Overcoming: A Concept Analysis

Abstract

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.

Introduction

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.

Definitions and Uses of the Concept

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 and Definition 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.

Antecedents

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

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

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.

Resiliency

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

Hope

Optimism

Self Efficacy (Multiple Bandura models)

Self Esteem

(Rosenburg, 1979 & 1965-Self-Esteem Scale)

(Wylie 1974 & 1979),

(Coopersmith, 1967-Self-Esteem Inventory)

Perceived Social Support

Quality of Life

Cases Studies

Three categories of case studies are provided to further expand the concept of overcoming. While cases may be invented or found in the literature, those presented here derive from actual examples in our work with homeless families. Abbreviations used to identify each case are fictitious and are not based on participant’s actual names given that focus group data was collected and categorized by group participant number. The model case demonstrates all of the defining attributes of the concept while the borderline case contain most but not all of them. This helps to more fully articulate the concept’s meaning. The final contrary case is a clear example of what the concept is not (Walker & Avant, 2005).

Model Case and Analysis

A.B. is a 24-year-old African American woman living in a subsidized apartment in Detroit, Michigan. In May 2009, she was nine months pregnant with her second child when her husband physically assaulted her. Fearing further harm to herself and her two-year-old son, she left her home with only $10 in her pocket, the clothing on her back, and two diapers. She immediately sought refuge at a women’s shelter, frightened and embarrassed by her situation and in full recognition that being homeless with a baby on the way was a desperate situation. Within days of becoming homeless, she also reached out to family, but was disappointed by the lack of support and assistance they offered. Quickly realizing that she was on her own and that any change in her situation would be self-motivated, she applied for emergency housing assistance, found legal aid services, and discovered a variety of community resources aimed at supporting women in similar circumstances. She did not wait for others to inform her of available assistance programs, but actively engaged in her own rehousing process. Within two months, with the assistance of a service agency geared to supporting homeless families, she and her two children relocated to an apartment and she enrolled in college to become a social worker, determined to build a better life for her sons and herself. She also continues to attend a weekly program to acquire the skills she needs to make this plan a reality and to create and sustain a support network that she deems critical to her ongoing ability to overcome homelessness.

This model case study fully demonstrates all three attributes of overcoming: recognition of the need to change a current behavior, situation, event, or problem; demonstrated readiness and determination to change or surmount the behavior, situation, event, or problem; and belief that efforts to change or surmount the behavior, situation, event, or problem will improve one’s future life quality. First, our model case participant identified that her living situation was unhealthy and potentially harmful to herself and her child. While leaving the harmful environment was sudden and unexpected, she was able to locate emergency shelter and then attempted efforts to seek assistance. When her family was unable to provide support and the shelter system revealed itself unprepared to meet the needs of her growing family, she shifted her efforts to other resources in an effort overcome her circumstances. Her resiliency in the face of repeated barriers allowed her to take action that led to change rather than succumb to inertia. She was able to successfully secure and maintain housing and made additional changes (e.g. by continuing her education and expanding her life skills) with the hope that her life and those of her children would improve. She not only overcame her own domestic situation but was so well versed in community resources that she was able to offer guidance and encouragement to her peers and serve as an inspiration for their journeys toward overcoming homelessness.

Borderline Case and Analysis

C.D. is a 30-year-old Hispanic female who, along with her 8-year-old daughter, was recently rehoused after living in a homeless shelter for several months. This is her second episode of homelessness in less than a year and now she is nine months pregnant with her third child from her current boyfriend, who was recently imprisoned. Another child, a 2-year-old son, is currently in medical foster care because of a cardiac condition deemed too complicated to manage while she was sheltered or living temporarily with acquaintances. Both episodes occurred after a male partner, on whom she was financially dependent, was unable to support her and her children. Though new to the Detroit area when she became homeless this time, C.D. was highly motivated to find housing and locate available resources so that she could reunite her family. During the process of overcoming homelessness, however, C.D. was frustrated to learn that she had to seek out resources for herself. She readily utilized available services but relied on others to direct her toward them and, while her goal of rehousing was achieved and she was reunited with her son, she had no long term plans for maintaining stable housing, was not seeking employment, and was living day-to-day.

C.D.’s story exemplifies a borderline case, where only two of the three attributes of overcoming are realized. Once C.D. was faced with the reality of a homeless shelter and separation from her child, she recognized and acknowledged her own dire circumstances. She acted upon this by accepting the help offered to her at the shelter and actively participating in rehousing efforts. Still, while her efforts to find housing were successful, she was not engaged in planning for her future to remedy root causes that led to homelessness on two occasions. Substituting her financial dependency to subsidized resources to abate her current homeless situation, she has not overcome the risk for future episodes.

Contrary Case and Analysis

E.F. is a 23-year-old African American female living in a Detroit family shelter with her 2 year old son. During the focus group sessions, she did not share the circumstances which led to her episode of homelessness but expressed dismay that the local shelter system did not directly aid her in the rehousing process. She spoke of unsympathetic case workers, cold, filthy sleeping conditions, and strict rules and regulations regarding food and meal times. She could not envision a way out of her current situation and when her peers offered suggestions regarding potential housing opportunities, she responded negatively, noting that those buildings were in the ‘wrong part of town’ or that she would be unable to afford them anyway. She was tearful and down-trodden, did not speak of her future housing or employment prospects, and revealed no hope for a brighter future for herself or her child.

This final case reflects an absence of the attributes of overcoming. E.F. recognized that she was in an unfortunate situation, but was not able to acknowledge that there was potential for a better circumstance. She spoke in negative terms and was not personally motivated to seek resources or plan for the future. E.F. did not believe that she could sustain housing, even when her peers pointed out that they had been successful with similarly limited resources. In this case, failure to overcome led to a prolonged episode of homelessness, and high risk for recurrence of homelessness in the future.

Implications for Nursing Practice

Overcoming is a phenomenon that has yet to be sufficiently studied to provide a base for nursing knowledge. Analysis of the concept overcoming helps nurses design clinical interventions that promote the process, contributing to positive physical, psychosocial, and environmental health outcomes. Nurses working with particular populations, such as the homelesss, may find overcoming and its attributes integral to assessment and intervention. Our current research suggests, for example, that overcoming is a key element in the ability of homeless mothers to move beyond their current homeless state, identify and change root behaviors that put them at risk for future homeless episodes, and create healthier and happier lives for themselves and their children (Gulteken, Brush, Baiardi, Kirk, & Lapides, under review 2010). Clearly, however, this is an area for further clinical research for nursing that can extend to all settings and individuals.

Conclusion

A first step toward developing a theory of overcoming is a systematic analysis of the concept. This concept analysis has identified the antecedents, defining attributes, and consequences of overcoming. Overcoming is theoretically defined as a process whereby an individual and/or group acknowledges a behavior, situation, event or problem and its negative health or social impact, becomes willing to change the behavior, situation, event or problem, and derives hope that by doing so, one can improve quality of life for oneself and/or others. The next step in the development of the theory of overcoming for nursing is the construction and testing of theoretical relationships between overcoming and outcome variables. Systematic studies of overcoming, whether quantitative or qualitative, can ultimately enhance nursing science and promote health in individuals and populations served.