Clinical Nursing Research

Volume 17 Number 1
February 2008 32-49
© 2008 Sage Publications
Women’s Experience of 10.1177/1054773807311691
http://cnr.sagepub.com
Spirituality Within hosted at
http://online.sagepub.com

End-Stage Renal Disease

and Hemodialysis
Ruth A. Tanyi
Loma Linda University, Loma Linda, California
Joan Stehle Werner
University of Wisconsin–Eau Claire

The purpose of this descriptive, phenomenological qualitative study is to

describe women’s lived experiences of spirituality within end-stage renal dis-
ease (ESRD) and hemodialysis. The purposive volunteer sample of 16 women
regularly attended two outpatient dialysis centers in a large Midwestern city.
Audiotaped, transcribed interviews were analyzed using Colaizzi’s method. These
women affirmed that spirituality was extremely important in living with their ill-
ness and necessary treatment regime. Four major clusters of themes pertaining to
the women’s spiritual experience within their illness emerged: acceptance, under-
standing, fortification, and emotion modulation. Findings show that spirituality
is of great importance in living with ESRD while receiving hemodialysis and
suggest that spirituality may be a significant consideration in nursing and inter-
disciplinary health care. These findings may be used to improve holistic nursing
practice and education in related areas.

Keywords: spirituality; renal failure; end-stage renal disease; hemodialysis;

women; phenomenology

S pirituality has been described as an innate human component that can

facilitate meaning in illness, solace, and optimism and provide a solid
coping mechanism for adjustment to chronic disease (Tanyi & Werner,
2003). Qualitative researchers are increasingly examining the meaning of
spirituality in the lives of patients with chronic illnesses including breast
cancer (Ashing-Giwa & Ganz, 1997; Chiu, 2000; Henderson, Gore, Davis,
& Condon, 2003; Lackey, Gates, & Brown, 2001), disability (Do-Rozario,
1997), HIV (Dunbar, Mueller, Medina, & Wolf, 1998; Hall, 1998; Sowell
et al., 2000), rheumatoid arthritis (Iaquinta & Larrabee, 2004), and sub-
stance abuse (Wright, 2003). Overall, these studies support the fact that

32

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 Tanyi, Werner / Spirituality Within End-Stage Renal Disease 33

spirituality is a core human component that can decrease suffering in ill-

ness, facilitate recovery, and contribute to adjustment.
In spite of the influence of spirituality in other chronic diseases, there is a
lack of research and resultant knowledge exploring the meaning of spiritual-
ity in the lives of people with end-stage renal disease (ESRD) receiving
hemodialysis (HD) treatment. Walton (2002) completed a grounded theory
investigation focusing on spirituality in four men and seven women receiving
HD. Her meaningful findings initiated theory development and provided a
theoretical underpinning for understanding spirituality in individuals receiv-
ing HD. In this population, a few quantitative studies do indicate that spiritu-
ality plays an integral role in the adjustment process in ESRD and HD
treatment (Kimmel, Emont, Newmann, Danko, & Moss, 2003; Patel, Shah,
Peterson, & Kimmel, 2002; Tanyi & Werner, 2003). These studies, however,
do not tap the depth of the associated human experience.
Spirituality and religion are often used interchangeably, but these two
phenomena are different. Spirituality is more individual, encompassing
relational components with others, God or a higher power, and the self and
one’s search for life’s meaning and purpose (Tanyi, 2002). Religion
involves an organized entity with rituals, practices, and beliefs about God
or a higher power (Koenig, McCullough, & Larson, 2001). Because all
humans are spiritual beings, one need not be religious to be spiritual.
Nonetheless, some individuals express their spirituality through religious
practices, whereas others do not. Spirituality is broader than religion or reli-
giosity (Tanyi, 2002).
For women with ESRD receiving HD, spirituality may be an important
resource, facilitating finding meaning in illness and supporting adjustment.
Because the experience of spirituality within ESRD in women on HD has
not been studied phenomenologically, the purpose of this study, which is
part of a larger study exploring women’s experience with ESRD, HD, and
spirituality, is to explore and describe the lived experience of spirituality in
these women’s lives. Women were selected for this study because they have
been found to interpret and respond to stressful circumstances differently
than men and may adjust differently (Taylor et al., 2000).

Background

ESRD is debilitating and progressive and occurs when the kidneys

are unable to remove metabolic waste products from the body. Although
there is no cure, life can be prolonged by HD, peritoneal dialysis, or kidney

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34 Clinical Nursing Research

transplantation. According to the U.S. Renal Data System (2006) 209,773

women had ESRD in the United States in 2004, with 141,362 (67%) of
them receiving HD treatment.
Medical technology prolongs lives of people with ESRD, yet it comes
with significant cost. According to Collins et al. (2005), “The ESRD program
currently consumes $25.24 billion dollars, with the Medicare and Non-
Medicare sectors accounting for $17 billion and $8.24 billion, respectively”
(p. 4). In 2002, 6.8% of all Medicare expenditure was attributed to ESRD
program, an increase of 4.8% from a decade before, thus exhibiting the grow-
ing population of ESRD patients in the United States (Collins et al., 2005).
ESRD results in many physiological, psychological, and relational prob-
lems (Peters, Hazel, Finkel, & Colls, 1994). For example, physiological
complications may include uremia, anemia, joint pain, cardiovascular prob-
lems, and dialysis site infections. Psychosocial problems, such as body
image distortion, low self-esteem, helplessness, dependency on medical
staff or technology, and, sometimes, strained relationships with significant
others, occur (Beer, 1995; White & Grenyer, 1999). Adjustment and adap-
tation, therefore, are major issues.
The illness trajectory of ESRD is unique to each patient and family
(Jablonski, 2004). As these patients continue to live with the medical prob-
lems and associated stress, questioning the meaning of illness and life can
occur and often becomes crucial in adjustment (Gregory, Way, Hutchinson,
Barrett, & Parfrey, 1998). Questioning meaning may involve the search for
spiritual answers. It is yet unknown what place spirituality has in adjustment
to ESRD and HD. Therefore, the specific aim of this study is to explore and
describe the experience and impact of spirituality in the day-to-day lives of
women with ESRD receiving HD. Because of a lack of knowledge in this
area, new insights about the meaning of spirituality as a potential resource
within ESRD were sought. Nurses play a pivotal role in providing care to
people with ESRD receiving HD treatment. It is therefore germane for them
to understand spirituality in these patients’ lives. This understanding would
provide knowledge with which to meet spiritual needs and support adjust-
ment, thereby facilitating quality of care and holistic nursing practice.

Method

Descriptive phenomenological methodology was used, defined as the

“direct exploration, analysis, and description of particular phenomena, as
free as possible from unexamined presuppositions, aiming at maximum

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 Tanyi, Werner / Spirituality Within End-Stage Renal Disease 35

intuitive presentation” (Spiegelberg, 1975, p. 57). Phenomenology aims to

describe phenomena as experienced daily from the perspectives of those
who live it without explanations why the phenomena occur (Spiegelberg,
1975). The central goal in maintaining rigor in qualitative inquiry is to cor-
rectly represent participants’ experiences as reported (Streubert &
Carpenter, 1999). Phenomenological inquiry is appropriate for nursing
because, as those in a practice discipline, nurses are involved in the lived
and subjective experiences of their patients.

Sample and Settings

The purposive and convenience sample included 16 women receiving
HD three times a week. Settings were two outpatient dialysis centers for
individuals living in the community, located in a large metropolitan area in
the Midwestern United States. About 60 women were receiving dialysis
from the two outpatient centers, with about 60% of them being African
American. For inclusion in this study, participants were required to have
been diagnosed with ESRD and on HD for at least 6 months, older than 18,
able to read and speak English, free of any acute medical conditions, and
not diagnosed with cognitive disability or mental illness.
Participants’ ages ranged from 29 to 77. In all, 11 identified themselves
as Black or African American, 3 as Caucasian, 1 as Hispanic, and 1 as
Asian. Length of time since ESRD diagnosis was 7 months to 21 years, and
time receiving HD was 7 months to 13 years. Regarding religion, 2 identi-
fied themselves as Protestant, 3 as Catholic, 3 as Christian, 3 as Baptist, and
1 each as Jewish, Lutheran, Seventh Day Adventist, Pentecostal, and
Nondenominational. Of the women, 3 were married, 2 indicated live-in
partners, 7 had never been married, 3 were widowed, and 1 was divorced.
The women’s monthly income ranged from $200 to $2,000 (2 participants
declined to report income).

Procedures and Data Collection

Institutional review board approvals were obtained from the two dialy-
sis centers and the relevant college and university. Participants were
recruited with help from dialysis unit managers (registered nurses) who had
in-depth knowledge about women attending their dialysis site who would
be willing to share their experiences. Selecting women who were willing to
share their experience ensured that rich descriptions of the phenomenon
would be obtained (Colaizzi, 1978; Streubert & Carpenter, 1999). Of the 60
women attending both dialysis centers, unit managers selected 25 potential

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36 Clinical Nursing Research

participants who met study criteria. The principal investigator approached

each woman with a description of the study. In all, 16 agreed to participate
(5 were hospitalized, 2 were out of town, and 2 declined, referring to spir-
ituality as private). All questions were clarified before informed consents
were signed. Thereafter, demographic forms were completed. Two partici-
pants preferred interviews before dialysis; the remainder chose to be inter-
viewed during the first hour or hours of dialysis to avoid fatigue that often
occurs later in the procedure. Privacy was maintained by pulling curtains
around the dialysis chair unit and by speaking quietly.
All audiotaped interviews lasted from 45 to 90 minutes. An interview
guide was used to fully explicate these women’s lived experiences. Women
were first asked to describe their experiences of renal disease and HD.
Subsequently, several specifically worded probes were used. Particular to this
analysis were the probative questions “Has spirituality helped you in any way
during your experiences of renal disease and hemodialysis? If so, how?” and
“How important is spirituality in adjustment to your illness?” General probes
such as “Can you tell me more about that?” were also used. Consistent with
phenomenology, data were created by participants rather than collected. For
some, unconscious awareness became real in the interview process, as they
made comments such as “Whoa! It really has been a journey for me.”
The principal investigator who collected the data adhered to the core
processes of phenomenological methodology throughout the data-collection
process. Bracketing was achieved through journaling, which encompassed
self-reflection about the process, logistics of the study, methodological
issues, subjective observations of the participants in the centers, and how
decisions were reached. During the entire process of interviewing, the
researchers’ presuppositions, beliefs, and prior experiences about the concept
of spirituality and ESRD were noted in a journal to minimize any potential
biases. In addition, the principal investigator’s thoughts, feelings, and reac-
tions following each interview were recorded in field notes to minimize any
possible bias during data analysis. Once participants stopped revealing new
information about their experiences, data saturation was reached.
Data analysis began during data collection as significant statements
emerged and were further explored. Thereafter, brief second interview ses-
sions lasting about 10 to 15 minutes ensued to clarify and corroborate the
data. Guba (1981) recommends that credibility, dependability, confirmabil-
ity, and transferability be used to support rigor in qualitative research.
Credibility and dependability were achieved through prolonged interac-
tions, as the principal investigator was at the dialysis centers three times per
week for about a month, observing the participants while collecting data.
Credibility and dependability were also attained through continual verification

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 Tanyi, Werner / Spirituality Within End-Stage Renal Disease 37

of emerging themes and exploration and validation of alternative interpre-

tations as the data were collected. Confirmability was established as two
other experienced qualitative researchers evaluated the audit trail using
field notes and transcripts. The rich, in-depth descriptions contribute to
their transferability.

Analysis
Verbatim transcripts including field notes were analyzed using
Colaizzi’s (1978) methodological interpretation. Colaizzi’s methodology
was chosen because of its well-delineated analytical steps, hence lending
itself to a much easier and fuller exploration of the phenomenon. The prin-
cipal investigator listened to each tape in its entirety to ascertain transcrip-
tion accuracy. Researchers then independently reviewed the transcripts
line-by-line several times, and the data were managed by cutting, pasting,
and grouping the relevant significant statements into their respective theme
cluster. The researchers then dwelled on the data for a few weeks before
agreeing on significant statements and formulated meanings. Data with
related and similar content and meaning were then sifted into four major
clusters of themes. Ongoing data validation occurred as participants agreed
that meanings and themes were representative.

Results

A total of 114 significant statements pertaining to spirituality were extracted from

the data. The women’s significant statements led to formulated meanings,
with four major clusters of themes emerging. Representative significant state-
ments are presented in the ensuing discussion, whereas formulated mean-
ings and theme clusters are presented in Table 1. In all, 15 participants
described their spirituality as involving a religious component in addition to
significant relationships, whereas 1 woman described her spirituality as not
related to God but to significant relationships only. The four emergent clus-
ters of themes representing spirituality within ESRD and HD include accep-
tance, understanding, fortification, and emotion modulation.

Acceptance
All women related that it was very difficult to accept their ESRD diag-
nosis and adjust to the necessary procedures involved with HD. The women

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38 Clinical Nursing Research

Table 1
Theme Clusters and Formulated Meanings in Women’s Experience of
Spirituality Within End-Stage Renal Disease and Hemodialysis
Theme Clusters Formulated Meanings

Acceptance Over time, my spirituality has propelled me to accept my illness and

put things in perspective.
Spirituality has aided me in following medical advice.
Spirituality is the source of my patience, necessary for ongoing
treatment.
Spirituality has assisted me in relinquishing control over things that
are not controllable.
My spirituality has helped me be open to spiritual guidance
from others.
Spirituality is the source of being able to face my mortality.
Spirituality helps me to live day by day.
God keeps me alive.
My spirituality is defined by keeping the faith.
Spirituality helps me to believe God will help me.
Fortification My spirituality imparts an inner strength which helps me go on.
Spirituality assists me in fighting my illness and not giving up.
My relationship with God or others is the core of my spirituality.
My spirituality has impelled me to increase my communication with
God through prayer.
My prayers often focus on being thankful I am alive.
My spirituality has been the force behind my helping others.
Understanding My spirituality has helped me to learn from my illness.
Spirituality has helped me to learn that I need to slow down.
Supporting my own self-care has been supported by my spirituality.
Emotion modulation My spirituality has been instrumental in reducing my anger
and bitterness.
I put many treatment and illness issues in God’s hands, and He
reduces my fear.
My spirit provides and supports my happiness and positiveness.
When I start to feel depressed, I rely on my spirituality, which
reduces my depression.

expressed that their spirituality enabled them to come to terms with their
diagnosis and treatment and accept themselves and their lives. Putting
things into perspective helped them to follow medical advice, gave them
patience, and helped them relinquish control. These processes supported
receptivity to spiritual guidance and allowed participants to face mortality.
Regarding the theme of accepting, one woman related,

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 Tanyi, Werner / Spirituality Within End-Stage Renal Disease 39

I can’t take transplant medications, so I really had to come to grips of the fact
that this is a chronic disease that is life threatening, that’s life ending and when
I knew I couldn’t have a transplant. . . . I got to the place where I didn’t
want a transplant.

Another participant stated, “It helps with accepting the illness and just work
with it instead of fighting it and just work with it and see what you can do
with it.”
Putting things into perspective was common, illustrated by the quote:
“It’s a balance you have to strike. You have to strike that balance between
wanting to live but also knowing that life is not forever.” Some related that
spirituality helped them actually come to the outpatient center to receive
dialysis, even when they would rather be elsewhere. One woman stated,

[Spirituality] has helped me with dialysis as far as . . . making myself come.

I never liked dialysis. . . . I don’t like the time it takes and sometimes I get
to the point where I don’t want to be here at all, and I think my spirituality
helps in getting me here and knowing that I need to take care of myself.

Facing mortality was an area in which most women reported spirituality was
crucial. One woman stated that spirituality helps in “preparing yourself for the
inevitable because dialysis just is a postponement of what we . . . come to
in the end. It makes you face your mortality . . . puts you more in touch with
your spirituality.” For most of these women, accepting their disease empow-
ered them to live day-by-day. This day-by-day experience was seen as allow-
ing them to “just be” and was described as keeping them alive. For example,
one participant related that spirituality helped her with “being able to just get
up everyday and take one day at a time and if it is the end, it’s the end, but if
it isn’t, He will pull you out.” Regarding keeping her alive, another participant
explained that “God have brought me a long way and it couldn’t have been
nobody but God. You know, I’m not taking no pills. I have been over here for
7 years and never took them in 7 years.”
For 15 of these women, accepting to live day-by-day led to deeper faith
and believe in God. They talked about walking in faith and trusting “the
Lord” as they lived through and adjusted to the various aspects of their ill-
ness trajectory. Significant statements portray the importance attached to
faith: “My faith . . . I got to have faith in God. If I don’t have faith in
Him, it don’t mean no good, so I step out in faith.” By stepping out in faith,
this participant relayed that she got to a place in her disease process in
which she had to entirely trust God to handle her daily struggles. Other

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40 Clinical Nursing Research

women talked about believing as a conscious act. For example, one partic-
ipant related, “[Spirituality] helps me trust and believe, because I always
believe even when I don’t trust. It took me a long time to trust that, you know,
it will all work out.” Believing in a future and believing in God’s power to
heal were frequently mentioned, as illustrated by one woman’s words:

Cause if I believe, I know that the Lord will do these things [healing], and I
know the Lord will. You have to be a believer first. If you say, “I don’t believe
that this can happen or this and that,” then you will not be healed.

Fortification
As the women accepted their disease, seeking God’s strength to handle
challenges and problems became a daily undertaking for 15 of them.
Because of their spirituality imparting strength, they were able to endure
and “fight” their illness. With the exception of one participant whose
strength came from meaningful human relationships, all of the women
talked about an “inner voice and strength” that “pushed” them to attend
dialysis and supported them. They described this inner voice as protective
and labeled it as either “the Holy spirit,” “God,” or “Guiding Angels,”
which helped them fight their illness, shielding them from dependence. One
woman summarized it this way:

I guess my spirituality has helped me have, how can I put this, an inner
strength where I don’t have to suck other people’s strength. You know now
we all need to suck other people’s strength at some time but also I know that
if there is nobody there, I can make it.

To this woman, spiritual strength enabled her to walk through the jour-
ney of her illness. She elaborated, “I think spirituality gives you that [inner
strength] because you come here alone and you leave here alone, and in the
meantime, we try to have friends and loved ones and stuff that we are con-
nected to.” Another related that “[spirituality] doesn’t allow me to give up
so easily whatever my fight is.” Participants also described that the strength
derived from their spirituality empowered them and led to a deeper con-
nection and relationship with God, themselves, and others. The relational
dimension of these women’s spirituality was evident, as a strong sense of
relationship echoed in their daily lives. Most of the women talked about
better communication and relationships with God and others since their
diagnoses. Prayer was the main medium of communication with God, as

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 Tanyi, Werner / Spirituality Within End-Stage Renal Disease 41

illustrated by one participant: “Well, I do a lot of praying, so I can have the

courage to go on. Once I start praying and have communication with God,
then I can continue with a whole lot of stuff.” Another elaborated,

I have better communication with God since I have been on dialysis, and I do
communicate with Him more often than I did before I was on dialysis, but I
always had been a spiritual person. Since my dialysis treatments, I have been
more communicative with Him. That gives me strength and courage to continue.

For some, connectedness with God translated into prayers of thankfulness:

“I guess the only thing I have really consciously did was thank God I was
still alive.”
Some participants increased their connectedness with others through
helping. For example, one woman stated,

Along the way, you’ve got to take up somebody. Somebody needs your help
. . . . Sometimes it means going in your pocket and helping them pay their
rent or they have bills or buy food for the kids. My husband was a pastor, and
we have done that.

Others described helping others through leading singing and by treating

others with respect.

Understanding
Participants characterized their spirituality as an inner force that engen-
dered insights and allowed them to question, understand, and learn from their
illness. For a few of them, this inner force was described as unconscious, but
for most of them it was a conscious awareness. For some, increased knowl-
edge and understanding about their illness as a result of their spirituality
involved “slowing down,” self-care, and understanding that helping others
was positive in their own lives. One woman poignantly elaborated,

Like my son said, he believes that the reason why I am in the state I am in,
is because I don’t know how to slow down. I kept on going and the doctor
said, “[Name], you’ve got to slow down. You’re not a spring chicken no more.
You can’t do what you did when you were young.” I said okay, but I never
did. I just kept on going and kept on going until He said, God has to do some-
thing to make me slow down. This is why He took the kidney. It will be all
right, I know . . . as soon as I learn how to slow myself down.

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42 Clinical Nursing Research

Another woman related that spirituality helps “take care of myself and hav-
ing that inner voice saying: you know you need to be there for your kids
and you need to get healthy.” One participant summed up the essence of the
experience of understanding when she stated,

When I sit down and think about it, there are things that you have to do. I
mean you have to discipline yourself and stuff like that and so taking the
lessons out of it, I think that’s because of my spirituality, because if I didn’t
feel the way I do about God, the things that . . . gone on in the world and
His relationship to it, then I just would be angry and dead.

This understanding gave the women a sense of direction in their daily

lives. All of the women reported that their spirituality gave them direction
in life (providing goals) and also bestowed motivation to go on. For
example, regarding direction, one participant related, “Well, [spirituality]
gives me a goal that I think I am going to . . . beat this.” The following
words of one woman illustrate the motivational aspects of spirituality, “I
don’t feel the need to say, ‘Oh, you know, poor me and I have kidney fail-
ure and my whole life has gone to pot now.’ . . . I just feel like it’s, you
know, one more thing to get through.”

Emotion Modulation
All of the women described their spirituality as essential in buffering
against and reducing anger, depression, anxiety, and bitterness, thereby fos-
tering coping. Spirituality was also essential in reducing fear, giving peace,
and helping women maintain a positive outlook and encounter happiness.
Spirituality’s power to modulate negative emotion and support positive
emotions was pervasive in these women’s lives. Reduction of negative emo-
tions was eloquently articulated:

Without spirituality you are a bitter person, and that’s the one thing that hav-
ing spirituality has done for me. . . . There is no bitterness. Whatever is put
in their path, they step over it, around it, through, whatever, but there is not
that bitterness of “Why, why me?” or that type of thing.

Another poignantly related,

When I first started dialysis, I was very angry. . . . I don’t know, it seems
like when I got to . . . a point where I was not coming back to dialysis—it

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 Tanyi, Werner / Spirituality Within End-Stage Renal Disease 43

was just whatever happens, happens, kind of thing—that’s when I had to sit
down and talk to God and figure out what was going to happen and a lot of
that bitterness kind of left just because, you know, for all I know, it could be
time for something great . . . and maybe this is just something that you
have to do.

A prevailing sense of solace and reduced fear as a result of their spiritual-

ity also pervaded these women’s lives. Buttressing this theme, one partici-
pant declared, “At times, you know, it gives me inner peace cause then I say
to myself, there is people a lot worse than me and basically I just accept it.”
Another related,

I’ve had to have lots of surgeries, and I’m scared of . . . anesthesia, and that
is . . . bigger than me. I am just really, really afraid of that. So I have to get
in a place where I put it in God’s hands because, if not, I would panic.

To this woman, anesthesia is such a frightening procedure; hence, she

described it as “bigger than me” to denote the fear she had regarding the
procedure, although her trust in God helped her through it.
Finally, women expressed that spirituality supported their positive moods
and outlooks. In describing spirituality’s uplifting capacity, a participant
offered, “It keeps me positive and . . . when I start to feel depressed and
everything, you know, I just reach inside of me and find something to think
about that makes me happy.” Another described her related experience as,

Well, it’s like there is a little person inside of me that keeps saying, “Be pos-
itive, be positive. You can do it if you just put your mind to it. Don’t get
depressed. I’ll be here when there is nobody else here. You can talk to me
when there ain’t nobody else.”

As the women experienced positive emotions and feelings of decreased

depression because of their spirituality, they were better able to cope with
their disease. Women referred to coping with dialysis, coping with their ill-
ness, and coping with daily circumstances, all supported by their spiritual-
ity. Illustrative of these sentiments, one woman related, “Other people say
that they can see . . . that I cope well and sometimes I am not coping
well, but people do think I cope well, you know.” Another, spoke of her
spirituality as central to coping with the death of others in the dialysis unit:

I just have to cope with it. It’s my own self that has to cope with all of this
stuff. Nobody else can help me. I have to make all of my own decisions.

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44 Clinical Nursing Research

[How has your spirituality helped you?] Well probably just coping. I think
having to deal with seeing your friends here pass away.

In summary, the four theme clusters, although described as separate,

were frequently interrelated in the participants’ descriptions of their expe-
rience. The women expressed their spirituality through various means:
prayer, singing, belief system, faith, dancing, and connectedness to them-
selves and others. These results signify that spirituality permeates the lives
of these women and assists them in nearly every aspect of their existence.

Discussion

This study sought a deeper understanding of spirituality in the lives of

community-dwelling women with ESRD receiving HD treatment. It was
pivotal to put aside presuppositions about spirituality to allow these
women’s voices to emerge. This was done as the researchers’ presupposi-
tions, beliefs, and prior experiences about the concept of spirituality and
ESRD were noted and put aside in a journal during data collection and data
analysis to minimize any potential biases. The women enthusiastically dis-
cussed their spiritual experiences to embody acceptance, fortification,
understanding, and emotional modulation.
Overall, these women described their spirituality as encompassing a
relational phenomenon. With the exception of one woman whose spiritual-
ity centered on meaningful human relationships, the other women’s spiritu-
ality encompassed connectedness with God, others, and themselves and a
belief and faith in the unseen. Given that this study is unique, the findings
are discussed in the context of other chronic diseases.
Acceptance was of utmost importance and crucial for adjustment. Without
God, most participants believed accepting ESRD and HD treatment would
have been impossible. Facing their own mortality was a catalyst that led to
introspection and caused participants to view their health from a new per-
spective of seeking a balance in their relationships and improving self-care to
live. The adjustment engendered by acceptance was evident as participants
became adherent to medical advice and relinquished control of questioning
their disease state. This result supports Walton’s (2002) finding about the
importance of dialysis patients’ yearning to find balance in their adjustment
process and substantiates other research that highlights the value of consider-
ing individuals’ spirituality in facilitating adherence to medical treatment
(Caspi, Koithan, & Criddle, 2004; Singleton, 2002).

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 Tanyi, Werner / Spirituality Within End-Stage Renal Disease 45

For 15 of the women, God provided the inner strength that enabled
endurance for the daily challenges. This strength emanated from their faith,
trust, and growing optimism. Inner strength was a vital resource on which
they drew daily, propelling them to proceed with HD even when they felt
like discontinuing it. This strength was empowering and enabled them to
become more self-reliant and confident about fighting their disease.
Consistent with participants in Walton’s (2002) study, whose faith provided
a vehicle for them to cope with ESRD and HD, the faith of the women in
the present study facilitated adjustment to the daily aspects of their disease.
Other qualitative studies support the magnitude of the importance of spiri-
tual strength in adjusting to chronic disease (Albaugh, 2003; Chiu, 2000;
Dingley & Roux, 2003; Do-Rozario, 1997; Hall, 1998).
Participants’ spirituality provided the impetus for knowledge acquisition
and enhanced understanding about the dynamics of their disease. It was as
if the diagnosis of ESRD and having to undergo HD generated an intense
need for self-evaluation and a desire for understanding and answers pro-
vided through spiritual searching. In this process, participants gained deeper
insights about their disease and refrained from self-blame and the “why me”
mentality. Enhanced understanding facilitated improved decision-making
skills and confidence in questioning their health care providers about care.
This empowerment was motivating and provided direction in their lives.
Other research has shown that increased knowledge and understanding are
spiritual experiences demonstrated by patients with other chronic diseases
(Hall, 1998), facilitating decision making (Caspi et al., 2004).
Although depression, fear, and anxiety have been suggested as ubiquitous
at various stages of the illness trajectory of ESRD and HD treatment, specif-
ically during the early months, (Jablonski, 2004), none of the 16 women in
this current study reported existing problems with these phenomena.
Spirituality modulated their emotions, thereby warding off anger, bitterness,
fear, and anxiety. As a result, they became less fearful about the trajectory of
their disease, experienced solace, and maintained relatively positive perspec-
tives. O’Baugh, Wilkes, Luke, and George’s (2003) study of cancer patients
and their nurses corroborated this finding. Similar to this present study, their
findings highlighted the essence of maintaining a positive attitude as a cop-
ing mechanism in adjustment to chronic disease, such as cancer.
The value of meaningful relationships as the core of spirituality was
omnipresent among all 16 women. Of them, 15 talked about becoming
closer to God, whereas all 16 women verbalized the importance of nurtur-
ing existing relationships with loved ones and connectedness with the self.
In the realm of these relationships, they found meaning and purpose in their
daily lives, the thrust for just “being” and “living,” and a sense of gratitude

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46 Clinical Nursing Research

to God and loved ones for their adjustment. Just as prayer and “giving
back” were significant spiritual aspects in the adjustment process for some
participants in Walton’s (2002, p. 453) study, increased communication
with God through prayer was also vital for 15 of the women in the current
study. Altruism was expressed by all 16 women and was a transcendent fea-
ture of their spirituality that fostered adjustment. The powerful impact of
meaningful relationships on adjustment has been illustrated by patients
with other chronic diseases (Dingley & Roux, 2003; Dunbar et al., 1998;
Narayanasamy, 2004)
Overall, the spirituality of these women was instrumental in their coping
and adjusting to ESRD and HD treatment. Their spirituality transcended the
day-to-day struggles of living with their disease. This transcendence pro-
moted meaning and purpose in their daily lives, which resonated with all of
the women and was displayed in their optimism. To summarize, one woman
eloquently conveyed her perception of the meaning of spirituality:

Oh . . . this is a place that you have gone to when you pass religion, when
you have gotten rid of all the trappings of religion, when you can understand
the essence of why we worship God. Why we . . . umm . . . it’s just a
better understanding for me of not being Catholic or Baptist or any religion.
Spirituality is something that is inside you, a place that, um, you grow to. You
come . . . you just come to understand there is a bigger meaning in the uni-
verse than you. [sigh] . . . That’s what I think of spirituality.

Clinical Application

Spirituality has been continuously shown as a core resource in amelio-

rating difficulties associated with chronic diseases and fostering adjustment
(Do-Rozario, 1997; Hall, 1998; Loeb, Penrod, Falkenstern, Gueldner, &
Poon, 2003; Tatsumura, Maskarinec, Shumay, & Kakai, 2003). The elu-
siveness of spirituality should not deter nurses from providing spiritual care
given the fundamental role of spirituality in patients’ lives as revealed in
this and other studies. Because nursing espouses holistic care, nurses
should aim at considering each patient’s spirituality as an essential factor in
attaining and maintaining adjustment in patients with ESRD undergoing
HD. Entering the spiritual dimension requires nurses to become attentive
listeners to patients’ spiritual experiences. A beginning step would be for
nurses to engage patients in spiritual dialoguing by asking their permission
to broach their spiritual preferences. A no would end the discussion,
whereas a yes would pave the way for the nurse to begin to gain a deeper
understanding of the patient’s experiences.

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 Tanyi, Werner / Spirituality Within End-Stage Renal Disease 47

Dialysis centers can be very busy. However, spiritual discussions can

occur during times when nurses are placing patients on or off the dialysis
machines or when periodically checking on them during the procedure.
Although a lack of time may be a problem for nurses who want to engage
in spiritual discussions to better understand their patients, research suggests
that spiritual discussions and interventions are not required to be lengthy to
be effective (Tanyi, Werner, Recine, & Sperstad, 2006). As nurses gain
better understanding of patients’ spirituality, they will become better pre-
pared to support patients’ spiritual perspectives and practices. This under-
standing of patients’ spiritual perspectives will help nurses to better
incorporate patients’ unique spiritual strengths, practices, and beliefs into
their care, thus facilitating adjustment and holistic care (Tanyi et al., 2006).
To further assist these patients in the adjustment process, nurses must take
time to understand what keeps patients positive and support their optimism,
healing, and ultimately their adjustment. Much more, these women need to
be applauded for their adjustment efforts as this may further strengthen them.
Because connectedness to God and fellow human beings is an essential
component of spirituality in these women’s lives, nurses can support this
dimension by establishing trusting and meaningful relationships with these
patients while encouraging strengthening of other existing positive rela-
tionships. Nurses can promote and support faith, trust, and belief in God or
a higher power by listening, by being present, and by referring patients to
faith-based communities or other spiritual activities the patient desires,
especially because referral is considered an important part of nursing care.
Assisting women to take time for introspection, a catalyst for improved
knowledge, understanding, and treatment adherence, is another method
nurses can adopt to support these women’s spirituality and adjustment.
This study is a beginning step in understanding the meaning of the lived
experience of spirituality in the lives of community-dwelling women with
ESRD receiving HD treatment. The overall implication of these findings is
that patients would benefit from nursing assessments and interventions that
support and promote their spirituality through trusting relationships, respect-
ing and supporting their beliefs, listening, applauding their strengths, and
encouraging a positive outlook, thereby upholding holistic nursing practice.

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Ruth A. Tanyi, RN, MSN, FNP-C, APRN-BC, is a doctoral candidate in the Preventive Care
Program at Loma Linda University School of Public Health, Loma Linda, California. She also
practices as a family practice nurse practitioner and medical journalist. Her several publica-
tions have focused on spirituality, renal failure and sickle-cell disease. Her current research
involves incorporating spirituality in primary care practice.

Joan Stehle Werner, RN, DNS, FAAETS, is professor of adult health nursing in the College
of Nursing and Health Sciences, University of Wisconsin–Eau Claire. Her publications have
focused on stress, coping, and spirituality.

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