I read with particular interest this article and commend the authors for their investigation into a particularly challenging and emotive clinical issue. The author's findings were particularly enlightening for me because they match, to a large extent, my personal experiences of working in this discipline – some 15 years ago – and the issues that I encountered with spinal-injured clients. To me, it is obvious why this is the case. The issues and challenges that face spinal-injured patients are little different today than they were then. The technology may be significantly improved, but the dilemmas of prognosis and rehabilitation for this client group remain relatively unchanged and challenging.

On a personal level, I was surprised to see that the findings of Lohne and Severinsson's (2005) study did not explicitly unearth issues related to ‘finding meaning or connectedness’ for and in relation to the injury suffered by the participating clients. An overarching memory of mine was the perpetual quest, of a significant proportion of the patients I encountered, to ‘make sense’ of their injury and their experiences and their personal struggle to come to terms with their condition – what I would refer to as their existential quest. I have tried in the literature to define what I mean by existential health states in patients and how they relate to a number of interchangeable factors – namely a state whereby an individual seeks to place their illness in the context of who they are and what they might do and why, a search for meaning in the context of how their illness connects and co-exists with their world, and an awareness of self and self-understanding as it applies to their altered health state (Whitehead 2003, p. 680):

In essence, an existential experience is a manifestation and an attempt at an awareness of being.

I add, however, that Lohne and Severinsson (2005) do allude to some elements of what I would call an existentialist context in mentioning certain terms, such as awakening, transcendence and spirituality – but these are only in passing. The link that does not come across to me in this study, is that much of the contemporary literature on hope-related issues clearly establishes the relationship among hope, suffering and existential health states (i.e. Flemming 1997, Rustoen & Hanestad 1998, Benzein et al. 2000, Arman et al. 2004).

I published an article in the pages of Journal of Clinical Nursing with the express aim of addressing the lack of acknowledgement and subsequent assessment for existential health states in clinical practice (Whitehead 2003). I believe that it is a vital and integral role for nurses and one that I would like to see implemented as routine assessment practice in the clinical setting. I would particularly welcome, at least in the interim, seeing existential assessment being piloted in areas where client groups are most likely to need to gain introspective insight into their radically altered health state – such as terminal disease and spinal injuries. It is known that an existential potential lies in everyone but is not usually realized or noticed until triggered by some significant life event or crisis (Whitehead 2003). I would welcome more studies, such as this one by Lohne and Severinsson (2005), but would also like to see them linked to more specific attempts to investigate the existential dimension of vulnerable client groups’ health states, as they relate to the issues of hope, suffering, meaning and connectedness.


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