This article provides an operational definition of overcoming as a first step in the systematic analysis of the concept. Using the method described by Walker and Avant (2005), the authors identify the attributes and characteristics of overcoming and its theoretical and practical application to nursing. Sample cases from clinical research illustrate the concept further. Further nursing research needs to test the theoretical relationships between overcoming and outcome variables.
Nurses often work with individuals and populations with complex health and social problems, assisting them to promote health, whether in terms of their mental or physical states, their environments, or their social habits, lifestyles, and choices. This interactive process can be fraught with nuanced meaning and approaches that may differ between patients and providers. In a recent qualitative study exploring the lives of homeless mothers, for example, study participants often spoke of “overcoming” their situations as a desired outcome (Gulteken, Brush, Baiardi, Kirk, & Lapides, under review 2010). The discussion that then ensured included measures to reach that aim (e.g. securing stable housing and employment and/or completion of or furthering education) and what services and support were needed to promote them. As data from the focus groups was analyzed, moreover, it was also apparent that the perceptions of need between providers and service recipients was discordant; that is, homeless women identified and prioritized barriers and obstacles they needed to overcome differently from those anticipated by the providers. Thus, while “overcoming” conjured up images of participants’ rising above an undesirable situation and moving toward brighter and better futures for themselves and their children, the term’s definition in the literature remains vague and variable in meaning. Often used interchangeably with terms such as resilience, survival, adaptation, or resourcefulness, overcoming has yet to be systematically explored or defined as a concept in nursing.
Utilizing the concept analysis method described by Walker and Avant (2005), we explicate the meaning of overcoming and examine its attributes and characteristics. Sample cases from our research and practice with homeless families illustrate the concept further and help us develop an operational definition. The results of this analysis will enhance understanding of the concept and its theoretical and practical implications for nursing more broadly.
According to the American Heritage Dictionary (2009), the word overcoming is derived from the Old English word, ofercuman, and means to get the better of; to defeat (another) in competition or conflict; to conquer, prevail over, or surmount; or to overpower or overwhelm, as with emotion. Synonyms such as vanquish, survive, best, beat, conquer, and hurdle and antonyms: give in, surrender, relapse, and yield, connote a process of winning over losing, success over failure, or surmounting rather than succumbing to.
Certain individuals have come to symbolize the concept of overcoming and serve as models of inspiration to others. For example, Helen Keller, in the face of seemingly insurmountable physical disabilities, went on to become a preeminent author and activist who penned the now famous “All the world is full of suffering. It is also full of the overcoming of it” (Keller, 2000). Like Keller’s victorious navigation over blindness and deafness, so too have others overcome significant social barriers and personal adversity to achieve success (Davis & Sturdevant, 2002), better health (Cameron, 2005), or ensured survival (Penner, Ferdinand & Carter, 2009).
The process of overcoming has also been popularized in songs of protest, activism and/or spiritual awakening as well as in a host of self-help books from binge eating (Hirschmann & Munter, 2008) to problems in everyday life (Kushner, 2006). The Civil Rights movement’s key anthem, “We Shall Overcome,” signifies surpassing barriers to racial discrimination. The song’s lyrics were adapted from Charles Tindley’s 1900 gospel song, “I’ll Overcome Someday,” which describes surmounting temptation and the “thousands of snares set for me” through prayer and faith (cite). Tindley’s prayerful discourse mirrors references to overcoming in the Bible’s New Testament, Book of John, where it is noted that “For whatsoever is born of God overcometh the world: and this is the victory that overcometh the world, even our faith” (I John I 4,5). References such as these highlight that one’s ability to overcome is a process that necessitates willpower, internal strength, and motivation to change an existing condition for another more enlightened or more freeing one.
As in more public uses of the concept, the term “overcoming” has also been used across health disciplines to define one’s ability to work through or surmount an issue, problem, obstacle, or situation such as addictive behaviors (Dende & Kline, 1995; Hodgins, 2001; Houston et al., 2008), physical or mental health illnesses or disorders (Ledoux & Gorman, 2001; Pinquart, Duberstein, & Lyness, 2007; Shellman & Mokel, 2010; Strickland, Hodges, North & Weghorst, 1997), traumatic events (Bush, 2002; Joseph & Linley, 2005) or barriers to care access and quality (Robert Wood Johnson Foundation, 2008; Schooley, Horon, Lee, & West, 2010; Tod & Joanne, 2010). In the pharmacology literature, the term is also used to denote ways to surpass resistance and maximize drug effect on target illnesses (Ahmad, Barnes & Adcock, 2008; Marwick, Adcock & Chung, 2010; Petersen, Peyton, Minna & Wang, 2010).
Typically portrayed as a difficult process, overcoming is an active and conscious effort, made willingly and in response to a desire to move beyond one state to a better alternative or situation. In some instances, the process of overcoming leads to recovery and reparation from the issue such that the condition is no longer problematic (Henderson, 2010; Polcin, Korcha, Bond, Galloway, & Lapp, 2010; Van Vliet, 2009). Indeed, the terms “adaptation,” “resilience,” and “survival” have been used interchangeably to describe the process of overcoming.
Earvolino-Ramirez (2007) defined resilience as the ability to bounce back or cope successfully despite substantial adversity, implying that there has been a deviation from a more desired norm to which one hopes to return. Tusaie, Puskar, and Sereika (2007) used the term when describing rural adolescents’ ability to cope with emotional distress, describing the process as “the capability to adapt better than expected in the face of significant adversity or risk” (p. 54). Thus, resilience implies a process of hurdling resistance and, in doing so, gaining strength against future stressors, challenges, crises, or trauma, much like a microbe develops resilience over time to an antibiotic and ultimately adapts to and survives its environmental conditions. Survival in the case of the microbe is the ability to live despite a life-threatening event but survivorship has also been associated with life-altering incidents such as sexual abuse, violence, and homelessness (Bender, Thompson, McManus, Lantry, & Flynn, 2007; Peck, 2008). Adaptation and survival are thus consequences of resiliency (Hernandez, Gangsei & Engstrom, 2007) while resiliency is an important individual characteristic in the process of overcoming.
Defining attributes, similar to signs and symptoms, are critical characteristics that help to differentiate one concept from another related concept and clarify its meaning (Walker & Avant, 2005). Three key defining attributes have been identified for the concept overcoming: (1) an ability to recognize or acknowledge that a behavior, situation, event, or problem exists and is undesirable, impeding, or unhealthy; (2) demonstrated readiness and determination to change or surmount the behavior, situation, event, or problem; and, (3) belief that efforts to change or surmount the behavior, situation, event, or problem will improve one’s future life quality. Overcoming is thus defined as a deliberate and thoughtful process of changing or conquering a self-perceived problematic circumstance, challenge, or adversity in order to live a healthier and happier future.
Walker and Avant (2005) define antecedents as the events or attributes that must arise prior to a concept’s occurrence. In the process of overcoming, an individual must first identify the existence of and need to change a current behavior, situation, event, or problem. According to Bandura (1977), behavior change and maintenance are a function of one’s expectations about the outcomes of engaging in a behavior and the expectation about one’s ability to execute that new behavior. Thus, outcome and efficacy expectations include beliefs about whether or not the desired outcome will occur and the individual’s perceived capacity to perform relevant tasks toward that aim (Bandura, 1977). Self-efficacy thus plays a significant role in overcoming; individuals need to believe in themselves and their ability to make and sustain change in their situations in order to overcome that situation. It is generally accepted that individuals with low self-efficacy are less likely than those with high self-efficiency to consider overcoming their situations and, when they do, to be successful (Bandura & Locke, 2003; Stretcher, DeVellis, & Becker et al, 1986; Vancouver, Thompson & Williams, 2001; Yeo & Neal, 2006).
Change is paramount to overcoming, which, as delineated by Prochaska and DiClemente’s (1982) Stages of Change Model, is a process that evolves through five distinct phases and denotes one’s readiness to engage in overcoming an identified behavior, situation, event, or problem. The first stage, precontemplation, is a time when there is no foreseeable readiness to change one’s current behavior, situation, event, or problem, largely because the individual is not fully aware of the need for remedy. Stage two, or the contemplation stage, signifies a period when a person gives serious thought to overcoming a behavior, situation, event, or problem but does not commit to action. Should this stage be met, an individual next moves to the preparation stage, in which he intends to make necessary changes and then begins to incorporate small behavior changes into his life. Still, it is not until the fourth stage, the action stage, that individuals modify their behavior or environment to overcome their situations. Modifications in this stage are visible and often receive external recognition from others. The final stage is where individuals work extremely hard to maintain their behavioral change and prevent relapse of the behavior. It is important to note that no matter how well-intended an individual may be, relapse and recycling through the stages occurs frequently and is a well documented part of the struggle to overcome (Prochaska, DiClemente & Norcross, 1992).
Indeed, the reality of relapse requires that an individual be resilient and flexible, particularly since the process of overcoming is neither linear or absolute on first attempt. Overcoming also requires that individuals have optimism and hope for a better future than the present and past lives that define them. It is this hope that serves as motivation for the difficult stages of change, thus helping to move the individual beyond adapting to or surviving a difficult situation to acquire a life of purpose and meaning. Social support also serves as motivation. Once change is in progress, individuals must believe that their achievements are supported by significant others, agencies, or systems.
For optimum success in overcoming an identified source, therefore, individual characteristics must ally with environmental factors to support the process. Social factors that predict one’s ability to overcome include access to services that can assist them with their individual needs, family or friend support, and a broader community social network. Although the need for environmental support may vary with the degree and complexity of the issue, problem, or situation at hand, the individual needs to perceive that it is available and helpful in the process of overcoming. Cone and Waters (2006) described the process of reconnecting in their grounded theory study of formerly homeless mothers and found that social interactions were critical to resolving homelessness. Likewise, Tischler (2008), examining the resettlement and reintegration experiences of single homeless mothers after rehousing, noted that improving one’s physical surroundings (e.g. living away from violent neighborhoods and/or relationships) helped one maintain the ability to overcome homelessness. Their findings mirrored many of the issues reported by women in our study sample (Gulteken, Brush, Baiardi, Kirk, & Lapides, under review 2010). For example, several participants in our study had been homeless multiple times. Individuals suffering from substance addiction, caring for multiple children, and lacking intimate partner, family, or friend support were particularly vulnerable to repeat homelessness. The inability to overcome the challenges of these component issues precluded the ability to overcome homelessness as an outcome.
In her meta-synthesis of qualitative research regarding homeless women, Finfgeld-Connett (2010) described homeless women as “ill-prepared to prevent and resolve homelessness” (p. 462) unless they were able to overcome the multitude of complex interconnected intrapersonal, interpersonal, and environmental stressors that led them to homelessness in the first instance. She defined three stages necessary in the process of overcoming homelessness: crisis, assessment, and sustained action. Similar to the Change Model (Prochaska & DiClemente, 1982), these stages were iterative and often difficult to maintain in the face of social, personal, emotional, and environmental barriers. As she put it, “women who successfully extricate themselves from a homeless existence overcome self doubt and fear and are able to rally enough self-esteem to sustain them through multiple ordeals (Finfgeld-Connett, 2010, p. 464). In other words, women needed to be resilient in the face of obstacles to housing stability, be hopeful that they would attain their goals of housing stability, and have the necessary support in place to do so.
Consequences are those events or incidents that can occur as a result of the occurrence of a concept and that can often stimulate new ideas or avenues for research pertaining to certain concepts (Walker & Avant, 2005). Possible consequences of overcoming include an individual’s return to a more stable and better quality of life, finding hope and meaning in life, and moving beyond a difficult situation or circumstance toward a healthier and more satisfactory future. This is generally a positive process yielding positive outcomes.
Empirical referents are measurable ways to demonstrate the occurrence of the concept (Walker & Avant, 2005). There are no measures of overcoming, however, measures of related constructs are available that may help quantify the process and its outcome. Below, we elaborate on the empirical referents for categories of the related phenomena of resiliency, hope, self efficacy, and perceived social support on the process of overcoming.
Connor-Davidson Resilience scale developed in response to low generalizability of resilience scales (Connor & Davidson, 2003)
Deployment Risk and Resilience Inventory,
Suicide Resilience Inventory
Richardson Model Richardson 1990 & Richardson 2002 ,
[Bartone et al., 1989; Wagnild and Young, 1993] not widely used
Self Efficacy (Multiple Bandura models)