Spirituality in nursing: A concept analysis

Abstract

Background:

Spirituality has always been present in the history of nursing and continues to be a topic of nursing interest. Spirituality has ancient roots. The term ‘spirituality’ is interpreted as spirit and is translated as breath and soul, whereas spirituality (immateriality) is spiritual nature. Historically, the term spirituality is associated with the term religiosity, a definition that persists today, and often the two terms are used interchangeably. In the healthcare context, the construct is still.

Objective

To clarify the concept of spirituality in nursing.

Research design

In this article spirituality was explored using Rodgers' evolutionary and inductive method of concept analysis.

Participants and research context

For this analysis, a sample of 71 articles published in English, from 2008 to 2018 from PubMed/Medline, CINAHL Plus with full text, PsycINFO, SciELO databases were retrieved. It was also accomplished an empirical search of dictionaries and e-books.

Ethical considerations

This study was conducted according to good scientific practice.

Findings

It emerged that “spirituality” is a dynamic process and has a range of attributes. The cultural dimensions, the religious and spiritual traditions, the ethnic diversity and the influence of the historical and social contexts represent the societal and historical conditions ingrained in the Western thought that influence the emergence of spirituality as a concept. Antecedents, attributes and onsequences appeared to inform and strengthen one another over time. Spirituality is a significant concept for the discipline of nursing with profound consequences for caring patients and for work organizations.

Keywords

Concept analysis ethics nurse nursing sociology of religions spirituality

Introduction

Spirituality has always been present in the history of nursing and continues to be a topic of nursing interest, as shown in the literature.^1

–4

It has been postulated that there is little clarity on the meaning of the term ‘spirituality’ and that there is a need to understand it within the social and health language, particularly due to the myriad of interpretations the term gives rise to.

The range of interpretations of spirituality has branched out in recent years, influenced by religious culture and by historical time, by societies that are increasingly pluralistic and also depending on the perspective of the person using the construct. For some, it refers to the belief in a supreme being. For others, it discusses the purpose and meaning of life and the values and practices individuals use to reach this purpose.^5
–8

Although there are references in the literature from nursing researchers who have attempted to better comprehend and define this term within the nursing context,^9
–11 the term ‘spirituality’ appears to be ‘amorphous’ – conceptually stimulating, but difficult to define.^11
–13

As noted by some scholars who have investigated this subject, the notion of spirituality is still under construction; it has, and inevitably always will be, a social construction.^7,12

–16

In agreement with Pesut et al.,¹⁰ spirituality remains an unexplored and uncertain terrain, possibly indicating a fear of the unknown. To date, there is no clear definition of spirituality within the healthcare; to integrate spirituality more directly into the discipline of nursing, a clearer understanding of the concept is required.

Hence, it is pivotal to discover its meanings within the religious and spiritual pluralism of the increasingly globalised society. Hence, it is pivotal to discover its meanings within the religious and spiritual pluralism of the increasingly globalised society, derive a deeper understanding of the intertwined beliefs, cultures, traditions and other religions, Islam, Hinduism, Buddhism, and humanism. Where, in particular, in the European contexts modernization, secularisation and persistence of strong religion beliefs co-exist are occurring in conjunction with increasing ethnic diversity associated with global migration.^{5,8,10,11,17

–32}

The major European Christian religions, especially Catholicism, Orthodoxy and Protestantism, assume the role of more widespread religions. Largely, the European continent is pervaded by more and more consistent and attentive religious currents. Non-Christian religion and spirituality thrive in different forms, as a developing form of religiosity, new religious movements, and majority and minority religions.³²

Spirituality represents a fundamental key value for humanity, including nurses and patients alike.⁸ It can contribute positively to the health and well-being of the patients, families and communities^8,17
–19 in dealing with illnesses and diseases and help them in understanding the proposed therapy.²⁰

Spirituality can, on one hand, contribute to improving a holistic nursing approach,²¹ and on the other, develop a value-based leadership model for transforming work environments.^22
–24

The purpose of this article is therefore to clarify the concept of spirituality in nursing according to the method of Rodgers et al.^33,34

Background

Concept identification

Spirituality has ancient roots.¹³ The term was coined in the 14th century, derived from the ecclesiastic Latin spiritualitas, which, in turn, was derived from spiritus.³⁵ Etymologically, the Latin spiritus,³⁵ until the end of the 13th century, meant ‘soul, courage, vigor, breath, life force’.^36,37 Spiritus not only motivated people but also influenced their life, health, behaviour and relationships.³⁷

The term spirituality has become a key concept of Western culture because it has represented the Greek word pneuma, which is the highest and most immaterial part of the human being, the soul or the vital spirit, the conferment of life. It is a life principle, a life force in contrast with the materiality of the body.^35,38

In the English and Sanskrit dictionary by Monier Williams,³⁹ the term spirituality is interpreted as spirit and is translated as breath and soul. Spirituality (immateriality) is spiritual nature. In Sanskrit, the term atman [self] is defined as ‘spiritual essence of life’, ‘breath–cosmic thought in evolution’.^40,41

This meaning is closer to the English definition of spiritual and, among the Sanskrit words, could be the one that comes closest to the term sacred.⁴¹ In Chinese, spirit means ‘who’, the ‘energy’ that fulfils the sky, the earth, the universe and the nature.⁴²

Historically, the term spirituality is also associated with the term religiosity, a definition that persists today; the two terms are often used interchangeably.⁴³ Spirituality is intimately connected to religion but differs from it.^17,44 Many researchers tend to separate spirituality from religion. Religion is more institutional; tends to be rigid, exclusive and hierarchical; it can be defined as a set of beliefs and practices associated with sacred traditions. Although, the belief may or may not be religious.¹⁹

Spirituality, on the contrary, is a more personal experience that can be associated with religion but which is becoming increasingly viewed as being more independent and might not have association with an organised institution.^36,27

It is a more fluid concept and is defined by creating or looking for meanings shared by all human beings,^14,17,26,38 including those individuals who claim to be religious, humanists, hedonists or atheists.^13,36,44

This is a crucial factor in responding to people who state that they have not got a spiritual attitude because they are not religious, and it is possessed by people of all religions and faiths. ‘The significance of these statements is that no single faith or religious tradition can claim that their understanding of spirit is unique to a specific way of thinking but rather it is a characteristic of humanity’.³⁶ Spirituality also relates to meaning, purpose, connection, mystery, transcendence and energy. These considerations suggest that terms such as spirit, spiritual and spirituality can be defined within a range of connotations that extend from the depths of the supernatural world to the natural world. Indeed, on this understanding, one can be ‘spiritual but not religious’.^19,27,44

However, the naturalist rejects the spiritual realm and simply avoids the use of the word spiritual, as it is considered vague, useless for describing the experiences and activities that give an individual meaning.^7,14

Spirituality can be utilised in ways that invoke mystical elaborations or religious theories, or in ways that are explainable by psychological terms such as thoughts, emotions, desires and human experiences.^14,41

Dynamic concept

Today, the meaning of the term spirituality has different nuances and appears to be changing due to changes in society. Rudolfsson et al.²¹ follow the path of two distinct concepts, religion and spirituality, and describe the experiences of spirituality and spiritual values as closely entwined with the concept of care and resulting in positive influences in the care context. From their integrative revision, seven themes have emerged: ‘Being part of a greater wholeness’, ‘Togetherness – value-based relationships’, ‘Developing inner strength’, ‘Ministering to patients’, ‘Maintaining one’s sense of humanity’, ‘Viewing life as a gift evokes a desire to give back’ and ‘Achieving closure − life goes on’. It is believed that today spirituality is more inclusive, fluid and personal.²¹

Timmins et al.⁴⁵ have attempted to elucidate the role of nurses in providing spiritual care to patients by examining the extent to which the concepts of spirituality and the core of spiritual care are addressed in nursing textbooks.

In their perspective, spirituality is a broader holistic concept that transcends religion. They report there is a common definition by Narayanasamy, who contends that spirituality

…gives us a sense of personality and individuality. It is the force that guides us behind our uniqueness, acts as an inner strength and it makes us emerge as a person. Spirituality is the intimate, intangible dimension that motivates us to be in relation with others and with our environment, it pushes us to search for meaning, for the purpose of establishing positive relationships and trust with others.⁴⁵

Furthermore, Timmins et al.⁴⁵ explored spirituality in the context of healthcare, in which spirituality was defined as the ‘essence’ of the human being, who is searching ‘for transcendental meaning, purpose and happiness’. Reinert and Koenig⁴⁶ reviewed the definitions of spirituality in articles published between January 2007 and December 2011 in nursing, excluding interdisciplinary articles.

In their research, they found that ‘hope, value, emotion, connection, transcendence, existential experience, power/force/energy and belief’ are common words that are often tangled with spirituality, whereas ‘meaning, purpose in live’ are common words that are often associated with the term sense of peace and are known as core mental health symptoms.⁴⁶

However, it was also understood that, in the realm of mental health, emotional states can confound health outcomes and be incorrectly treated as symptoms. Thus, Reinert and Koenig⁴⁶ believed it was a priority to define the term spiritual for a good outcome of good mental health. Reinert and Koenig⁴⁶ recognised the emergent importance of a philosophical approach to nursing for a critical understanding of the topic.

From a philosophical point of view, spirituality can be understood in the context of the individual and culture, as it is a changing notion that can take on a lot of connotations according to the situation. In contrast, Paley^7,14 affirmed that this notion is simply a reductionist thought because it covers everything from music to art, from the contemplation of nature to relationships and connectedness; it is a spiritual hedonism, a way like any other to give a definition.

He stated that methodological agnosticism^7,14 favours the utilitarian perspective that evaluates spirituality and theology in the same way. For this reason, he found the term could be ‘elastic’ because of human diversity, and the various definitions may therefore be appropriate in nursing since the term spirituality lacks definition and conceptual clarity.

However, there are also scholars who speak of ‘spiritualities’, not as a static transmission of traditions but as a product of societies changed by different generations in conjunction with professional and social pressures incorporated in the values of their own time.¹¹

Spirituality is also described as a ‘new alternative’ and as ‘emerging’ and ‘progressive’ in a secularised society, defined by flows of an increased sacralisation or globalised religions, and at times expression of fundamentalist religions.²⁷

This changing view of different spiritualities in a plural society occurs with the increase in ethnic diversity associated with global migration,^10,27,47 particularly in Western countries. It is in these countries that the shifting notion of spirituality can be better recognised. Thus, understandably, this lack of clarity about spirituality is reflective of a post-modern pluralist society,^7,13 as demonstrated by many authors who have tried to explain the ontological meaning of the term. Hussey⁵ began from the assumption that spiritual matters are distinct from material ones.

He affirmed that something classified as ‘spiritual’ is always seen as morally or aesthetically precious. This supports Pesut’s view that ‘spirituality is an innate aspect of all individuals, an important dimension that brings integrity and meaning, harmony, connecting, purpose and transcendence’.²⁵

The problem of defining spirituality is exacerbated by the fact that the meaning has changed over time and continues to do so, depending on cultural settings and how people perceive it.^6,13

Rykkje et al.⁴⁸ developed an understanding of the concept of spirituality from the perspective of health sciences, through the synthesis of 17 studies, focused on ‘love in connectedness’.

The key themes that emerged were ‘connection with an inner space, at the centre of spirituality’, ‘connection with a superior force, with nature, with others and with the community’.⁴⁸

Always Rykkje et al.⁴⁸ found that love plays a key role in spiritual connection and is a ‘core ontological category’ that concerns a union with transcendental or universal love, which is seen as a positive force and a potential resource for health. Love is a motive and a ‘glue’ that works among the categories. Universal love is present in care relationships and is demonstrated through actions. When we speak of spirituality as an inner strength and potential resource, it is because it recognises the person as unique and embraces the whole human being – body, mind and spirit – and therefore all dimensions of the individual are influenced by it.⁴⁸

Spirituality studies have been conducted primarily in the Western context (Australia, Canada, Europe and the United States), although a growing number of studies come from the Middle East, especially Iran. The role and space dedicated to spirituality among nurses has been addressed by Iranian studies for a while. Mahmoodishan et al.¹⁷ explored nurses’ perceptions of spirituality and spiritual care.

From their interviews, three themes emerged: (1) the ‘meaning and purpose of work and life’, including spirituality for their profession, since for them work is a divine blessing, as well as a ‘positive attitude’, ‘commitment and professional responsibility’; (2) the ‘religious attitude’, ‘approval of God’, ‘spiritual reward’, ‘accepting advice’, ‘innate belief in the Supreme Being’, ‘interaction and altruism based on faith’; and (3) the ‘search for the transcendent’, including the need for personal and professional respect and transcendence.¹⁷

Spirituality is the sublime aspect of human existence bestowed on all humans in order for them to traverse the path of transcendence that is closeness to God (Allah).¹⁷

The concepts of spirituality and religion are thus inseparable within the context of an Islamic society, although not in the sense that they are one and the same, but in the sense that religion is necessary for spiritual improvement.¹⁷

Islamic spirituality involves a connection with the world rather than a turning away from it. Connecting with, caring for and serving the family is vital. It is a spirituality of the family, the neighbourhood and the workplace. Within Islam, individuals and communities co-exist, live, work and pray together in peace and harmony.¹⁸ Some scholars, such as Zakaria Kiaei et al.,⁴⁹ found that nurses need more knowledge and training regarding this concept and they emphasised that spiritual care needed to be included more in nursing practice to provide holistic care. McSherry and Jamieson² also recognised that nurses still require clear boundaries between their personal and professional lives to enable them to feel more confident and competent in providing spiritual care.

Method

Although there are various methods by which a conceptual analysis can be led, we used Rodgers and Knafl’s³⁴ evolutionary approach to gain clarity on this construct. This methodology seemed to us the most appropriate for the analysis of the concept of spirituality, because it has an interdisciplinary perspective that emphasises the similarities and differences in how a concept is utilised across various disciplines.^34,50 As Rodgers and Knafl³⁴ reported, ideas are most commonly expressed through written or spoken language. This dynamic process is supported by eight main activities, which are outlined in Table 1.

Table 1.

Applying Rodgers’s method of concept analysis to spirituality.

Rodgers’s evolutionary method	Concept analysis of spirituality
Rodgers’s steps in concept analysis
1. Identify the concept of interest and associated expressions/terminology	1. Concept: Spirituality
2. Identify and select an appropriate discipline and period of time for data collection	2. Disciplines: philosophy, psychology, sociology of religion, business, nursing; Databases: CINAHL, PsycINFO, Medline, SciELO; Time period: 2008–2018
3. Collect data regarding the attributes of the concept, including surrogate terms, antecedents, consequences and references	3. Surrogate terms: spiritual care and spiritual need Antecedents: religious, cultural, ethnic pluralism, beliefs, traditions, values, culture/s, religion/s diversity, meditation (prayer, reflection, contemplation, Yoga) Consequences: holistic care, physical psychosocial spiritual, awareness and self-awareness, quality of life, well-being, ethic (environment, welfare, ecological); nursing: cultural skills, life-long learning; References: review of literature
4. Identify related concepts	4. Related concepts: religiosity, mysticism, sacred, self
5. Analyse data regarding the above characteristics	5. Identification of major themes: religion
6. Conduct interdisciplinary comparisons	6. Spirituality in psychology, sociology of religion, philosophy
7. Identify a model case of the concept, if appropriate	7. Identified
8. Identify hypotheses and implications for further development	8. Attributes: being part of a whole or a greater being, transcendence, values, non-violence, generosity, karma and rebirth, inner silence, harmony, connectedness with self, to others, to God, to nature

The philosophical perspective embodied in this inductive method is characterised by the development of an understanding of this dynamic concept, and the identification of the consensus or the state of the art.³⁴

In addition, this method of analysis involves the identification of the concept of interest, the spirituality and related terms, the selection of a relevant sample (set of articles) to search for attributes, the analysis of data, the identification of the theoretical model and eventually, the implications for further developments of the concept.

Data sources

Rodgers and Knafl³⁴ introduced a procedure for concept analysis that begins with a systematic literature review to retrieve all the studies discussing the concept of interest. According to this logic, a bibliographic search was carried out on some of the major international electronic databases: PubMed/Medline, CINAHL Plus with full text, PsycINFO, SciELO, without limits, and through an empirical search of dictionaries and e-books.

In the PubMed database, the dictionary defines spirituality as sensitivity or attachment to religious values.⁵¹ On this database, once we found a study that represented a good example of a research topic, we looked for other similar studies by clicking on the ‘Related Citations’ function.⁵²

Database limits were set to include only English articles and keywords evident in the title and abstract. The databases were queried using the following key words: ‘concept analysis’ ‘diversity religion’, ‘nursing’, ‘religion’ and ‘spirituality’.

The review included studies conducted from January 2008 to May 2018, published in English, inherent to the researched topic. Once we identified the articles, the duplicates were excluded, and the articles of interest were selected with the analytical support of the Discovery Sapienza University system. According to Rodgers et al.,^33,34 a data analysis is a continuous process of organisation and reorganisation of data literature.

The current results were compared to the attributes reported by classic authors.^6,7,10,32,44 Moreover, a more detailed analysis of spirituality attributes, antecedents, consequences, surrogates and related terms was conducted. After scanning titles and abstracts, deleting duplicates and unavailable full text, 842 articles were saved. These articles were re-examined by either scanning or reading the full texts, and 324 articles were included. Based on Rodgers and Knafl’s recommendations,³⁴ 20% of the 324 articles were chosen for review using a stratified random sampling. This resulted in a total number of 71 documents, which were incorporated in the concept analysis: 65 journal articles, an e-book, 2 methodological research books, 3 dictionaries (Figure 1).

Figure 1.

Flow chart of the data selection obtained from the CINAHL, PubMed/Medline, PsycINFO and SciELO databases.

Each of the 71 documents was read in full and analysed for any data relevant to attributes, antecedents, consequences, surrogates and terms related to spirituality. A conceptual framework that represents the concept of spirituality is shown in Figure 2.

Figure 2.

Conceptual framework.

Results

Attributes and surrogate terms of ‘spirituality’

The dissection of the articles was aimed at putting together the inclusion criteria not only to find the meaning of spirituality but also to identify its attributes.³⁴ As Rodgers and Knafl³⁴ suggested, identifying the attributes of a concept represents the primary realisation of the analysis of the concept itself, because they represent a real definition.

Numerous attributes of spirituality are discussed in the nursing literature. Several of them were identified and have been found in fundamental sentences referring to temporal, sociocultural and disciplinary situations; they are used by people with different perspectives and cultures.³⁴

In this article, the following attributes of spirituality have been identified:

Being part of a whole or a greater being is the entirety and the balance between body, mind and spirit in relation to and in total harmony with oneself, with others, with God and with nature. This is a transcendental expression and a dimension of spirituality.^{21,36,42,53
–55}

Transcendence underpins all spirituality.^36,41 It is connected to the fundamental and ultimate questions in life that go beyond what is interiorised or physically understood to the reading of spirituality; it means to gain a deeper insight into what spirituality represents. It takes meanings from other psychosocial constructs.^36,46,54,56

The transcendent is what is outside the self and yet also within the self. It is a higher power, which is also known as God, Allah, Hashem and Truth in Western traditions, and in Eastern traditions may be called Brahman, manifestations of Brahman, Vishnu, Krishna, Buddha, Dao or Ultimate Reality.⁴⁶

The diverse religious communities engage in a lot of different forms of spirituality, making it a more applicable concept for nurses dealing with a wide cross-section of the community.⁴⁶

Spirituality implies a search for transcendence and involves human beings on a journey of movement and transformation of the self along a path that leads to belief without asking and faith through devotion.^46,54,56 In the Hindu beliefs, spirituality is the movement and transformation of the self, in relation to the society in which one lives and works.

It is a journey towards spiritual liberation that revolves around the renunciation of superficiality and the emptiness of the world. Spirituality is a means of seeking awareness of the divine in daily practice.¹⁸ Travelling is a living experience or a spiritual feeling, an epiphany of the heart when you do not expect it.^57

–60

The aim in Hinduism is to fight for the unique and ultimate unity with the divine.¹⁸ Spirituality is the common denominator between Man and God, between divinity and the ultimate reality.⁴¹ In the Hindu tradition, the spiritual experience is inclusive and implies going beyond the expression of the senses. This is useful for explaining the experience of the sacred that transcends religious experience and ensures that those who do not believe in one God only experience the relationship with the mystical.^{10,18,21,36,41,54,58}

Self-transcendence, on the contrary, is a person’s ability to become highly aware of the ‘self’. It is the skill to expand personal boundaries beyond oneself, outwards and upwards, and to connect with the spirit of the universe to find the meaning of one’s existence. For example, this could occur during a moment of crisis, as an illness, a mourning or a death.^36,60

A nurse’s understanding of this phenomenon potentially increases positive interactions between the nurse and the patient and supports the healing process for the patient.⁴⁵ A connection, union or relationship that is based on shared values and solidarity is at the centre of spirituality.⁴⁸

This constitutes an addition to the understanding of oneself in one’s ‘inner space’, as the basis of the human being who is part of the whole: in conjunction with oneself, with others, with a higher being, with nature and with animals, which leads to expressing one’s own spiritual experience, not necessarily linked to a religious system.^{4,15,19,29,36,59
–62}

Values are important elements in the spiritual relationship and can include love, harmony, integrity, altruism, compassion, hope, trust and wisdom. The recognition of the positive therapeutic effect of patient’s values and beliefs is gaining ground as patients and their families ask for respect for their beliefs and values in the healthcare environment with increasing frequency.^{15,19,36,37,45,54}

However, these Western values and beliefs should not be understood to be universal. It is useful to highlight not only these values but also the values of Hinduism, which include non-violence, generosity and the concept of karma and rebirth, in which the good or bad actions performed in the present influence the quality of one’s life now and in the future.⁶³

Inner silence can be interpreted as a form of self-healing, such as entering harmony with oneself or with another, for example, with the patient, nature or the whole.⁵⁷ A silent reflection contributes to the healing process together with a welcoming environment. Spirituality is an innate gift and this practice evokes a desire to give back.

For example, when a person has experienced a state of disease and overcomes it, the person often feels a desire to help others. In the literature, this is described as an expression of love and altruism. Helping others creates a sense of self-awareness, self-fulfilment and satisfaction. This could be a good opportunity to discuss evidence of a growing awareness of the need for spirituality through prayers and meditation rooms in hospitals.^20,21,36

Another attribute that we frequently found in the literature of spirituality equated to a ‘search for meaning and purpose in life’.^4,19,29 We found frequent questions that were not only connected to religion but to everyday life issues, as well as to the meaning of illness and death.^15,36,45

The search for meaning is to find an answer to the nature of one’s existence. The development of inner forces in everyday life leads to the belief there is something more than material life; it is trying to understand who we are and why we are in the world.²¹

Spirituality is a vital force, support or creative energy, motivation, orientation and search for inspiration so that the individual can meet the needs of life and overcome crises to give meaning to life and death.¹⁵

As Lepherd³⁶ noted, spirituality can be manifested through behaviour carried out inwardly (p. 570). These attributes are parallel to the elements included in the nursing texts. If we compare the notes of Pesut et al.,¹⁰ we find parallel definitions of what spirituality is, regardless of religion. These are, ‘meditation that involves reflection, contemplation and prayer’; ‘integrative energy’; ‘meaning in life’; ‘unfolding in the mystery’ or ‘harmonious interconnection’; and ‘search for the sacred’.^10,38,41

Natural development and conscious aspect,^60,63 comfort and upholding the principles of life and well-being complete the list of attributes.^19,41

Again, the initial literature review provided clarity because additional terms were sought. Surrogate terms are those used to express a concept in other words (p. 92).³⁴ In this sense, the terms spiritual, spiritual values and religiosity have specific meanings in healing and are often used to identify the concept of spirituality. In the 71 nursing documents included in the study, a series of surrogate concept terms were highlighted as spirituality.

Terms related to spirituality

To further clarify any concept, Rodgers and Knafl³⁴ encouraged the identification of concepts that have some connections to the concept of interest, but do not always share the same attributes. Religion was the first term that appeared in the reviewed literature and was occasionally interchanged with spirituality.⁴³ They have different definitions, although both involve a focus on what is held sacred to the individual. Terms as religiosity,^{8,15,18,21,38} mysticism^14,32,41,60 and sacred^36,38,41 are often used to express the same or similar processes. Caring and spirituality are perceived as having no difference in meaning.²¹

The antecedents and consequences of spirituality

Antecedents are the events or instances that generally precede the concept.³⁴

The cultural dimension, religious and spiritual traditions,³⁶ religious and ethnic diversity of our society, the influence of the historical and cultural context (secularisation and sacralisation), as Paley¹³ and Pesut et al.¹⁰ highlighted, are the social and historical conditions located in the context of Western thought that influence the emergence of spirituality as a phenomenon.

The spiritual experience varies significantly between the various religions and individuals; in any case, although formal and informal practices may precede spirituality, it may be the actions carried out in life that support the individual in cultivating the attributes of spirituality. Among these actions, meditation appears to be an important element of informal practice among various cultures, such as Tibetan Buddhism.³⁶

The practice of yoga is another element of spiritual practice where the individual engages with his or her body and breath, heart and soul, mind and intellect. It is a form of communication with oneself, with others or with a higher being and can include both reflection and meditation. This can be practised in private or in public, individually, collectively, or in groups within the community.¹⁸

Hinduism or the philosophy of life and Sikhism, with their specific forms of spirituality and spiritual practices, include not only meditation and yoga but also the quest for the blessing of devas (deities), puja (veneration and worship of deities in public, in a temple or privately at home) and fasting. Both at home and in temples, Hindus often create a sanctuary decorated with icons dedicated to representing the form of their divinity. Prayers, mantras, invocations and praises, with their expressions of sounds and songs, food offerings to the representations of Lord Krishna and other deities, and the recitation of sacred texts such as the Gita, are vital aspects of the Hindu spiritual practice that help the devotee to concentrate on holy or devotional thoughts.¹⁸

The consequence³⁴ of spirituality for nursing is related to those themes or phenomena around the main concept. Holistic assistance takes into consideration all aspects of the individual and their resulting needs, including social and spiritual ones.⁸

Recognising and addressing spiritual needs is vitally important, especially in a multicultural and multi-faceted environment,^4,43 because cure and care are aimed at the individual as a whole to support and improve health not only on the physical and mental level but also on a spiritual and societal one.

Health and well-being,^{4,19,38,46,61,62,64} the concept of well-being includes physical, emotional, social, functional and spiritual dimensions, confirms that each of these elements is interconnected and affects the others.^{1,19,22,36,42} Ultimately, Spirituality is an important part of the care of an ill person's well-being as it concerns the integrity or the wholeness of a person.

Persons who have a better spiritual expression can find more satisfaction in life than those who are not, as they may have a sense of well-being that transcends the physical circumstances of getting old or suffering from a terminal illness.^19,36

Comfort as a final state of well-being¹⁹ and a recognised outcome of spirituality is peace of mind and it is associated with concepts of harmony. Comfort in people’s faith is a demonstration of the person’s ability to fulfil that being and this requires the person to ‘be’, to know himself/herself and ‘to do’ (p. 571),³⁶ while self-transcendence means pushing beyond those boundaries of self-actualisation.^{18,19,21,41,63}

The consequences include communication,²¹ therapeutic dialogue and satisfaction^22,62,65 because helping others also brings a sense of self-worth,²³ self-reflection and personal fulfilment, and offers the gift of self to others.^21,23 Perhaps, workplace spirituality can effectively foster connections or repair dysfunctional workplace relationships. Therefore, where in healthcare environments, process to relational and to connect, key emerging attributes are supporting, recognising and encouraging staff, and relationship building and demonstrating compassion. So, the staff who experience an organisational well-being,²³ healing,⁴ are ultimately more likely to provide patient centred care and their families.

Spirituality is linked with many concepts of health and well-being such as spirituality and gender,^23,66 and spirituality and aging^4,23,66 as well as quality of life and ethics,^8,23,67 awareness of the sacred^{4,27,36,41,59} and awareness and self-awareness.^{4,21,22,43,57,66,68}

In caring, confidence implies self-awareness, being non-judgemental and consistent as well as able to identify patient needs.²¹ It also includes the cultural and religious skills of nursing towards the increasing plurality of ethnic, religious and spiritual diversity²⁷ and self-fulfilment (self-realisation).^{18,21,36,41,63}

These competencies should be adjusted according to the problems, settings and culture in which nurses are immersed.⁵⁵ Nurses have the responsibility to update their competencies continuously. Self-care; life-long learning^23,48; a dynamic life-long, search process that arises from life and spiritual experiences; and environment healing ^4,19,22,23 complete the consequences.

Linguistic approaches,¹⁵ Interdisciplinary approaches,^27,32 the sociology of religion and philosophy because these disciplines help to understand the forms of spirituality expressed in different social and religious cultural contexts.^{13,15,19,27,44}

A conceptual framework that represents the concept of spirituality is shown in Figure 2.

Case study

According to Rodgers and Knafl,³⁴ an example of the analysed concept from the literature will help to promote understanding of the identified construct in an appropriate context. The following example was constructed from the experiences of one of the authors of this article in her dialogue with a nurse who had an experience of spiritual care with a person who was practicing the Hindu religion in a prevalent Catholic Christian setting:

Kranthi (the name is fictitious) is a woman of about 45 and is a mother of four young children, three boys and one girl. She is admitted to a general surgery department but does not speak Italian and barely manages to say anything in English. The lady is dressed in a bright-coloured sãrī. She is accompanied by her young daughter. Kranthi and her family are Hindus. The daughter reveals in the interview that the mother prays a lot at home. Sabrina is a nurse who works in this department and has observed that Kranthi had placed small statues on the bedside table and adorned them with garlands of yellow and orange flowers (they looked almost like Madonnas). But the woman (Kranthi) cannot get through the night. The chaplain on duty is called. When the family arrives, they request to take care of Kranthi. They also ask to have their rites with members of their community – in a secluded room – because Kranthi was not Christian, and this is what she wanted.

The case study represents a clinical experience narrated by nurse Sabrina (a fictitious name of a nurse working in an Italian hospital), in a relationship with a patient near death and her family.

This story illustrates many aspects of spirituality and the quest for the sacred. The nurse (Sabrina) discussed it with the other nurses. At first, Sabrina and her colleagues did not realise the patient belonged to a different religion. In fact, they provided religious help, as is generally the case for Catholic Christians. Sabrina learned that the patient and her family belonged to another religion (Hinduism) because she noticed different sacred objects.

Sabrina and her colleagues then learned the important function of the family, the unity of family or community, and the need for the ritual of a collective practice through Kranthi’s daughter. It was a very first way for Sabrina to ponder on spirituality. It is always essential to treat each patient as unique and not to assume that the spirituality of an individual Hindu or Christian is the same as another. This new information again confirms the need that nurses have clear awareness of the existence of religious diversity in accordance with the teaching of holistic and cross-cultural nursing.

This model reflects the understanding of the religious cultural diversity that now defines our society. It is the expression of all attributes and values of spirituality, as follows: a dynamic and intrinsic aspect of humanity through which people seek ultimate meaning, purpose, transcendence and relational experience with themselves, with others, with the community, with society, with nature and with the sense of the sacred. Through beliefs, values, traditions and daily practices, one person is more able to cultivate and sustain the qualities of spirituality, the way to reach the divine.^32,41,66

According to Sharma and Mehrotra,⁶⁶ ‘spirituality is the experience that, through this, leads everyone to experience the divine or the sacred’.⁶⁶

Ethical considerations

This concept analysis and the case study were conducted in accord with the principles of research ethics. The case study was not part of a larger research and the informed consent was obtained verbally from the nurse who voluntarily narrated this case study and it is based on the primary author’s clinical experience.

Discussion

We can affirm that issues surrounding spirituality have been seriously considered in the past 40 years.^13,26,57 Various methods have been used to analyse the concept of spirituality in an attempt to find a meaningful linear path between ideas and constructs spoken, unspoken, ambiguous and amorphous.^{10,13,15,19,36,38} Many scholars have attempted to formulate a framework within a range of disciplines.⁴¹

One of the important benefits of spirituality for holistic care is that it has helped in arousing new interests in the science of nursing.^69,70 In this framework, one of the main challenges for nursing is its capacity to contribute to the debate on spirituality in nursing practice.^71,72

In fact, one of the central tenets of spirituality is the question of the choice to recognise it as an important theme for clinical practice. Consequently, the discipline of nursing requires making a choice to integrate spiritual practice into clinical practice,^42,73 university teaching programs^45,68 and managerial arrangements for professional development.^63,74 Solutions are still to be found, and as such, require further investigation. It is crucial, however, that the choices of individual patients and their families are respected.

Nurses need to intuitively recognise the multidimensionality of ethnic, cultural and religious diversity in spirituality.^10,27 This, as Paley¹³ states, could be helpful for the sociology of religion. Considering this aspect and despite the criticism, it is necessary to build an interdisciplinary dialogue.

The idea is to analyse in-depth various religions, cultures, beliefs and rituals and avoid considering all situations alike.^75,76 According to this perspective, ‘spirituality’ or the ‘way to the divine’ does not represent something static, but dynamic and different, that constantly changes in relation to the individual.^{6,18,41,60,76}

Another reason why spirituality could play an important role is the avoidance of religious inequality, which could constitute a concern at individual and community level, precisely because, from an ethical point of view, it would represent a question of lack of respect for the dignity of persons.^44,47

In recognition of the importance of spirituality in nursing practice, legislation, statutory regulations and professional guidelines have been established. Similarly, codes of conduct developed by professional nursing organisations have asserted the importance of the spiritual dimension.¹⁵

In this sense, the Italian National Nursing Regulatory Body (FNOPI) in its last Code of Ethics (2019) states that nurses take into account the biological, psychological and social relationships and spiritual comfort of persons in healthcare, to develop and implement the holistic approach to the person, which are appropriate to our increasingly multicultural and globalised society.

Conclusion

Analysing the concept of spirituality was an important step in shedding light on its meaning. Analysis has allowed the identification of the characteristics of spirituality within the context of nursing care and has added new elements to be also explored in other cultures or religions.

A surprising result of this analysis was that the term spirituality turned out to be the key function for the search for the meaning of the sacred. It emerged, from this analysis, that little attention has been paid to religious diversity or to religion, to date. Our society, complex and globalised, is made up of many facets of humanity and requires non-linear answers for non-linear, fuzzy needs that cannot be provided without having an overview of religious pluralism.

This conceptual analysis of the term ‘spirituality’ has been fundamental to reconsider the crucial connection between spirituality and nursing ethics. In fact, integrating patients’ spiritual and religious beliefs into good ethical nursing practice is essential for holistic care.

To this end, nurses need sound theoretical foundations to recognise the different spiritual meanings of important periods of life for patients as birth, death and suffering, and link them to ethical issues in the practice of care.

Footnotes

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iDs

Carla Murgia

Ippolito Notarnicola

References

Pike

. Spirituality in nursing: a systematic review of the literature from 2006-10. Br J Nurs 2011; 20(12): 743–749.

McSherry

Jamieson

. The qualitative findings from an online survey investigating nurses’ perceptions of spirituality and spiritual care. J Clin Nurs 2013; 22(21–22): 3170–3182.

Ross

van Leeuwen

Baldacchino

, et al. Student nurses’ perceptions of spirituality and competence in delivering spiritual care: a European pilot study. Nurse Educ Today 2014; 34: 697–602.

Blasdell

. The evolution of spirituality in the nursing literature. Int J Caring Sci 2015; 8: 756–764.

Hussey

. Nursing and spirituality. Nurs Philos 2009; 10: 71–80.

Pesut

. Ontologies of nursing in an age of spiritual pluralism: closed or open worldview? Nurs Philos 2009; 11: 15–23.

Paley

. Religion and the secularisation of health care. J Clin Nurs 2009; 18: 1963–1974.

Reimer-Kirkham

. Lived Religion: implications for nursing ethics. Nurs Ethics 2009; 16(4): 406–417.

Ellis

Narayanasamy

. An investigation into the role of spirituality in nursing. Br J Nurs 2009; 18(14): 886–890.

10.

Pesut

Fowler

Taylor

, et al. Conceptualising spirituality and religion for healthcare. J Clin Nurs 2008; 17(21): 2803–2810.

11.

Clarke

. A critical view of how nursing has defined spirituality. J Clin Nurs 2009; 18(12): 1666–1673.

12.

Swinton

Pattison

. Moving beyond clarity: towards a thin, vague, and useful understanding of spirituality in nursing care. Nurs Philos 2010; 11(4): 226–237.

13.

Paley

. Spirituality and secularization: nursing and the sociology of religion. J Clin Nurs 2008; 17: 175–186.

14.

Paley

. Spirituality and nursing: a reductionist approach. Nurs Philos 2008; 9: 3–18.

15.

Bruce

Sheilds

Molzahn

. Language and the (im)possibilities of articulating spirituality. J Holist Nurs 2010; 29: 44–52.

16.

Pargament

Mahoney

. The search for the sacred. In: Lopez

Snyder

(eds) Oxford library of psychology. Oxford handbook of positive psychology. Oxford: Oxford University Press, 2009, pp. 611–619.

17.

Mahmoodishan

Alhani

Ahmadi

, et al. Iranian nurses’ perception of spirituality and spiritual care: a qualitative content analysis study. J Med Ethics Hist Med 2010; 3: 6.

18.

Barber

Spirituality within non-Christian faiths: HCA/AP approaches. Br J Health Assist 2012; 6: 484–487.

19.

Mesquita

Caldeira

Chaves

, et al. An analytical overview of spirituality in NANDA-I taxonomies. Int J Nurs Knowl 2017; 29: 200–205.

20.

Tavares

Gomes

AMT

Barbosa

, et al. Spirituality and religion in the daily routine of hospital nursing. J Nurs UFPE 2018; 12: 1097–1102.

21.

Rudolfsson

Berggren

da Silva

. Experiences of spirituality and spiritual values in the context of nursing. An integrative review. Open Nurs J 2014; 8: 64–70.

22.

Reimer-Kirkham

Pesut

Sawatzky

, et al. Discourses of spirituality and leadership in nursing: a mixed methods analysis. J Nurs Manag 2012; 20(8): 1029–1038.

23.

Paal

Neenan

Muldowney

, et al. Spiritual leadership as an emergent solution to transform the healthcare workplace. J Nurs Manag 2018; 26(4): 335–337.

24.

Pirkola

Rantakokko

Suhonen

. Workplace spirituality in health care: an integrated review of the literature. J Nurs Manag 2016; 24(7): 859–868.

25.

Pesut

. There be dragons: effects of unexplored religion on nurses’ competence in spiritual care. Nurs Inq 2016; 23(3): 191–199.

26.

Lazenby

. On ‘spirituality’, ‘religion’, and ‘religions’: a concept analysis. Palliat Support Care 2010; 8(4): 469–476.

27.

Reimer-Kirkham

Sharma

Pesut

, et al. Sacred spaces in public places: religious and spiritual plurality in health care. Nurs Inq 2012; 19(3): 202–212.

28.

McBrien

. A concept analysis of spirituality. Br J Nurs 2013; 15: 42–45.

29.

Weathers

McCarthy

Coffey

. Concept analysis of spirituality: an evolutionary approach. Nurs Forum 2015; 51: 79–96.

30.

Jones

Topping

Wattis

, et al. A concept analysis of spirituality in occupational therapy practice. J Stud Spirit 2016; 6: 38–57.

31.

Memaryan

Rassouli

Mehrabi

. Spirituality concept by health professionals in Iran: a qualitative study. Evid Based Complement Alternat Med 2016; 2016: 1–9.

32.

Cipriani

. Diffused religion. Beyond secularization. Cham: Palgrave Macmillan, 2017.

33.

Rodgers

. Concept analysis and the development of nursing knowledge: the evolutionary cycle. J Adv Nurs 1989; 14: 330–335.

34.

Rodgers

Knafl

. Concept development in nursing. Foundations, techniques, and applications. 2nd ed. Philadelphia, PA: W.B. Saunders, 2000.

35.

Nocentini

. Dizionario [Dictionary]. L’Etimologico. Le Monnier [The Etymological. Le Monnier]. Milano: Mondadori Education, 2010.

36.

Lepherd

. Spirituality: everyone has it, but what is it? Int J Nurs Pract 2015; 21: 566–574.

37.

Dhamani

. Spirituality and nursing: an Ismaili perspective on holistic nursing care. J Holist Nurs 2014; 32(4): 341–346.

38.

Lomas

. The dynamics of spirituality: a cross-cultural lexical analysis. Psychol Relig Spirit 2018; 11: 131–140.

39.

Monier Williams

. Dictionary, English and Sanskrit. Whitefish, MT: Literary Licensing, 2014.

40.

Rendich

. Dizionario etimologico comparato delle lingue classiche indoeuropee [Comparative etymological dictionary of classical Indo-European languages]. Roma: Palombi Editori, 2010.

41.

Oman

Paranajipe

. Indian spirituality: how relevant is Pargament’s framework? Psychol Stud 2018; 63: 140–152.

42.

Mok

Wong

. The meaning of spirituality and spiritual care among the Hong Kong Chinese terminally ill. J Adv Nurs 2010; 66(2): 360–370.

43.

Molzahn

Sheilds

. Why is it so hard to talk about spirituality? Can Nurse 2008; 104(1): 25–29.

44.

Rousseau

Self, spirituality, and mysticism. A systems model of spirituality. J Relig Sci 2014; 49: 476–508.

45.

Timmins

Murphy

Neill

, et al. An exploration of the extent of inclusion of spirituality and spiritual care concepts in core nursing textbooks. Nurse Educ Today 2015; 35(1): 277–282.

46.

Reinert

Koenig

. Re-examining definitions of spirituality in nursing research. J Adv Nurs 2013; 69(12): 2622–2634.

47.

Reimer-Kirkham

. Nursing research on religion and spirituality through a social justice lens. ANS Adv Nurs Sci 2014; 37(3): 249–257.

48.

Rykkje

Eriksson

Råholm

. A qualitative metasynthesis of spirituality from a caring science perspective. Int J Hum Caring 2011; 15: 40–53.

49.

Zakaria Kiaei

Salehi

Moosazadeh Nasrabadi

, et al. Spirituality and spiritual care in Iran: nurses’ perceptions and barriers. Int Nurs Rev 2015; 62(4): 584–592.

50.

Tofthagen

Fagerstrom

. Rodgers’ evolutionary concept analysis – a valid method for developing knowledge in nursing science. Scand J Caring Sci 2010; 24(Suppl. 1): 21–31.

51.

Merriam-Webster’s Collegiate Dictionary. 10th ed., and Oxford English Dictionary, 2nd ed., 2002.

52.

Polit

Beck

. Essentials of nursing research. Appraising evidence for nursing practice. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2014.

53.

Withers

Zuniga

Van Sell

. Spirituality: concept analysis. Int J Nurs Clin Pract 2017; 4: 234.

54.

Vachon

Fillion

Achille

. Conceptual analysis of spirituality at the end of life. J Palliat Med 2009; 12(1): 53–59.

55.

Martins

Romeiro

Caldeira

. Spirituality in nursing: an overview of research methods. Religions 2017; 8: 226.

56.

King

Koenig

. Conceptualising spirituality for medical research and health service provision. BMC Health Serv Res 2009; 9: 116.

57.

Nolan

. In defence of the indefensible: an alternative to John Paley’s reductionist, atheistic, psychological alternative to spirituality. Nurs Philos 2009; 10(3): 203–213.

58.

Pesut

Fowler

Reimer-Kirkham

, et al. Particularizing spirituality in points of tension: enriching the discourse. Nurs Inq 2009; 16(4): 337–346.

59.

Gottheil

Groth-Marnat

. A grounded theory study of spirituality: using personal narratives suggested by spiritual images. J Relig Health 2011; 50(2): 452–463.

60.

Prater

Riley

Garner

, et al. Travel as a transformational spiritual event. J Transcult Nurs 2015; 27: 546–549.

61.

Egan

MacLeod

Jaye

, et al. What is spirituality? Evidence from a New Zealand hospice study. Mortality 2011; 16: 307–324.

62.

Zyga

. Assessing patients’ spirituality: a new age holistic approach or a forgotten nursing practice? Health Sci J 2015; 9(3): 1.

63.

Fowler

From staff nurse to nurse consultant. Spiritual care part 6: Hinduism. Br J Nurs 2017; 26: 996.

64.

Pedrão

Beresin

. Nursing and spirituality. Einstein 2010; 8: 86–91.

65.

Gupta

Kumar

Singh

. Creating satisfied employees through workplace spirituality: a study of the private insurance sector in Punjab (India). J Bus Ethics 2014; 122: 79–88.

66.

Sharma

Mehrotra

. The spiritual revolution in India from the ritual to the spiritual Indian: factors shaping spiritual seeking in modern Indians. J Spirit Ment Health 2018; 20: 225–238.

67.

Gielen

Bhatnagar

Chaturvedi

. Spirituality as an ethical challenge in Indian palliative care: a systematic review. Palliat Support Care 2016; 14(5): 561–582.

68.

Lewinson

McSherry

Kevern

. Spirituality in pre-registration nurse education and practice: a review of the literature. Nurse Educ Today 2015; 35(6): 806–814.

69.

Nascimento

Santos

TMF

Oliveira

FCS

, et al. Spirituality and religiosity in the perspectives of nurses. Texto Contexto Nurs 2013; 22: 52–60.

70.

Pattison

. Religion, spirituality and health care: confusions, tensions, opportunities. Health Care Anal 2013; 21(3): 193–207.

71.

Sartori

. Spirituality 1: should spiritual and religious beliefs be part of patient care? Nurs Times 2010; 106(28): 14–17.

72.

Scammell

. Religion, spirituality and belief: is this the business of nurses? Br J Nurs 2017; 26(9): 528.

73.

Tiew

Creedy

. Integration of spirituality in nursing practice: a literature review. Sing Nurs J 2010; 37: 15–22.

74.

Pardasani

Sharma

Bindlish

. Facilitating workplace spirituality: lessons from Indian spiritual traditions. J Manag Dev 2014; 33: 847–859.

75.

Singh

Freeman

. The important role for nurses in supporting the Asian Hindu patient and family at end of life: providing culturally sensitive end-of-life care. Can Oncol Nurs J 2011; 21(1): 46–49.

76.

Puchalski

Vitillo

Hull

, et al. Improving the spiritual dimension of whole person care: reaching national and international consensus. J Palliat Med 2014; 17(6): 642–656.