcendence are spiritual resources that promote the use of rituals to alleviate the fear and anxiety related to HIV disease symptom manifestation (Carson et al., 1990; Greene et al., 1999; Hall, 1998; Peri, 1995; Soeken & Carson, 1987). Carson and Green (1992) and O’Neill and Kenny (1998) found that HIV-positive persons who routinely used guided imagery, visualization, and/or prayer experienced an improvement in their immune function and a delay in disease progression. In addition, these rituals provided a framework for these individuals to think and reflect about spiritual issues (Hall, 1994, 1998; O’Neill & Kenny, 1998; Peri, 1995). The integrated spiritual perspective includes rituals ranging from formal prayer to meditation to drinking tea while watching the sun rise each morning, providing individuals opportunities to use those routines that produce the greatest satisfaction and meaning (Fryback & Reinert, 1999; Hall, 1997, 1998). Spiritual Barriers Social stigma, uncertainty, and a lack of religious resources are major barriers to the spiritual growth of HIV-infected persons. Social stigma is a constant challenge for people with HIV that results in feelings of low self-esteem, isolation, and discrimination (Barosso, 1997; Carson et al., 1990; Kendall, 1994; Nunes et al., 1995; Peri, 1995). The stigmatization of people with HIV arises from the two groups first impacted by this disease in the United States, gay men and intravenous drug users (Relf, 1997). Discrimination can be especially devastating to those people already struggling with issues of sexual orientation,

61

substance abuse, and low self-esteem (Carson et al., 1990; Hall, 1998; O’Neill & Kenny, 1998; Peri, 1995; Relf, 1997). Not surprisingly, research findings indicated that people with HIV who experience more HIV-related discriminatory acts report greater dissatisfaction in their lives (Heckman et al., 1997). One way to mitigate the negative effects of stigmatization is by establishing a network of social support for people with HIV (Barroso, 1997; Heckman et al., 1997; Kylma & Vehvilainen-Julkunen, 1997; Nunes et al., 1995). Uncertainty results from a sense of vagueness, lack of knowledge, unpredictability, or ambiguity that is present for an indeterminate time period. HIV is a complex disease with an unpredictable and extremely medicalized course, which creates a high level of uncertainty and anxiety. For people who were preparing to die of AIDS, the prospect of living with HIV may be intimidating and stressful due to uncertainty (Brashers et al., 1998; Fryback & Reinert, 1999; Nunes et al., 1995). Hope and social support are especially important in reducing the stress of uncertainty (Brashers et al., 1998; Landis, 1996; Nunes et al., 1995). The freedom to blend those aspects of religion and existentialism most important to the individual can also decrease uncertainty (Brashers et al., 1998; Hall, 1994; Landis, 1996). Some people with HIV have been ostracized by organized religious groups and may lack religious resources. Religious groups that equate a diagnosis of HIV with a lack of morality and an improper lifestyle engender feelings of guilt and isolation in HIVinfected persons, which in turn results in people with HIV feeling unworthy of true acceptance and support (Barosso, 1997; Carson et al., 1990; Peri, 1995). Unfortunately, people raised with a particular religious doctrine are sometimes unable to imagine a spiritual life outside of their doctrine. These individuals whose spiritual needs are not met through their traditional faiths may abandon religion for existentialism (Carson et al., 1990; Hall, 1998; O’Neill & Kenny, 1998). However, the availability of trained clergy and religious groups willing to work with and support this population’s spiritual growth would support these individuals in the utilization of religious opportunities.

62

JANAC Vol. 12, No. 3, May/June 2001

Discussion The literature defines spirituality and its related concepts (meaning in life, hope, self-transcendence, and rituals) in various ways. Spirituality has both a religious and an existential component (Coleman & Holzemer, 1999; Landis, 1996; O’Neill & Kenny, 1998; Relf, 1997). The idea of using religion and existentialism as resources for HIV-positive individuals to deal with the negative effects of HIV disease is supported by the literature (Brashers et al., 1998; Carson et al., 1990; Coward & Reed, 1996; Hall, 1994; Landis, 1996; O’Neill & Kenny, 1998; Soeken & Carson, 1987; Sowell et al., 2000). However, authors hold different views as to how these two components of spirituality interact to promote positive outcomes for people with HIV disease. Much of the literature separates spirituality into religion and existentialism, focusing on the existential aspect and its effect on people with HIV disease. Hall (1998) describes HIV as creating a shared reality for those infected with the virus that is best managed through existentialism. Several authors state that the existential perspective supports hope and defines meaning in life for most people with HIV (Carson & Green, 1992; Carson et al., 1990; Coleman & Holzemer, 1999; Hall, 1998; Kendall, 1994; Landis, 1996). However, some individuals prefer to address spiritual matters within the context of an organized religious structure. The religious perspective offers established rituals (e.g., worship services, prayers), trained clergy, and the built-in social support system of a congregation. Although stigma has historically been attached to HIV disease and this has prevented some HIV-positive individuals from utilizing all that religion has to offer, some religious organizations and groups have supported HIV-positive people and their issues. For example, some faith communities facilitate HIV support groups that reach beyond their congregations and into their communities. Although religion and existentialism can be considered alternatives to each other, they are not mutually exclusive. Enabling people with HIV to utilize those aspects of both religion and existentialism that are personally meaningful to them expands the internal coping resource that is spirituality.

Implications for Practice In today’s health care environment, advanced practice registered nurses (APRNs) provide care to a variety of specialized patient populations, including people with HIV disease. The advent of managed care, with its de-emphasis on specialty care, has shifted much of the responsibility for the chronically ill to the primary care provider. Advanced practice nurses are increasingly serving these specialty populations as primary health care providers, case managers, educators, and patient advocates (Hickey et al., 2000). Advanced nursing care needs to be sensitive to spiritual issues to meet the total needs of the patient with HIV disease (Coleman & Holzemer, 1999; Soeken & Carson, 1987). Not all nurses are willing and/or able to address spiritual concerns. APRNs need to be aware of their own potential biases and comfort level when dealing with spiritual issues. Spiritual counseling is not an expectation of nurses. However, APRNs should be able to direct clients to other care providers or appropriate community resources experienced in spiritual care. O’Neill and Kenny (1998) believe that spirituality can positively impact clients with HIV and that nurses are uniquely positioned to assist clients in fostering spiritual growth. APRNs must first assess the patient’s belief system, which is best done within the context of an ongoing relationship. An empathetic presence is the most important approach that nurses can use to get to know their patients (Hall, 1997; O’Neill & Kenny, 1998; Peri, 1995; Relf, 1997; Soeken & Carson, 1987). Listening with compassion and being nonjudgmental are important ways of understanding an individual’s view of life (Landis, 1996). Is the patient able to establish meaning or purpose in life? Does the patient have hope for the future, and how is that hope supported? Does the patient participate in ritual practices and, if so, what are they? Nursing interventions to assist HIV-positive patients in utilizing spirituality as a way of coping with their disease should focus on the resources which religiosity and existentialism share, including meaning in life, hope, self-transcendence, and rituals. These resources can be operationalized as nursing interven-

McCormick et al. / Spirituality and HIV Disease

63

Table 1. Nursing Interventions Intervention

Strategies

Promote hope

Encourage reciprocal social support—significant others, family, friends, peer support groups, clergy, pets Encourage involvement in a supportive faith community Encourage client to focus on the small joys of life Encourage client to maintain significant work or hobbies as able HIV pathophysiology HIV transmission and prevention methods HIV medications—dosing schedules, side effects, food/drug interactions Local HIV resources and social services Local spiritual resources and supportive faith communities Encourage adjunct therapies—vitamins, nutritional supplements, exercise, massage Encourage use of rituals—prayer, meditation, guided imagery, visualization Encourage helping others with similar concerns Encourage participation in HIV research studies/clinical trials when applicable Promote self-determination by completing a living will/health care power of attorney when applicable

Teaching

Share information Create a sense of empowerment

tions that promote hope, instill knowledge, facilitate social support, and empower patients whose lives are continually challenged by a chronic illness such as HIV disease (see Table 1). Hall (1994) states that hope is necessary to sustain life and promote quality of life. A belief in a higher power can be an important part of hope (Kylma & Vehvilainen-Julkunen, 1997). Nurses should support ways of maintaining hope, including involvement in meaningful relationships, affiliation with a supportive faith community, maintaining significant work or hobbies, gathering information, and using rituals (Barroso, 1997; Coward & Reed, 1996; Hall, 1994; Harrison, 1997; Kylma & VehvilainenJulkunen, 1997). Facilitating social support is important in a stigmatized population (Barroso, 1997). APRNs can recommend local clergy who have experience working with HIV-positive individuals and HIV support groups to facilitate spiritual learning and growth (Hall, 1997; Peri, 1995). Peer support groups promote self-transcendence through the use of self to share, teach, and learn with others who have related concerns (Coward & Reed, 1996). APRNs can identify opportunities for their patients to help others with HIV disease through counseling, education, and prevention efforts. Activities such as these can give life meaning, encourage human connectedness, foster hope, and improve selfesteem (Coward & Reed, 1996; Hall, 1994; Landis, 1996). APRNs can assist patients with HIV by sharing information with them and acting as a resource person

(Peri, 1995). Knowledge related to HIV disease processes, HIV medications, and HIV transmission is important to both the newly diagnosed patient and the established patient because much of this information is constantly evolving (Brashers et al., 1998). This ever-changing “state of the art” in HIV care presents a challenge to all HIV-positive individuals and their health care providers. Knowledge and information related to both HIV disease and spiritual resources are important tools the person with HIV can use to combat uncertainty (Carson & Green, 1992; Hall, 1997; Peri, 1995). APRNs can share information on spiritual resources and assist patients in establishing a perspective that includes both religious and existential viewpoints. Empowerment includes encouraging patients with HIV to take an active role in managing not only their disease but their lives through activities that nurture healthy lifestyle habits: exercise, adequate nutrition, taking vitamins, and using rituals (Carson & Green, 1992; Heckman et al., 1997). Rituals are of special importance related to HIV disease because of their stress-reducing and immune-enhancing benefits (Carson & Green, 1992; Hall, 1998; O’Neill & Kenny, 1998; Peri, 1995). Peri (1995) advocated the use of both prayer and meditation to empower individuals with HIV to address both spiritual- and disease-related issues. HIV disease can be looked upon as a stimulus for personal spiritual growth, and patients can be empowered to recognize and embrace this. The literature is full of individual stories describing HIV disease

64

JANAC Vol. 12, No. 3, May/June 2001

as a stimulus for life-affirming activities for those who were able to use spirituality as a coping resource (Fryback & Reinert, 1999; Hall, 1994, 1997, 1998; Kendall, 1994). The APRN can also empower HIVpositive individuals and promote self-determination by providing information on advance directives when appropriate (Peri, 1995). Implications for Research The literature reviewed for this article provides evidence for a relationship between spirituality and effectively coping with HIV disease. A comprehensive understanding of the relationship between spirituality and HIV disease requires a longitudinal research design, which has not been used in existing studies. The literature is split equally between quantitative and qualitative studies. There are no consistent conceptual definitions for any of the terms discussed, including spirituality itself. Further investigations to define the role of spirituality in the lives of people with HIV need to be pursued. Additional studies, especially longitudinal ones, of spirituality utilizing the concept of an integrated spiritual perspective and its relationship to coping are necessary. The proposed nursing interventions (Table 1) that promote the integration of both components of spirituality need to be tested and validated in future research studies. Also, it is important to define indicators for determining the reliability and efficacy of these interventions in promoting holistic nursing care of HIV-positive individuals.

Case Study John W. was raised as a conservative Southern Baptist in the mountains of a rural southern state. He left home to attend college in a metropolitan area of a bordering state and was disowned by his family and his church when he revealed his homosexuality following graduation. In 1988 he was diagnosed with asymptomatic HIV and began medical treatment. Amy S., an advanced practice nurse from the local medical center, was assigned as John’s case manager. She connected him with a peer support group facilitated by the local AIDS Services Organization (ASO).

Amy also gave John information on HIV disease and included local and state resources for people with HIV. John continued to work and took great pride in his job and related affiliations. He utilized a close-knit group of friends and his peer group for social support. In 1991, John was diagnosed with lymphoma of the neck and underwent extensive radiation treatments while continuing to work. Amy facilitated John’s enrollment in the hospital’s cancer rehabilitation program, which taught him appropriate diet and exercise for his situation. John had maintained no church affiliations since his college graduation but expressed a desire for spiritual counseling to his case manager. Amy set up weekly counseling sessions with a hospital chaplain who had experience working with HIV-positive individuals. By this time, John was taking AZT and had embarked on a nurse-recommended regimen of moderate exercise, vitamin and calorie supplementation, and meditation. In the spring of 1992, his advancing tumor growth necessitated palliative surgical reduction and a tracheotomy. These procedures required nearly one month’s hospital stay. During this time, his close friends stayed with him around the clock. John was unable to work now, and Amy negotiated with John’s health insurance company to maintain his health insurance through COBRA payments subsidized by the ASO. Amy also set up a living will and health care power of attorney for John at his request. Amy encouraged John to contact his family of origin, who began to provide additional nonjudgmental support and encouragement. John died 2 months later. His funeral and burial were at his home church. The following note written by John to a friend 2 months prior to his death highlights those aspects of spirituality that remain important to many individuals with HIV, regardless of their situation: social support, hope, self-transcendence, connection to a higher power, empowerment, self-determination, and daily rituals of personal significance. Home at last . . . what a great sound to hear. After 25 days in the hospital I never imagined how much recovery there will be. I now humble myself and thank God for each day and for people like you. While I still do not remember those days, I am reminded of your friendship and

McCormick et al. / Spirituality and HIV Disease

dedication in sticking with me and seeing my well being through the night. I realize the road to recovery is much tougher—I have determination and self-will and friends like you. While the ahead is unknown I rejoice in life at present and plan to fill it as I have today with just these couple of notes. We never got the chance to “all get together” as I had hoped. I still want to see your house, your dog and new car! Maybe the weeks ahead will allow. I hope so my friend.

Conclusions In summary, the limited research on spirituality and HIV disease suggests that spirituality can assist people with HIV in coping with the demands of their disease. The literature concentrates on existentialism instead of the integrated use of both components of spirituality. However, review of the literature provides a basis for integrating religion and existentialism into a model for advanced nursing practice and research.

References Barroso, J. (1999). Long-term nonprogressors with HIV disease. Nursing Research, 48(5), 242-249. Barroso, J. (1997). Social support and long-term survivors of AIDS. Western Journal of Nursing Research, 19(5), 554-582. Brashers, D. E., Neidig, J. L., Reynolds, N. R., & Haas, S. M. (1998). Uncertainty in illness across the HIV/AIDS trajectory. Journal of the Association of Nurses in AIDS Care, 9, 66-78. Carson, V. B., & Green, H. (1992). Spiritual well-being: A predictor of hardiness in patients with acquired immunodeficiency syndrome. Journal of Professional Nursing, 8(4), 209-220. Carson, V., Soeken, K. L., Shanty, J., & Terry, L. (1990). Hope and spiritual well-being: Essentials for living with AIDS. Perspectives in Psychiatric Care, 26(2), 28-34. Coleman, C. L., & Holzemer, W. L. (1999). Spirituality, psychological well-being, and HIV symptoms for African-Americans living with HIV disease. Journal of the Association of Nurses in AIDS Care, 10, 42-50. Coward, D. D., & Reed, P. G. (1996). Self-transcendence: A resource for healing at the end of life. Issues in Mental Health Nursing, 17, 275-288. Fryback, P. B., & Reinert, B. R. (1999). Spirituality and people with potentially fatal diagnoses. Nursing Forum, 34(1), 13-22. Greene, K. B., Berger, J., Reeves, C., Moffat, A., Standish, L. J., & Calabrese, C. (1999). Most frequently used alternative and

65

complementary therapies and activities by participants in the AMCOA study. Journal of the Association of Nurses in AIDS Care, 10, 60-73. Hall, B. A. (1994). Ways of maintaining hope in HIV disease. Research in Nursing and Health, 17, 283-293. Hall, B. A. (1997). Spirituality in terminal illness. An alternative view of theory. Journal of Holistic Nursing, 15(1), 82-96. Hall, B. A. (1998). Patterns of spirituality in persons with advanced HIV disease. Research in Nursing and Health, 21, 143-153. Harrison, R. L. (1997). Spirituality and hope: Nursing implications for people with HIV disease. Holistic Nursing Practice, 12(1), 9-16. Heckman, T. G., Somlai, A. M., Sikkema, K. J., Kelly, J. A., & Franzoi, S. L. (1997). Psychosocial predictors of life satisfaction among persons living with HIV infection and AIDS. Journal of the Association of Nurses in AIDS Care, 8, 21-31. Hickey, J. V., Ouimette, R. M., & Venegoni (2000). Advanced practice nursing: Changing roles and clinical applications (2nd ed.). Baltimore: Lippincott. Kendall, J. (1994). Wellness spirituality in homosexual men with HIV infection. Journal of the Association of Nurses in AIDS Care, 5, 28-34. Kylma, J., & Vehvilainen-Julkunen, K. (1997). Hope in nursing research: A meta-analysis of the ontological and epistemological foundations of research on hope. Journal of Advanced Nursing, 25, 364-371. Landis, B. J. (1996). Uncertainty, spiritual well-being, and psychosocial adjustment to chronic illness. Issues in Mental Health Nursing, 17, 217-231. Matthews, D. A., McCullough, M. E., Larson, D. B., Koenig, H. G., Swyers, J. P., & Milano, M. G. (1998). Religious commitment and health status. Archives of Family Medicine, 7, 118-124. Nunes, J. A., Raymond, S. J., Nicholas, P. K., Leuner, J. D., & Webster, A. (1995). Social support, quality of life, immune function, and health in persons living with HIV. Journal of Holistic Nursing, 13(2), 174-198. O’Neill, D. P., & Kenny, E. K. (1998). Spirituality and chronic illness. Image: Journal of Nursing Scholarship, 30(3), 275-280. Peri, T. C. (1995). Promoting spirituality in persons with acquired immunodeficiency syndrome: A nursing intervention. Holistic Nursing Practice, 10(1), 68-76. Relf, M. V. (1997). Illuminating meaning and transforming issues of spirituality in HIV disease and AIDS: An application of Parse’s theory of human becoming. Holistic Nursing Practice, 12(1), 1-8. Soeken, K. L., & Carson, V. J. (1987). Responding to the spiritual needs of the chronically ill. Nursing Clinics of North America, 22(3), 603-611. Sowell, R., Moneyham, L., Hennessy, M., Guillory, J., Demi, A., & Seals, B. (2000). Spiritual activities as a resistance resource for women with human immunodeficiency virus. Nursing Research, 49(2), 73-82.