With up to 83% of women with advanced breast cancer reporting pain (Puetzler, Feldmann, Brascher, Gerhardt, & Benrath, 2014), management of this symptom continues to be a critical problem. Spirituality (a dynamic process by which humans experience connection with self, others, nature and/or higher power and a sense of meaning) is one area that has not yet been adequately investigated, as it may positively impact the experience of pain in this population. The purpose of this dissertation was to examine the impact of spirituality on pain in women with advanced breast cancer within the context of a Complementary and Integrative Health (CIH) intervention, using the Theory of Self-Transcendence (ST) as a guide. This dissertation is comprised of three manuscripts: 1) Literature review; 2) Report of a quantitative secondary data analysis; 3) Report of a qualitative study. Each address the central topic; the impact of spirituality on pain.Manuscript 1 is a scoping literature review characterizing how pain and spirituality have been conceptualized, assessed, and addressed among women with advanced breast cancer. Forty-two publications were included. Most focused on pain (n = 33), while others addressed pain and spirituality (n=5), and exclusively spirituality (n=4). Women cited dimensions of spirituality as important for coping with their disease, suggesting the value of spirituality to cope with pain. A gap in understanding spirituality and its influence on pain in this population was identified.Manuscript 2 is a secondary analysis based on a National Cancer Institute-funded randomized controlled trial of foot reflexology for women with advanced breast cancer (n=256) (Wyatt, Sikorskii, Holmstrom, & Luo, 2011-2016). This manuscript examined demographic and clinical factors associated with pain and spirituality, the impact of spirituality on pain, and how spirituality and pain impacted engagement with the CIH intervention. Results revealed that various demographic and clinical factors were associated with pain and/or spirituality. The impact of spirituality on pain was not significant over time. Spirituality and pain were not associated with engaging in reflexology sessions.Manuscript 3 describes a phenomenological qualitative study examining pain and spirituality in women with advanced breast cancer, as well as perceived relationships between these concepts. N=9 semi-structured interviews were conducted. Data were analyzed using an open-coding process. Themes included: 1) Spirituality provides positive cognitive framing to help women face pain; 2) Spirituality brings about positive emotions such as peace and tranquility despite pain; 3) Spiritual practices serve as pain self-management tools; 4) Connection with others and service activities (aspects of spirituality) help women cope with pain.The findings from these three manuscripts advance nursing science by providing new insight into the nature of pain and spirituality. The Theory of ST was supported, and potentially extended, through findings from each of the three manuscripts. This work impacts nursing by providing novel insights into the nature of pain and spirituality in women with advanced breast cancer, and how spirituality may impact perceptions associated with how pain is experienced. This dissertation is the first step in a program of research to develop CIH-based, nurse-led pain management interventions for patients with cancer, which may include spirituality.
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