spiritual resources of chinese immigrants with breast cancer in the usa

Spiritual resources of Chinese immigrants with breastcancer in the USA

L. Chiu*

School of Nursing, University of British Columbia, T201-2211 Wesbrook Mall, Vancouver, BC V6T 2B5, Canada

Received 15 September 1999; received in revised form 25 November 1999; accepted 7 February 2000

Abstract

A synthesis of ethnographic and phenomenological research approaches was used to investigate spiritual resourceas the lived experience of Chinese immigrants with breast cancer in the US. The assumptions for the phenomena in

this study were based upon Tu's cultural China and Confucian spirituality, as well as van Manen'sphenomenological perspectives and Kleinman's ethnographic works. Fifteen Chinese immigrants with breast cancerin the US were recruited. The results reveal six cultural themes including family closeness, traditional Chinese

values, religion, alternative therapy, art, prose and literature and Chinese support groups. 7 2001 Elsevier ScienceLtd. All rights reserved.

Keywords: Spiritual resource; Spirituality; Spiritual care; Chinese immigrants; Breast cancer

1. Introduction

Spirituality represents a holistic human characteristicthat is important in human health and well being(Brallier, 1982; Catterall et al., 1998; Miller, 1995;

Newman, 1989; Pilch, 1988; Reed, 1992). The need fornurses and other health care professionals to attend tothe spirituality of their patients has been addressed by

many authors (Barker, 1989; Burkhardt, 1993; Carson,1989; Colliton, 1981; Chiu, 1989, 1996, 2000a,b; Hilland Smith, 1985). Those studies related to spiritualitythat have been reported in the nursing literature are

derived primarily from the empiricists who focus onperceptions and practices of patients with regards tospiritual needs or care (High®eld, 1991; High®eld and

Carson, 1983; Reed, 1991; Sodestrom and Martinson,

1987; Walter, 1997). In most of these studies, the mainindicators of spirituality include religious beliefs or

practices re¯ective of a deistic orientation that is pri-marily from a Judeo±Christian perspective. Littleresearch has examined the spiritual resource of patients

and no studies have described spiritual resource with acultural perspective.Krekeler (1989) suggested that exploring the spiritual

resource of clients could help health care professionalsto meet the clients' spiritual needs. Taylor and her as-sociates (1995), after investigating spiritual care prac-tice among oncology nurses, indicated that nurses need

to be educated with regards to spiritual resources whenproviding spiritual care. Conco (1993) investigated theessence of spiritual care from the recipients' perspec-

tives and found that spiritual care sources, excludingspiritual caregivers, included literature, inner re¯ectionsand calling upon one's own spiritual background and

practices. Krekeler (1989) performed a literature reviewand includes prayer, support from a caring, religious

International Journal of Nursing Studies 38 (2001) 175±184

0020-7489/01/$ - see front matter 7 2001 Elsevier Science Ltd. All rights reserved.

PII: S0020-7489(00 )00036-5

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* Tel.: +1-604-822-7472; fax: +1-604-822-7466.

E-mail address: [email protected] (L. Chiu).

community and religious rituals as part of the spiritualresources. Miller (1995) also suggests that prayer,

faith, pastors and the Bible are important resources tohelp persons strengthen their spiritual, mental andphysical health. He believes that medicine, prayer and

rituals often provide cultural solutions to anxiety-pro-ducing problems, giving one a sense of mastery overthreats (known or unknown) and increasing one's

sense of well-being.Each culture usually has a set of beliefs about the

meaning of health/illness and health maintenance and

about the correct behavior for preventing illness(Miller, 1995). Clients' spirituality may be determinedentirely by cultural norms, by behaviors that are inopposition to the cultural norms, or by both of these

norms and the life experiences of individuals. The pur-pose of the study is to investigate cultural±spiritualresources that are available to Chinese immigrants

with breast cancer in the US. With increasing knowl-edge of spiritual resources that are pervasively used indi�erent cultures, spiritual care would become more

e�ective.

2. De®nition of terms

1. Spirituality is the state of being harmonious with

self, others, Nature and the transcendent (asdescribed by the informants of the study in anotherreport).

2. A spiritual resource is the resource that supportsone's spirituality including inward and outwardresources, to enable an individual to cope with ill

circumstances.3. The Chinese immigrants in this study were born in

Taiwan, mainland China or Hong Kong and immi-grated to the US during adulthood.

3. Methodology

The study explores the pattern of spiritual resources

that were used by, or made available to Chinese immi-grants in their everyday situations and relationships. Asynthesis of ethnographic and phenomenologicalresearch approaches was used because it is well suited

to studying the lived experience of the women's illnessand their spiritual resources within the cultural con-text. Kleinman (1988) refers to this approach as a

mini-ethnography with a phenomenological sense.Based on an inductive approach, the method allowsdimensions of analysis to emerge from patterns found

in a cultural group, without ®rst presupposing whatthe dimension might be (Creswell, 1998; Patton, 1980).Thus, the ®ndings are grounded within a speci®c cul-

tural context, and the ®nal results are grounded in thereal world of the culture (Creswell, 1998; van Manen,

1990).

3.1. Assumptions

Assumptions for the phenomenon studied werebased upon Tu's (1994) cultural China and Confucian

spirituality, as well as van Manen's (1990) phenomeno-logical perspectives and Kleinman's (1988) ethno-graphic works. Major assumptions include: (a) Chinese

immigrants are able to act as self-observers and tocommunicate valid data regarding their values and ex-periences; (b) Chinese immigrants who indicate their

sources of spirituality are able to identify the elementsof the phenomenon and relate these experiences toothers; (c) Chinese immigrants are bearers of their cul-

ture; and (d) people are inseparable from their experi-ences in the physical world.

3.2. Sample

Informants were recruited primarily from two Chi-nese aggregating sites in the US: New York and San

Francisco. Informants in the study involved 15 Chineseimmigrants with breast cancer who met the followingcriteria: (a) older than 20 years; (b) able to acknowl-

edge and articulate their experiences; and (c) immi-grated from Hong Kong, China or Taiwan.Recruitment for individual interviews was accom-

plished through community-based, purposive samplingmethods that maximize the potential for diverse experi-ence with the phenomenon of interest. Informants

were selected from groups of individuals at di�erentstages of cancer and from three di�erent Chinesegroups. Potential informants were identi®ed throughgatekeepers in three Chinese communities. A one-page

description of the study was given to referees to usewhen approaching potential participants. Each refereecontacted the researcher with the names and telephone

numbers of potential informants who were interestedin learning more about the study. Then the researchercontacted potential informants individually to explain

the purpose of the study in more detail and to requesttheir participation if they met the eligibility criteria.The investigator approached the Chinese immigrantswith breast cancer who met the inclusion criteria and

expressed an interest in the research, fully explainingthe nature of the research, using a tape-recording ofthe dialog. Participation was fully voluntary and infor-

mants were told about the study's purpose, potentialrisks and bene®ts, extent of participation that wouldbe required and safeguards to preserve con®dentiality.

Prior to the ®rst interview, a pilot interview was con-ducted to determine if the interviewer's questions wereappropriate for the participants.

L. Chiu / International Journal of Nursing Studies 38 (2001) 175±184176

Fifteen women, ranging in ages from 33 to 67 years,having breast cancer and living in the US were

included in the study (Table 1). Twelve informantswere born in Taiwan, two in Hong Kong and one inChina. Eight informants lived in New York, two in

New Jersey, two in California, one in Pennsylvania,one in North Carolina and one in Virginia. All 15 ofthe informants had been married, one was separated

from her husband, one was divorced and one waswidowed. All except two of the informants had chil-dren. All except two of the informants had completed

high school, 11 had completed college and three hadcompleted graduate studies. Nine of the informantswere employed; three stayed at home while theirspouses worked; one attended a school and received

®nancial assistance; and two lived using their savings.Nine of the informants identi®ed themselves withChristianity; one with Catholicism; three with Bud-

dhism; and two did not identify themselves with a reli-gion. All but one of the participants received theirdiagnosis after immigrating to the US and the time

since being diagnosed with breast cancer varied fromless than one year to more than ten years. Breast can-cer of stage I±IV was represented among the infor-

mants.

3.3. Data collection

Data were generated through a variety of qualitativetechniques including interviews, observation of partici-pants, document analysis and ®eld notes. After obtain-

ing institutional review board approval at HarvardUniversity, the investigator gained access to the poten-

tial informants through the leaders of the Chinese can-

cer societies. The investigator made several trips to theresearch sites and engaged in activities of the commu-nities (often occurring in the o�ces of the Chinese can-

cer societies). Fetterman (1989) recommendsproceeding with the ``big net approach'', where at ®rst

the investigator mingles with potential participants.Relying on her judgment, this investigator established

inclusion criteria to select members of the societies,some of whom were identi®ed by the leaders of the so-cieties.

After obtaining each informant's written consent toparticipate and be audiotape recorded, the investigator

made appointments to conduct in-depth, face-to-face,unstructured interviews with the participants. One or

two in-depth telephone interviews were utilized forthose informants who lived at a distance from the tworesearch sites.

At the beginning of an interview, a data sheet wascompleted on each informant to ascertain the demo-

graphic and descriptive characteristics of the sample.An interview guide was used and interview questions

explored the pattern of spiritual resources used or thatwere available for Chinese immigrants in everyday situ-ations and relationships. The opening questions

included ``What is your everyday life experience withbreast cancer?'' ``What are your sources of strength

while living with breast cancer?'' ``What is the meaningof the source for you?'' and ``How does that relate to

your spirituality?'' Subsequent, probing questioning,aimed at gaining further clarity and insight into theparticipant's experience of spiritual resource, was

guided by the participants' responses. After face-to-

Table 1

Description of the study informants (n=15)

Women Age Stage of breast cancer Time since diagnosis

(yr)

Marital statusa

(n )

Religion Job

(yes/no)

Education Origin

(current residence)

SCh 41 IV 12 M (1) Christian Yes Graduate Taiwan (N.C.)

HT 50 II 10 M (2) Christian Yes Graduate Taiwan (N.Y.)

JY 35 IV 4+ M (0) None No Graduate Taiwan (N.J.)

NR 48 II 1+ M (2) Christian Yes College Taiwan (N.Y.)

HZ 42 I 1+ M (2) Buddhist Yes College Taiwan (N.Y.)

YC 50 I 2 2-M (4) Buddhist Yes Grade Taiwan (N.Y.)

LS 48 II 1 M (3) None No High School H. K (N.Y.)

HS 50 II 1 Sp (2) Catholic Yes College Taiwan (N.Y.)

ZL 45 III 3 M (2) Christian Yes College Taiwan (V.A.)

SH 44 II 1+ M (2) Christian Yes College Taiwan (N.J.)

ST 46 IV 9+ M (2) Christian No College Taiwan (S.F.)

NC 49 I 2 M (1) Christian Yes College Taiwan (N.Y.)

LP 33 III 2 D (1) Christian No College China (N.Y.)

JN 51 II 1+ M (0) Buddhist No Grade School H. K. (P.A.)

SS 67 II 13.5 W (2) Christian No High School Taiwan (S.F.)

a Marital status: M=married, Sp=separated, D=divorce, W=widow; (n )=number of children.

L. Chiu / International Journal of Nursing Studies 38 (2001) 175±184 177

face interviews were conducted, the personal docu-ments (e.g. written books and manuscripts) for the

informant were collected and ®eld notes were writtenthat included the investigator's observations of en-vironmental circumstances, participant characteristics,

nonverbal behaviors, a�ect, discussion process, rap-port, impression and miscellaneous characteristics. Forthose who were interviewed over the telephone, per-

sonal documents were either secured by mail orobtained from bookstores. Field notes were notapplied to these participants.

3.4. Analysis of the data

Analytical processes, including deep re¯ection anddefamiliarization resulted in the emergence of cat-egories, patterns and critical tales. The audiotape

recordings and observation notes were transcribed intoa narrative form and combined with the informants'personal documents to serve as a protocol for data

analysis. Data analysis commenced after the data wasobtained from the initial interviews. The researcher lis-tened to each tape in its entirety to verify the accuracyof the transcriptions and the analysis proceeded by

analyzing the transcribed interviews, line by line andhighlighting important phases and words to identifyand code units of data. Field notes and personal docu-

ments were also continuously reviewed for potentialsources of bias or inconsistencies in the data. Theresearcher re¯ected on each transcript, making intuitive

guesses on themes and extracting signi®cant statementsand their meanings. Signi®cant statements wereextracted if the sentences were the same or similar, and

viewed to be signi®cant. This step was repeated threeor four times to validate the formulated meaning.Data that appeared to relate to the same content weresorted into themes, which were then clustered to ident-

ify and ®ll in the categories. This process led to thecollapsing of themes, which was followed by the for-mation of more inclusive categories and related dimen-

sions. Following this process came the integration ofthe signi®cant statements, the formulated meanings,the clusters of themes or inclusive categories into an

exhaustive narrative description and the interpretationof the text through conversation. van Manen (1990)suggests that the investigator should use a ``collabora-tive analysis'' approach Ð that is, an analysis team Ð

in which ``collaborative discussions or hermeneuticconversations'' are used to generate deeper understand-ings. In this study, the investigator sought to describe

relationships between the emerging cultural themes andcategories using universal cultural themes to scrutinizethe data. The essential themes were then determined.

The member check was done by taking the essentialstructure, which was based on the analysis process,back to the informant for validation. The investigator

was aware that the responses of members might beconstrained because of the (1) nature of the interaction

between researcher and member, (2) social norms con-cerning politeness and consensus building, or (3) con-¯icts of interest (Morse and Field, 1995; Sandelowski,

1993). In this study, ®ve of the 15 participants wereasked in follow-up interviews to examine the essentialstructure and validate that the interviews had captured

their experiences.To assure a full elaboration of the concept while

minimizing potential pre-assumptions on the part of

the researcher, several strategies were incorporated toensure an in-depth, culturally relevant description ofthe Chinese immigrants' interpretation of spiritualresource. Strategies such as hermeneutic interviewing,

collaborative conversation and member checks,increased the truth-value of the description in thisstudy. The ethnic background of the investigator,

being familiar with the informants' culture and nativelanguage, also adds to the validity of this research.During the analysis process, the investigator kept a

®eld journal, or re¯exive journal, on a daily basis or asneeded to record a variety of information about herselfand about the method. The ®eld journal contained a

schedule that included logistics of the research, a per-sonal diary that allowed for catharsis, bracketing andre¯ections on the researcher's thoughts and feelings,and a methodological log that was used to keep an

account of methodological decisions and their accom-panying rationale. At the end of the investigation, thejournals for all phases of the investigation were given

to a disinterested person who played the role of audi-tor and examined the process of the inquiry. From theexamination, the auditability and con®rmability of the

study were con®rmed.

4. Results

The data analysis of all 15 interviews revealed thesix categories of spiritual resources: (1) family close-ness, (2) traditional Chinese values, (3) religion, (4)

alternative therapy, (5) art, prose and literature, (6)Chinese support group. The six categories aredescribed separately using examples from the data.Informants are identi®ed by coded initials.

4.1. Family closeness

Family closeness refers to the intimacy or connected-

ness between the informant and her family membersincluding husband, mother and children. All of theinformants spoke of family closeness and how they

gained spiritual strength from this closeness. JY's hus-band was an example. JY was 35 years of age at thetime of study and was diagnosed with stage IV breast


cancer four years ago. She had met her husband six

months before they were married and then, just four

months after being married, she received the diagnosis.

She spoke about how she could get through the illness

process:

Since then, he did laundry and cooked meals for

me. He continuously encouraged me to live and

supported my spirituality. We made decisions

together for each treatment. He was always there

and available to me. He never complained and

never changed the way he did things for me.

HT, a 50-year old married women with two children,

also had a similar story. Since she was diagnosed with

stage II breast cancer, her husband told her every day

how he loved her and needed her, which helped her in

accepting her illness. She thought that love is the most

powerful and e�ective way of healing. She shared her

story as follows:

One day I decided to face the fact of losing

hair, which I was always proud of, and went to

the bathroom, taking o� the cover on my head.

When I looked into the mirror, I was shocked

at myself. I couldn't help but screaming and cry-

ing. My husband came in and held me in his

arms. He said to me that no matter how ugly I

would be, he would love me more than before.

The relationship between mother and daughter is

also an important source of spirituality. ST, 46 years

of age, is married with two children, and was diag-

nosed with stage IV breast cancer. Her mother never

stayed in the US until ST became sick. ST's mother

was old and weak and according to ST, was very sensi-

tive with a high level of imagination. She did not let

her mother know about her illness at the beginning

but later, told her mother about every single detail of

her illness because her mother was worried about her

and couldn't sleep well. After her mother learnt about

ST's illness, she became strong and supportive, praying

for her day and night. ST felt that her mother was

very helpful, especially during (her) recovery. ``She

granted me much comfort and encouragement and

became a source of my spirituality. I could not live

without her.''

JY and her mother are another example. JY's

mother has been hemo-dialyzed for many years and

required a strictly enforced dietary regimen. She

served as a role model for JY and consequently

became a source of her spirituality.

Being a mother also provides spiritual strength to

women who must cope with breast cancer. Most of the

women in this study spoke of ``children giving a reason

to live''. For LS, 48 years of age, and who had emi-

grated from Hong Kong with three children, being amother was a joy in her life: ``cooking meals for my

children is my responsibility and my joy as well''. ST,however, was afraid that their children had lost herprotection.

4.2. Traditional Chinese cultural values

All informants were born in a Chinese society, andsome were unaware of their culture values when speak-

ing of spiritual resources. Some, in contrast, foundstrength from their cultural assets while others were inopposition to their cultural values. ZL was 45 yearsold, married with two children and was diagnosed with

stage III breast cancer. She recognized the e�ectivenessof Chinese medicine but chose conventional treatmentduring her critical stage of illness. Later, she compro-

mised in her belief of Chinese medicine by choosingnatural sources of foods and found them to be usefulfor her recovery. She also gained spiritual strength

from Confucianism and Chinese Buddhism andbelieved that Chinese Buddhism, which was in¯uencedby Confucianism, helped her to transcend her fear ofdeath.

NR was 48 years old, married with two children,and was diagnosed with stage II breast cancer. Shebelieved that breast cancer was caused from an imbal-

ance and said that the ``Chinese emphasize chi and guhbern (strengthening the foundation)''. She further ela-borated by saying that ``chi must move smoothly in

our body and bern must be like vajra which is oftenindicated in Buddhist teaching, and then no one willreceive the disease''. She believed that meditation is a

way to achieve these purposes and so prayed andmeditated every day. She felt that her emotional gar-bage was being cleansed from her mind, which becameopen so that fresh air could tune into her spirit.

JY agreed about the ching and yi (important valuesof Chinese culture) of her husband that gave herstrength to live but was opposed to some cultural

values that kept her down. She said:

I can not iterate any Chinese values that have beenuseful for my spirituality. Chinese culture always

emphasizes continuing the family line by producinga male heir. I can't have children any more. So Idon't want to think about it. I have to accept the

fact.

4.3. Religion

Twelve of the 15 informants have religious beliefs

and almost all of them referred to religion as theirspiritual resource, either through religious teachings,deity, prayer or priests. ZL read many religious books


since receiving her diagnosis and spoke about herinsight into these teachings, through which she found

her meaning of life and was able to conquer her fearof death. She said:

I found the Bible, Buddhist teachings, and NewAge thoughts were very similar and useful. Theytaught me that our bodies shall die any time butour souls last forever. They also taught me my life

missions are both love and compassion. When Iwas depressed with my illness, I would think ofMother Teresa, whose love, devotion, and sacri®ce

brought me light and very much inspired my under-standing of meaning of my life.

HT is wife of a Christian priest. She and her hus-

band had always worked as a team when preachingabout the meaning of the Bible. When she was initiallyinformed of her diagnosis, she was shocked. Her hus-

band, however, reminded her of a message from theBible by telling her his story:

When I was small, I often watched Chinese

plays with my father and fell asleep during theplays. Then my father would embrace me in hisarms and walk me home. When I woke up, I

found myself home already.

HT's husband told her that death for Christians isthe same as in the story Ð ``When you close your

eyes, the Father of Heaven will embrace you in Hisarms and you will be safe at His home''. HT believedthis message was a turning point for her in accepting

her illness.ST is a Christian as well but seldom went to church

for she did not intend to disobey her mother-in-law's

religious belief. Soon after receiving her diagnosis, shewent back to church and found strength from her reli-gion. She said:

I still remember my husband and I were so helplessat that time. Actually he su�ered more than I didbecause he had to care for me. One night after hav-

ing been diagnosed with breast cancer, he called mefrom the priest's place, and the priest was also onthe line. He cried over the phone. He didn't usuallycry before people. The priest and his wife then

came to visit us for the next few days and prayedfor us. I slept well those days. Religion really haspower.

4.4. Alternative therapies: ba guo lian jun

Alternative therapy refers to treatments from naturalsources, other than conventional treatments andincludes natural foods, herbs, meditation, exercise and

the natural environment. ZL believed, `àlternativetherapy is spiritual therapy and is also a Eastern way

of healing''. ST and her husband worked as a teamand have tried various alternative therapies during thepast ten years. Natural sources have brought them

hope and strength. She further elaborated:

As long as these therapies might improve my illnessand would not con¯ict against each other, we

would try all of them. My husband called this baguo lian jun (joint forces of the eight powers thatoccupied Peking in the wake of the Boxer Move-

ment in 1990). In other words, if each therapydeserved 25% of the e�ect, and then all togetherthe therapies would account for 200% of the e�ect.

JY, after a fourth reoccurrence of illness, decided tolook for alternative therapies and tried raw foods, veg-etables, Chinese medicine, herbs, heat therapy and

meditation. She said:

Every morning, I make parsley juice and drink itslowly. Then I have some fruits to cleanse my

bowels. Then I will sit for a while to get rid of sickfeelings. I may meditate for an hour or take a littlewalk for about half an hour. I enjoy fresh air and

natural environment when I walk. I ®nd it's thera-peutic, too. During the evening, my husband and Isometimes attend a spiritual program led by an

Indian master called Mahasi. I believe about whatMahasi said about watching or looking inside ofyou. I believe that the ultimate goal of any religionis to reach ``there'' Ð something called peace. If

peace is what I pursue, I can attain this goalthrough meditation. Besides, I ®nd meditation hastherapeutic e�ects, which can be evident in my

headache that disappears after meditation.

Not only did JY talk positively about meditationbut also most of the other informants in the study

spoke highly about it. Statements that re¯ected the im-portance of meditation in their healing may be sum-marized by the following comments: `Ì meditate

because I need space. I have to clean my emotionalgarbage, and then my mind can become open thatwould let fresh air in''. `Ì believe we can use the wish

power of spirituality to transform our bodies, andmeditation is a way of achieving this purpose''.

4.5. Art, prose and literature

This area refers to the women of the study whoeither actively or passively engaged in creative works

such as arts, prose and literature. LZ said, ``readingand writing are part of my life and also sort of atherapy for my illness''. ST enjoyed painting and


believed painting was psychotherapeutic for her. Shesaid, ``I enjoy color very much. Whenever I paint, I

feel happy and attentive''. HT also enjoyed readingand writing and said:

What I read mostly is Chinese prose and literature.I especially bene®t from Liu Shya's (who overcameher handicap and became a famous writer in Tai-wan) Life Song. She wrote about how she lived day

by day with her illness. Her su�ering was neverending but she could overcome her disability. Mysu�ering is only temporary, and I should be able to

get through it. Her story is very much inspiring me.

4.6. Chinese support group

Many informants spoke of their breast cancer sup-port group as giving them their strength and being

helpful. Support group here refers to group processwhere members meet regularly and provide infor-mation and emotional support for each other. HT is

the founder of a Chinese cancer society and spokeabout how she came to the idea to start a Chinese sup-port group. She said:

A woman, who has been diagnosed with lym-phoma, like an angel came to me at a time when Ijust received the cancer diagnosis and stayed in a

hospital feeling hopeless. She comforted my souland encouraged my mind. She shared her illness ex-perience and granted me necessary information.

Her words eased my fear and my worry of myfamily. I then told myself, if I can survive the ill-ness, I will do the same thing like her to comfortother women's souls.

Just before my breast surgery, other women withbreast cancer in the hospital and I gathered to

share our feelings. Nurses used this meeting toteach us about what could happen during and afterthe surgery. I thought, if I didn't understand Eng-lish, I would feel hopeless and helpless at that time.

After surgery, a breast cancer survivor was invitedto share her experience during recovery. She lookedso clean and graceful, and I thought I could be like

her. Then I swore to myself, if I can survive thisdisease, I would like to organize a support group toassist Chinese women who may not speak English

and have no access to the health care services in theUnited States.

JY spoke about the importance of sharing in a sup-

port group that eventually became a source of herspiritual strength. She believed, ``if I can reach out andtell others that I have been diagnosed with breast can-

cer, my illness will improve a great deal''. She alsobelieved that ``many women were courageous and opti-

mistic and could bene®t from their stories''. JYattended a program called Share, which was a cancersupport program and said the following about this

program:

Due to my eagerness to learn and self help myself, Iattended a breast cancer support group under

Share. I was inspired by the women's stories in thegroup and even now, still appreciate their stories,though I don't remember their names.

JY was also active in the breast cancer supportgroup and often encouraged other women to partici-pate in cancer support groups. JN was another

example. JN, 51 years old, married with two children,was diagnosed with stage II breast cancer. She hadimmigrated from Hong Kong and had only an elemen-

tary education. She received support only from JY'sgroup and stated that ``JY helped many women. Shenot only gave us information but also much encour-

agement and spiritual support. I really appreciatedher''.

5. Discussion

In this study, informants expressed their lived experi-

ence of spiritual resources. Interpreting their narrativesrevealed that the women experience their spiritualresource through family closeness, traditional Chinese

values, religion, alternative therapy, art, prose and lit-erature and Chinese support groups. Spiritual resourceis multi-dimensional and involves values and belief,

systems and culture and a variety of activities andpeople.

5.1. Spiritual resource among three Chinese groups

One of biggest challenges in conducting this research

in the US was the recruitment of informants. Statisticson Chinese immigrants with breast cancer have notbeen reported and limited services exist that can

directly access Chinese immigrants with breast cancer.Chinese immigrants, especially those from China,

tend to feel ashamed about having breast cancer andoften refuse to contact any outside services. The lack

of a valid gatekeeper and trusting relationships withChinese women from China, created limitations whencomparing spiritual resources among the three Chinese

sub-groups in this study.

5.2. Spiritual resource person

The ®ndings reveal that the majority of informants


obtain spiritual strength from their family and friends,and members of the clergy and their Chinese churches

are also spiritual resources. Comparing these ®ndingswith those of Sodestrom and Martinson (1987), wherethe sample had a higher rate of using the clergy and

health care professionals, informants in this study didnot report a heavy reliance on the clergy and healthcare professional as spiritual resources. This pattern

may be explained by the nature of the Chinese culturein problem solving, when individuals seldom go out-side of their families to seek assistance or connections

(Suen and Ng, 1986). Sodestrom and Martinson's(1987) insight that nurses have a di�culty in identify-ing patients' spiritual needs and providing appropriatespiritual care may also explain this behavior. An indi-

vidual's ethnoracial background also a�ects a person'shealth status tremendously and the majority of immi-grants are usually marginalized as strangers in a new

society (Krulfeld and Camino, 1994).

5.3. Is Confucianism outdated?

Chinese culture has been dominated by Confucian-ism for over 2000 years. Confucius, a scholar, teacher

and philosopher, lived from 551 to 479 BC. Heexpounded the virtues of ®lial piety, loyalty, social dec-orum, humility, obedience and self-awareness. His

ideal, ``the Perfect Man'', as opposed to ``Every man'',epitomized all the virtues attainable by human nature.The teachings of Confucius were collected and com-

piled by his disciples and had profound in¯uences on

politics, education, music, art, customs and beliefs. Heexpressed no speci®c religious beliefs but only vaguelyreferred to the presence of a supernatural power as

``Heaven''. He saw ancestral worship as an acceptableand important ritual.Overall, Confucian teachings provide a structured,

hierarchical life system that can lead to a peaceful andorderly society (Suen and Ng, 1986), although theseconcepts are not necessarily in accord with current

values and practices.Many of the informants in this study indicated that,

for them, Confucianism was outdated and had no re-lationship with their spirituality. Nevertheless, some

participants would rather see Confucianism to evolvewith Buddhism or modernity. This idea is in accordwith one of the foremost authorities on Neo-Confu-

cianism, Professor Wei-ming Tu (1984), who views thecontinuing expanding aspects of Confucianism asre¯ecting on modernity in Confucianism, and regards

Confucianism as a religious belief and the personalquest of a re¯ective human being.

5.4. Religion shift

Compared with the Taiwanese sample in Chiu's

(1996) study, in which nine of 15 informants wereeither Buddhist or Taoist, the informants in this study

had a greater religious preference for Christianity orCatholicism (ten out of 15). Informants generally haveeither compromised or adopted a new belief about the

new society or utilized available spiritual resources forthe new society. Some informants were Christianbefore immigrating to the US.

5.5. Chinese support groups in the US

A majority of informants indicated that they bene-

®ted greatly from involvement in Chinese breast cancersupport groups, where they were able to use theirnative language to share information and obtain spiri-tual support. Not until 1991, however, was a Chinese

cancer society established in the US. Chinese breastcancer support groups are only found in some Chineseaggregate places such as New York City or San Fran-

cisco. Chinese immigrants who reside in other areas ofthe US may ®nd di�culties in obtaining group sup-port. Since the Chinese tend to look for assistance

inside of their families or communities, Chinese breastcancer support groups may be valuable resources forthem to better cope with cancer.

6. Conclusions and implications

Spiritual resources for Chinese immigrant women

with breast cancer in the US include family closeness,traditional Chinese values, religion, alternative therapy,art, prose and literature and Chinese support groups.

The Chinese women gained spiritual strength and sup-port in their connectedness with their family. Theyconsciously or unconsciously anchored themselves intheir culture values that provided spiritual strength

and power of interpretation to their health and illnessand their current situations. Regardless of theresources that were available, the women each

respected their religion as a source for their spiritual-ity. Extending from their cultural beliefs, the Chinesewomen found hope and strength in a wide variety of

alternative therapies and inspiration from art, proseand Chinese literature. The women also found strengthin breast cancer support groups where members couldnot only exchange information about breast cancer,

but also speak in their native language and share theircultural values and stories.Florence Nightingale noted that spirituality is intrin-

sic to human nature and is our deepest and mostpotent resource for healing (Macrae, 1995). The ®nd-ings of this study provide new insights into the ideas

of spiritual resources and the interplay of culture andspirituality with the perception of health. The experi-ences of Chinese immigrants in the US and their spiri-


tual resources involve unique individuals who should

be viewed as cultural beings, who should have their

needs recognized. Religion is a spiritual resource for

Chinese women with breast cancer and plays an im-

portant role in the healing. Chinese churches or tem-

ples should be available to Chinese women in the US

so that they may pray and connect with their Higher-

being. Chinese breast cancer groups should also be

encouraged to provide information and support to

Chinese clients and thus become e�ective, problem-sol-

ving agencies. Follow-up support was arranged after

this investigation, either via the internet or person-to-

person telephone calls. A web-based, multilingual com-

munication system is recommended to provide exten-

sive readable information (including alternative

therapies) and improve interactions among Chinese

immigrant women with breast cancer worldwide and

among these women and the US healthcare system.

Healthcare is in¯uenced by the beliefs of its provi-

ders and consumers. Health professionals must be

aware of the religious, spiritual and cultural values

possessed by their clients and what they bring to their

practice. They also should nurture and support their

own spirituality to be available as a spiritual resource

for their clients. The knowledge of spiritual resources

that permeates in di�erent cultures will help nurses to

provide their clients with spiritual support. Nurses, as

health care professionals, should also be culturally sen-

sitive and avoid stereotyping their clients, attending to

each client as a unique person. The Chinese women

with breast cancer may be eliciting spiritual quests for

quality of life or facing the spiritual distress caused by

such events as death and dying. Nurses need to for-

mally assess a client's resources so that each Chinese

woman will bring her spirituality to bear on her health

practice. For example, does the client's spiritual beliefs

have a strong impact on how she de®nes health and

the cause and e�ect of illness? Does the client believe

that a deity is involved in her life? How is her faith

meaningful to her? What is the role and meaning of

signi®cant others during health and illness? What has

been her past source of strength and coping? What

available resources in the US can provide spiritual

strength to a client?

In attempting to answer these basic questions, the

nurse may be able to encourage the use of spiritual

resources such as family closeness, cultural value sys-

tems, religion, alternative therapies, art, prose and lit-

erature or Chinese support groups. Enhancing the

client's use of spiritual resources is contingent on the

nurse's ability to use the individual's culturally based

beliefs and values in the design of nursing intervention

(Henkle and Kennerly, 1990). If this idea is an uncom-

fortable or unfamiliar area of practice, the nurse has

an obligation to attend continuing education o�erings

in this area (Cervantes and Ramirez, 1992; Corrine etal., 1992; Miller, 1995; Spector, 1991; Stoll, 1979).

Acknowledgements

This study was supported by the Harvard Yen-

Ching Institute. The researcher's thanks go to thewomen who participated in this project for their storiesand beautiful spirits, to Lucy Young for helping withthe interviews, and to Professor Wei-ming Tu and Pro-

fessor Arthur Kleinman for their mentorship with theresearcher at Harvard University.

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