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Original Article
Spiritual care in nursing: a concept analysis M. Ramezani1 MSN, RN, F. Ahmadi2 A. Kazemnejad4 MSc, PhD
RN, PhD, E.
Mohammadi3
RN, PhD
&
1 PhD Student of Nursing, Department of Nursing, 2 Professor, Department of Nursing, 3 Associate Professor, Department of Nursing, 4 Professor, Department of Biostatistics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
RAMEZANI M., AHMADI F., MOHAMMADI E. & KAZEMNEJAD A. (2014) Spiritual care in nursing: a concept analysis. International Nursing Review Background: Around the world, spiritual care in nursing is a critical part of providing holistic care, but within our profession, there is a lack of certainty over the meaning of spirituality and delivery of spiritual care, including nurses thinking of spirituality as religion. Methods: We adopted the eight-step Walker and Avant’s concept analysis approach to provide a definition of the concept, searching and analysing international and national online databases. Inclusion criterion included that articles were published between 1950 and 2012 in English or Persian language. Finally, 151 articles and 7 books were included in the analysis. Findings: The attributes of spiritual care are healing presence, therapeutic use of self, intuitive sense, exploration of the spiritual perspective, patient-centredness, meaning-centred therapeutic intervention and creation of a spiritually nurturing environment. Spiritual care is a subjective and dynamic concept, a unique aspect of care that integrates all the other aspects. It emerges in the context of nurses’ awareness of the transcendent dimension of life and reflects a patient’s reality. The provision of spiritual care leads to positive consequences such as healing for patients and promotion of spiritual awareness for nurses. Implications for Nursing and Health Policy: The conceptual definition of spiritual care provided in this study can help clinical nurses, educators and nurse managers to develop and implement evidence-based health policies, comprehensive staff training programmes and practical quality assessment guidelines to try to ensure that all nurses are competent to include relevant spiritual care in practice. Conclusion: A comprehensive definition of the concept of spiritual care ensued. The findings can facilitate further development of nursing knowledge and practice in spiritual care and facilitate correction of common misconceptions about the provision of spiritual care. Keywords: Concept Analysis, Nursing, Spiritual Care, Spiritual Needs
Conflict of interest: None declared.
Watson (2012, p. 65), ‘consists of transpersonal attempts to protect, enhance, and preserve humanity and human dignity, integrity and wholeness, by helping a person find meaning in illness, suffering, pain, and existence and to help another gain self-knowledge, self-control, self-caring, and self-healing wherein a sense of inner harmony is restored regardless of the external circumstances’. Human beings have a wide range of physical, psychological, social, emotional, intellectual, developmental, cultural and spiritual needs. Accordingly, one of the
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Introduction Nurses work across the holistic domain and spiritual care is a critical aspect of care and care giving. Nursing, as defined by
Correspondence address: Fazlollah Ahmadi, Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, PO Box 14155-4838, Tehran, Iran; Tel: +98 21 82883585; Fax: +98 21 82884555; E-mail: [email protected].
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most important components of nursing care is spiritual care (Burkhart & Hogan 2008). Callister et al. (2004) believed that nursing is a spiritually driven profession that aims at improving people’s morale and nourishing their spirits. Evidence shows that patients consider nurses as a good source of spiritual information and are able to fulfil patients’ spiritual needs. Similarly, nurses are also willing to address patients’ spiritual needs (Strang et al. 2002). However, despite the increasing importance of spiritual care in recent years (Lundmark 2006), there are still ambiguities about its nature and components (Strang et al. 2002). There are different definitions and descriptions of spiritual care in nursing literature, including, but not limited to, • an effort to touch the spirit of another person (Dell’Orfano 2002), • a set of highly fluid interpersonal processes of mutual recognition of human values and experiences (Mok et al. 2010), and • an interactive and intentional process between nurse and patient aiming at enhancing patients’ spiritual well-being (Burkhart et al. 2011). These latter authors noted that this process may also result in both good and bad spiritual memories, which, in turn, can affect nurses’ spiritual well-being, both negatively and positively. Watson (2008) used the terms ‘spirit’ and ‘soul’ and referred to care as a transpersonal process between nurse and patient that has the potential for transcending the moment and expanding human consciousness and healing capacity. However, no clear consensus exists over the definition of spiritual care. McSherry & Jamieson (2011) believed that despite serious attempts made to create awareness of spirituality and spiritual care, healthcare professionals lack certainty over the meaning of spirituality and the delivery of spiritual care. Nurses usually think of spiritual needs as religious needs and consider the provision of spiritual care as a difficult nursing task. Moreover, patients’ and healthcare providers’ perceptions of spiritual care differ clearly (Ross 2006). Consequently, it is hard to understand and operationalize the concept of spiritual care in clinical settings (Smith 2006). Narayanasamy (1999) reported that sometimes nurses even ignore the spiritual aspect of care and delegate it to clergy. The increasing interest of nursing educators and other specialists in spiritual care as a subject area (Rassool 2000), in spiritual care, has made the clarification of the concept absolutely necessary. We conducted this concept analysis to provide a clear and comprehensive definition of the spiritual care concept in nursing.
Concept analysis Concept development is an essential prerequisite for the advancement of nursing knowledge (Rodgers & Knafl 2000).
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Among different strategies developed for concept development, these authors believed that concept analysis is a popular and explicit approach where the attributes of the intended concept are initially identified and the concept is differentiated from other similar concepts. Moreover, concept analysis guarantees the correct use of the intended concept in the real world (Wills & McEwen 2002). There are many different approaches to concept analysis. The determining factors in adopting an approach are the scope of interest and the aim of the analysis (Rodgers & Knafl 2000). In this study, we adopted the eight-step Walker & Avant’s (2011) concept analysis approach that seemed to be well suited to the study purpose. This is a structured, step-by-step approach frequently used in previous studies (Baldwin & Rose 2009). The eight steps of the Walker & Avant’s (2011) approach are as follows: 1 selecting a concept, 2 determining the aim of the analysis, 3 identifying all uses of the concept, 4 determining the defining attributes of the concept, 5 constructing a model case, 6 constructing additional cases, 7 identifying the antecedents and consequences of the concept, and 8 defining empirical referents. Steps 1 and 2 were explained in the Introduction. Steps 3–8 are explained below.
Data collection We searched international and national online databases such as Proquest, Ovid, ScienceDirect, PubMed, Google Scholar, Scopus, Ebrary, Sage, MEDLINE, CINAHL, Wiley, SID, Magiran, INML, IranMedex and IranDoc using key terms such as ‘spiritual nursing’, ‘spiritual care’, ‘spiritual nursing care’ and ‘spiritual needs’. The inclusion criteria were as follows: being related to the definitions, attributes, antecedents and consequences of the spiritual care concept, as well as being published in peer-reviewed journals between 1950 and 2012 either in English or Persian languages. Articles published in non–peerreviewed journals, as well as letters to the editors and commentaries, were excluded from the analysis. Initially, 520 documents were retrieved and 157 journal articles and 7 books met the inclusion criteria. We retrieved and read the full texts of all these documents. Finally, 6 more documents were also excluded, and 151 journal articles, 1 complete book and 14 book chapters were included in the final analysis. The research team had full agreement on the inclusion of these documents in the final analysis. Data analysis was performed in the same way as the textual content analysis (Rodgers & Knafl 2000). We started the process
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Table 1 An example from data analysis: the development of the ‘Therapeutic use of self ’ defining attribute of the spiritual care concept Meaning units (excerpts from retrieved documents)
Words and phrases standing for the attributes
Sub-attributes
Defining attribute
In any case, communication concerning spiritual needs should be characterized by sensitivity and based upon a relationship of trust between the patient and nurse (Labun 1988, p. 318). Three important aspects of communication pertinent to spiritual care are attentive listening, nonverbal communication and the use of presence (McSherry 2006, p. 155). Giving your complete attention to the patient or service user. Suspending your own thoughts and opinions on the subject; clearing your own head (McSherry 2006, p. 157). The listener provides an open and free interpersonal space, in which the patient and family may find total acceptance and hospitality (Puchalski et al. 2006, p. 407).
Developing trust in the nurse–patient relationship
Therapeutic relationship
Therapeutic use of self
Attentive listening to what patient says
Active listening
Suspending personal thoughts and opinions
Being non-judgemental
Patients’ feelings of total acceptance
Unconditional acceptance
by reading each document at least for three times. At the third time, we identified words and phrases that stood for the attributes of spiritual care. Thereafter, we arranged the identified words and phrases in descending order according to their frequency to determine the attributes of the concept. Finally, we categorized the attributes according to their differences and similarities to identify the defining attributes of the concept (Table 1). The MAXQDA 10 software was used for data management. MAXQDA, software for qualitative data analysis, is a registered trademark of VERBI Software-ConsultSozialforschung, GmbH, Berlin, Germany.
Identifying all uses of the concept In nursing literature, spiritual care has been recognized as the core element (Carr 2010), essential component (McEwen 2005) and the cornerstone of holistic nursing practice (Dyson et al. 1997). Spirituality is larger than other dimensions of human beings, while at the same time integrating them all together. Kelly (2002) believed that it is inside us and beyond us, makes us unique and enables us to see what is happening beyond the moment. Integrative spiritual care permeates all aspects of care in the same way that spirituality gives meaning to all aspects of life (Sawatzky & Pesut 2005). Nursing scholars such as Florence Nightingale and Jean Watson considered spiritual care as the core of nursing care (Chung et al. 2007). The Joint Commission on Accreditation of Healthcare Organizations also considers the delivery of spiritual care as a fundamental prerequisite to quality care (McEwen 2005), whereas the International Council of Nurses Code of Ethics for Nurses has also emphasized the importance of an ideal physical, social and spiritual environment to patients’ health (ICN 2012). Brown & Lo (1999)
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believed that nurses’ role is not to overcome patients’ spiritual problems; rather, nurses should provide a supportive environment for patients’ spiritual growth and well-being. In providing spiritual care, a nurse’s approach is to ‘being with’ patients not to ‘doing for’ them (Martsolf & Mickley 1998, p. 299). Accordingly, nurses provide a comfortable environment in which patients can freely express their own spiritual anguishes such as pain and discomfort, hopelessness, fear and loneliness (Lane 1987). Dickinson (1975), an early pioneer in spiritual care, believed that spiritual care includes helping people develop the virtues according to the Erikson’s developmental theory in areas such as hope, will, purpose and care. Puchalski et al. (2006) also believed that healing, and thereby spiritual care, both originate from the therapeutic relationship. Moreover, spiritual care is the use of art and intuition in nursing (Dyson et al. 1997). Lane (1987) believed that providing spiritual care indicates the true humanity and complete professional commitment of a nurse. Finally, spiritual care is based upon unconditional love for human beings and affirming the unique value of every individual and their spiritual needs and is under the influence of their cultural beliefs, physical status, thoughts, emotions and relationships (Mok et al. 2010).
Determining the defining attributes of the concept Attributes provide a profound insight about the concept of interest and differentiate it from surrounding concepts (Walker & Avant 2011) and we found that spiritual care is the unique, integrating dimension of nursing care (McSherry & Jamieson 2011; Puchalski et al. 2006). It possesses seven defining attributes, including ‘healing presence’, ‘therapeutic use of self ’, ‘intui-
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Table 2 Defining attributes of the spiritual care concept Defining attributes
Sub-attributes
Healing presence Therapeutic use of self
Fully caring presence, altruism Active listening, therapeutic relationship, being non-judgemental, unconditional acceptance Intuitive sense Sensing into one’s own being, recognizing the opportunity for spiritual conversation with patient Exploration of the spiritual Spiritual assessment, assessment of patient’s perspective sources of strength and hope, assessment of patient’s spiritual needs Patient-centredness Reflection of patient’s reality, recognizing the uniqueness of each individual patient Meaning-centred therapeutic Developing meaningful relationships, intervention instilling hope, religious intervention, complementary therapy Creation of a spiritually Respecting patient’s spiritual beliefs, nurturing environment safeguarding the ethical aspect of care, respecting patient’s cultural and religious values
tive sense’, ‘exploration of the spiritual perspective’, ‘patientcentredness’, ‘meaning-centred therapeutic intervention’ and ‘creation of a spiritually nurturing environment’ (Table 2).
Constructing a model case A model case is an example of the real-world application of the concept of interest and embodies all the defining attributes of it. A model case can be either a real-world example drawn from the literature or a hypothetical scenario constructed by the researcher (Walker & Avant 2011), such as the one we constructed in Fig. 1.
Constructing additional cases Another part of the internal dialogue is the construction of additional cases. As some defining attributes of the concept of interest may overlap with other related concepts, identifying the most representative defining attributes is very difficult. Identifying cases that do not exactly correspond with the intended concept but are similar or contrary to it in some ways helps researcher identify the most representative attributes (Walker & Avant 2011). Contrary case
The contrary case does not illustrate the intended concept (Walker & Avant 2011). In other words, the contrary case shows
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that whatever the concept of interest is, it certainly is not an instance of this case (Wilson 1963). We constructed this in Fig. 2.
Identifying the antecedents and consequences of the concept Antecedents are events that exist or happen before the occurrence of the concept. On the contrary, consequences are the results or the outcomes of the concept (Walker & Avant 2011). Antecedents
The antecedents of the concept of spiritual care are transcendent awareness, self-awareness, religious affiliation, professional commitment, sensitivity and intentionality (Fig. 3). Nurses’ transcendent awareness is an important antecedent of spiritual care (Smith 2006). By acknowledging the fact that humans are spiritual beings, nurses can identify and plan to fulfil each patient’s unique spiritual needs (Meraviglia 1999). Factors such as nurses’ spiritual awareness and evolution (Tanyi 2002), spiritual well-being and prior experience of crises and spiritual issues in their personal lives (Burkhart & Hogan 2008), and receiving education about spirituality and spiritual care during nursing education (Ross 2006) promote nurse’s awareness of the transcendent dimension of life. Nurse’s self-awareness (Carpenter et al. 2008) is the second antecedent of the concept of spiritual care. It includes nurse’s awareness of personal beliefs, attitudes, values, fears, prejudices, and critical analysis of self and personal experiences (McSherry 2006). A nurse’s religious affiliation, religious insight and self-improvement (Lundmark 2006) facilitate the identification of patients’ spiritual needs and also the provision of spiritual care. Moreover, nurse’s professional commitment (Carson & Koenig 2008), professional responsibility and accountability (Chan et al. 2006), professional competency (Carr 2008), accurate sensory perception (Clark et al. 2003; Ross 2006) and ability to understand and accept others’ feelings and behaviours are among the essential prerequisites for the fulfilment of patients’ spiritual needs. Barnum (2006) and Carpenter et al. (2008) believed that nurses’ intentionality is a kind of focused consciousness that leads to the identification of patients’ patterns and cues and the enhancement of nursing assessment. Consequences
The delivery of spiritual care leads to positive consequences such as healing, promotion of spiritual well-being, psychological adaptation and feelings of satisfaction for patients, and promotion of spiritual awareness and job satisfaction for nurses (Fig. 3). The delivery of spiritual care helps patients restore and
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After 14 years of trying to get pregnant, Sophia, a 39-year-old woman, has eventually given birth to a preterm baby eight weeks ago. Her baby has been in neonatal intensive care unit since delivery. During the last three days, Sophia has learned from nurses how to feed her baby through a naso-gastric tube (NGT). She fed her baby through NGT for two times under the supervision of a staff nurse. This morning, she independently fed her baby through a displaced NGT. Consequently, her baby aspirated the food and was re-intubated and placed on mechanical ventilation. The baby is now given nothing by mouth. A nurse is by the baby’s incubator. While reading the last shift nursing report, she carefully observes Sophia’s behaviors. Sophia, with tearful eyes and trembling hands, is standing next to the incubator while mumbling. Understanding her perfectly, the nurse puts her own hand on Sophia’s shoulder and asks her to sit on a chair next to incubator. “Sophia! Would you like to speak for a few minutes?” the nurse asks Sophia. Nodding her head to say yes, Sophia hopelessly says: “Why did it happen to me? I suffered great hardships for this baby and finally, I, with my own hands… (A short silence) This morning, when I wanted to feed my baby, I followed all instructions nurses provided me in the previous days; why I did not pay attention to that sign on NGT? I think God wants to show me that I am not worthy of being a mother”. Nodding sadly Sophia tells the nurse, “I feel terribly anxious; I feel that my dreams will turn into nightmares. I wanted you to tell me the truth. Will my baby survive this crisis?” The nurse puts her hand on Sophia’s hand and looks her in the eye and answers, “To tell you the truth, your baby’s condition is critical; however, my colleagues are doing their best for your baby. Rely on God; all events are within the will of God. Thank God this problem occurred at hospital. Sure, the situation could have got notoriously dangerous if it had happened at home. When your baby recovers from this accident, feed him with the utmost care”. Sophia tells, “Would it be possible for me to cuddle my baby again?” The nurse leaves the room and brings a photo album from the nursing station. There are lots of photos of babies that doctors had given them a little, if any, chance of survival. Photos had been taken after obtaining consent from babies’ parents. Parents had been informed about the purpose of taking such photos. The nurse says, “However, these babies miraculously survived and were discharged from hospital”. The nurse reflectively pauses at some photos, while remembering and sharing her memories of caring for them. Looking at these photos, Sophia smiles and questioningly looks at the nurse’s eyes and says, “It seems that you are right; all events are within the will of God. I had been disappointed too soon. I try to do whatever I can for my baby”. The nurse replies, “Your current decision makes me truly happy. Can I help you?” Sophia says, “I feel I need my spouse and my mother to be here with me and my baby; it will be a great moral support for me. I want to see them but I cannot leave my baby”. The nurse guarantees that she will ask head-nurse to let Sophia’s spouse and mother to be with her.
Fig. 1 A constructed model case of the concept of spiritual care.
Karen, a 17-year old teenager, was admitted to the emergency room last night after an unsuccessful suicide attempt. After reading the nursing report and medical records, the nurse takes Karen’s medications to her room. Karen does not pay attention to the nurse. The nurse puts the medication on the table in front of Karen and says, “I know that you have experienced a difficult situation. If I had been in your shoes, I might have committed suicide too. These are your medications. Take them”. The nurse stays with Karen to make sure that she takes her medications and then leaves the room.
Fig. 2 A constructed contrary case of the concept of spiritual care.
maintain the integrity of their body, mind and spirit (Chung et al. 2007), and gives them internal energy and strength (Carr 2008). Accordingly, it can realize patients’ healing potential (Martsolf & Mickley 1998). Watson (1988) believed that during caring transaction, care providers and care consumers affect each other. She also believed that human caring process field of energy is greater than that of care providers and care consumers. This energy is a part of human consciousness process that originates from a person and becomes a part of his/her life history and a part of the larger complex pattern of life. Consequently, human core is full of energy and human’s caringhealing consciousness can accelerate the healing process and release individual’s internal strengths through creating a greater field of energy. Moreover, spiritual care encourages the hoping
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abilities of patient (Mayer 1992); gives real meaning to their lives (Mok et al. 2010); results in transcending beyond physical boundaries (Martsolf & Mickley 1998); fosters harmony and relationship with self, God and others (McEwen 2005); helps patients find meaning in the illness experience – a meaning that is congruent with the real meaning of life (Kelly 2002); strengthens confidence and belief in the supreme being (Soeken & Carson 1987); helps re-ordering of life priorities (Mok et al. 2010); and promotes the development of meaningful purposeful behaviours (Mayer 1992). Consequently, it stimulates patients’ spiritual growth (Smith 2006) and promotes their spiritual well-being (McEwen 2005). Another consequence of spiritual care is psychological adaptation (Mauk & Schmidt 2004). Spiritual care increases patients’
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Defining attributes
• Transcendent awareness • Self-awareness • Religious affiliation • Professional commitment • Sensitivity • Intentionality
Antecedents
• Healing presence • Therapeutic use of self • Intuitive sense • Exploration of the spiritual perspective • Patient-centredness • Meaning-centred therapeutic intervention • Creation of a spiritually nurturing environment
Nurse
Patient
Spiritual awareness Job satisfaction
Healing Spiritual well-being Psychological adaptation Patient satisfaction
Consequences
Fig. 3 Antecedents, attributes and consequences of the concept of spiritual care.
spiritual knowledge and coping skills (Narayanasamy 2001) and helps them effectively cope with the critical situations of life (Cavendish et al. 2006). Other positive consequences of spiritual care include greater reality acceptance (Mok et al. 2010), inner peace (McEwen 2005), reality-based peace (Mayer 1992), alleviation of anxiety (Carson & Koenig 2008), alleviation of depression (Mauk & Schmidt 2004), alleviation of psychological distress (Meraviglia 1999), enhanced resiliency (Smith 2006), optimism in stressful situations (Brown & Lo 1999), effective stress management (Battey 2009), increased self-control (Martsolf & Mickley 1998) and self-confidence (Meraviglia 1999), and reclaim a self-concept (Mattison 2006). Moreover, spiritual care provides patient satisfaction (Rieg et al. 2006), improves nurses’ spiritual awareness (Narayanasamy 2001), gives meaning and purpose to nurses’ professional life and provides them with job satisfaction (Rieg et al. 2006).
Defining empirical referents The last step of concept analysis is defining empirical referents for the defining attributes of the concept. In fact, empirical referents are defined to answer the following questions, ‘How we can measure the concept?’ and ‘What are the real-world applications of the concept?’ Empirical referents are directly related to the defining attributes of the concept, not to the entire concept itself. Additionally, they are clearly related to the theoretical underpinnings of the concept (Walker & Avant 2011). Based upon the reviewed literature, empirical referents of spiritual care included, but not limited to: • helping patients develop their personal spiritual coping strategies (Mok et al. 2010);
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• helping them re-establish relationships with self, family, friends and the supreme being (McEwen 2005); • encouraging self-care (Chung et al. 2007); • supporting patients and their family members’ spiritual and religious practices (Carpenter et al. 2008); • emphasizing the positive aspects of situations (Mauk & Schmidt 2004); • considering the uniqueness and individuality of each patient (Clark et al. 2003); • respecting the personal dignity of each patient (Callister et al. 2004); • listening to patients actively (Govier 2000); • creating and promoting confidence in the nurse–patient relationship (Dell’Orfano 2002); and • expressing unconditional love for patients (Tanyi 2002). It is noteworthy that spiritual care has different empirical referents in different contexts, situations and cultures. Therefore, defining other empirical referents of the concept requires further qualitative studies.
Discussion The aim of this study was to provide a clear and comprehensive definition of spiritual care. We found that spiritual care is a subjective and dynamic concept that demonstrates the unique aspect of care and integrates all the other aspects. We also found that it has seven defining attributes, including healing presence, therapeutic use of self, intuitive sense, exploration of the spiritual perspective, patient-centredness, meaning-centred therapeutic intervention and the creation of a spiritually nurturing environment. Spiritual care happens in the context of nurses’
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awareness of the transcendent dimension of life and reflects a patient’s reality. It has many positive consequences for patients – such as healing, promotion of spiritual well-being and psychological adaptation – and for nurses – such as promotion of spiritual awareness and job satisfaction for nurses. In the nursing literature on spiritual care, great emphasis has been put on the word ‘presence’. Words and expressions such as ‘pervasive physical-mental-spiritual presence’ (McSherry 2006); ‘being with patient when needed’ (Puchalski & Ferrell 2010); ‘conscious intention to appreciate the connection of the moment’ (Barnum 2006); ‘displaying a caring attitude and behavior’ (Mok et al. 2010); ‘immersion in the human beings’ conditions’ (Lane 1987); ‘being partner with patients in the midst of their pain’ (Puchalski 2001); partnership in patients’ experience of loneliness, anxiety and suffering (Carson & Koenig 2008); ‘empathy’ (Lundberg & Kerdonfag 2010); ‘showing patients great kindness and compassion’ (Carson & Koenig 2008); and ‘expressing unconditional love for patients’ (Narayanasamy 2001), all carry the meaning of ‘presence’. Based upon the sub-attributes of presence, we used the phrase ‘healing presence’ to describe the nature of presence in spiritual care. Spiritual care also embodies a complex interpersonal relationship between nurse and patient (Burkhart et al. 2011). The characteristics of this relationship are as follows: ‘creation and promotion of confidence in relationship’ (Tanyi 2002); ‘establishment of professional boundaries in relationship’ (Puchalski & Ferrell 2010); ‘transference of healing energy form nurse to patient’ (Carr 2008); ‘honesty in relationship’, ‘use of useful communication skills’; ‘establishment of eye contact’ (McSherry 2006); ‘attention to the power of speech in the promotion of healing’ (Carson & Koenig 2008); and ‘showing sensitivity to patients’ non-verbal signals’ (Rieg et al. 2006). Based upon these characteristics, we used the phrase ‘therapeutic relationship’ to describe the nature of nurse–patient relationship in spiritual care. Moreover, scholars referred to ‘therapeutic use of self ’ as a main attribute of the concept of spiritual care (Rieg et al. 2006). In the current study, we enhanced the clarity of the concept by identifying the sub-attributes of this attribute which included active listening, therapeutic relationship, being nonjudgemental and unconditional acceptance. This attribute reflects how a nurse uses self as a channel for giving patients hope and energy (Soeken & Carson 1987) to promote their well-being. Evidence shows that spirituality provides a dimension in nursing care in which patients and their family members continue to explore meaning in real-life situations. The aim of this exploration is the assessment of relationships and situations that give patients a sense of worth and a reason to live (Tjale &
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Bruce 2007). We found that the dimensions of this exploration included spiritual assessment, assessment of patient’s sources of strength and hope, and assessment of patient’s spiritual needs. These dimensions constitute the ‘exploration of the spiritual perspective’ defining attribute of spiritual care. Moreover, in Nursing Interventions Classification, a great emphasis has been put on the stimulation of spiritual growth (Smith 2006). The findings of the current study revealed that by respecting patients’ spiritual beliefs and cultural and religious values and emphasizing the ethical aspect of care, nurses can create a nurturing environment that facilitates patients’ spiritual development. In addition, our findings revealed that nurses’ spiritual care interventions are meaning-centred and therapeutic. The aim of these spiritual care interventions is to mobilize person’s inner healing resources. Moreover, spiritual care provides answers to fundamental questions about the meaning of life, pain, suffering and death. Finally, the conceptual definition of spiritual care we propose includes the art of ‘being with’ patients and helps to develop the current nursing theories in the area of spiritual care. This definition implies that spiritual care is not interchangeable with religious or psychosocial care.
Implications for nursing and health policy We argue that given the ever-increasing importance of spirituality in health care, undertaking policy reform to ensure patients’ spiritual needs are fulfilled is crucial. An important aspect of health policy reform in many countries concerns staff training programmes for developing healthcare professionals’ knowledge and skills in the area of spiritual care. As knowledge plays an important role in designing and implementing appropriate health care, evidence-based policy making is needed when considering spiritual care. We believe this study provided comprehensive definition of and clear evidence about the concept of spiritual care in nursing. Consequently, policy makers can use the findings of this study for designing effective health policies in the area of spiritual care. On the contrary, the findings of this study can guide nursing policy makers in revising nursing curriculum and developing a spiritually centred curriculum, as well as spiritual care quality assessment guidelines and instruments.
Limitations In this study, we only included documents published in English or Persian languages. Accordingly, documents in other languages, as well as unpublished data on spiritual care and documents published prior to 1950, were not included in the analysis.
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Conclusion In this study, we reviewed nursing literature to analyse different understandings of the concept of spiritual care and thereby identified the attributes, antecedents and consequences of the concept. As nurses’ perception of spiritual care affects the quality of spiritual care, the findings of this study can promote the development of nursing knowledge in this area. This knowledge can help facilitate the correction of common misconceptions about, and the delivery of, spiritual care.
Acknowledgements This study was funded by the Research Administration of Tarbiat Modares University which deserves our gratitude. Moreover, we would like to gratefully thank Tarbiat Modares, University Department of Interlibrary Loan and Article Delivery, for helping us retrieve the full texts of the articles and books.
Author contributions MR, FA, AK and EM: Study design and conceptualization. MR, FA, AK and EM: Data collection. MR, FA, AK, and EM: Data analysis and interpretation. MR, FA, AK and EM: Manuscript writing. FA, AK and EM: Study supervision.
References Baldwin, M.A. & Rose, P. (2009) Concept analysis as a dissertation methodology. Nurse Education Today, 29, 780–783. Barnum, B.S. (2006) Spirituality in Nursing: From Traditional to New Age. Springer Publishing Company, New York. Battey, B.W. (2009) Theory of Spiritual Care for Nursing Practice. Xlibris Corporation, Bloomington, IN. Brown, R. & Lo, R. (1999) Holistic care and spirituality potential for increasing spiritual dimensions of nursing. Australian Journal of Holistic Nursing, 6, 4–9. Burkhart, L. & Hogan, N. (2008) An experiential theory of spiritual care in nursing practice. Qualitative Health Research, 18, 928–938. Burkhart, L., Schmidt, L. & Hogan, N. (2011) Development and psychometric testing of the Spiritual Care Inventory instrument. Journal of Advanced Nursing, 67, 2463–2472. Callister, L.C., Bond, A.E., Matsumura, G. & Mangum, S. (2004) Threading spirituality throughout nursing education. Holistic Nursing Practice, 18, 160–166. Carpenter, K., Girvin, L., Kitner, W. & Ruth-Sahd, L.A. (2008) Spirituality: a dimension of holistic critical care nursing. Dimensions of Critical Care Nursing, 27, 16–20. Carr, T. (2008) Mapping the processes and qualities of spiritual nursing care. Qualitative Health Research, 18, 686–700. Carr, T. (2010) Facing existential realities: exploring barriers and challenges to spiritual nursing care. Qualitative Health Research, 20, 1379–1392.
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Carson, V.B. & Koenig, H.G. (2008) Spiritual Dimensions of Nursing Practice. Templeton Foundation Press, West Conshohocken, PA. Cavendish, R., et al. (2006) Patients’ perceptions of spirituality and the nurse as a spiritual care provider. Holistic Nursing Practice, 20, 41–47. Chan, M.F., et al. (2006) Investigating spiritual care perceptions and practice patterns in Hong Kong nurses: results of a cluster analysis. Nurse Education Today, 26, 139–150. Chung, L.Y.F., Wong, F.K.Y. & Chan, M.F. (2007) Relationship of nurses’ spirituality to their understanding and practice of spiritual care. Journal of Advanced Nursing, 58, 158–170. Clark, P.A., Drain, M. & Malone, M.P. (2003) Addressing patients’ emotional and spiritual needs. Joint Commission Journal on Quality and Safety, 29, 659–670. Dell’Orfano, S. (2002) The meaning of spiritual care in a pediatric setting. Journal of Pediatric Nursing, 17, 380–385. Dickinson, C. (1975) The search for spiritual meaning. In: Reed, P. G. (1991) Preferences for spiritually related nursing among terminally ill and nonterminally ill adults and well adults interventions hospitalized. Applied Nursing Research, 4, 122–128. Dyson, J., Cobb, M. & Forman, D. (1997) The meaning of spirituality: a literature review. Journal of Advanced Nursing, 26, 1183–1188. Govier, I. (2000) Spiritual care in nursing: a systematic approach. Nursing Standard, 14, 32–36. ICN (2012) Code of Ethics for Nurses. International Council of Nurses, Geneva. Kelly, E. (2002) Preparation for providing spiritual care. Scottish Journal of Healthcare Chaplaincy, 5, 11–15. Labun, E. (1988) Spiritual care: an element in nursing care planning. Journal of Advanced Nursing, 13, 314–320. Lane, J.A. (1987) The care of the human spirit. Journal of Professional Nursing, 3, 332–337. Lundberg, P.C. & Kerdonfag, P. (2010) Spiritual care provided by Thai nurses in intensive care units. Journal of Clinical Nursing, 19, 1121–1128. Lundmark, M. (2006) Attitudes to spiritual care among nursing staff in a Swedish oncology clinic. Journal of Clinical Nursing, 15, 863–874. McEwen, M. (2005) Spiritual nursing care: state of the art. Holistic Nursing Practice, 19, 161–168. McSherry, W. (2006) Making Sense of Spirituality in Nursing and Health Care Practice: An Interactive Approach. Jessica Kingsley Publishers, London and Philadelphia, PA. McSherry, W. & Jamieson, S. (2011) An online survey of nurses’ perceptions of spirituality and spiritual care. Journal of Clinical Nursing, 20, 1757–1767. Martsolf, D.S. & Mickley, J.R. (1998) The concept of spirituality in nursing theories: differing world-views and extent of focus. Journal of Advanced Nursing, 27, 294–303. Mattison, D. (2006) the forgotten spirit integration of spirituality in health care. Nephrology News & Issues, 20, 30–32. Mauk, K.L. & Schmidt, N.A. (2004) Spiritual Care in Nursing Practice. Lippincott Williams & Wilkins, Philadelphia, PA. Mayer, J. (1992) Wholly responsible for a part, or partly responsible for a whole? The concept of spiritual care in nursing. Second Opinion, 17, 26–55.
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Meraviglia, M.G. (1999) Critical analysis of spirituality and its empirical indicators. Journal of Holistic Nursing, 17, 18–33. Mok, E., Wong, F. & Wong, D. (2010) The meaning of spirituality and spiritual care among the Hong Kong Chinese terminally ill. Journal of Advanced Nursing, 66, 360–370. Narayanasamy, A. (1999) Learning spiritual dimensions of care from a historical perspective. Nurse Education Today, 19, 386–395. Narayanasamy, A. (2001) Spiritual Care: A Practical Guide for Nurses and Health Care Practitioners. Mark Alen Publishing Ltd, Wiltshire. Puchalski, C.M. (2001) The role of spirituality in health care. BUMC Proceedings, 14, 352–357. Puchalski, C.M. & Ferrell, B. (2010) Making Health Care Whole: Integrating Spirituality into Patient Care. Templeton Press, West Conshohocken, PA. Puchalski, C.M., Lunsford, B., Harris, M.H. & Miller, R.T. (2006) Interdisciplinary spiritual care for seriously ill and dying patients: collaborative model. The Cancer Journal, 12, 398–416. Rassool, G.H. (2000) The crescent and Islam: healing, nursing and the spiritual dimension. Some considerations towards an understanding of the Islamic perspectives on caring. Journal of Advanced Nursing, 32, 1476– 1484. Rieg, L.S., Mason, C.H. & Preston, K. (2006) Spiritual care: practical guidelines for rehabilitation nurses. Rehabilitation Nursing, 31, 249–256. Rodgers, B.L. & Knafl, K.A. (2000) Concept Development in Nursing. Saunders, Philadelphia, PA. Ross, L. (2006) Spiritual care in nursing: an overview of the research to date. Journal of Clinical Nursing, 15, 852–862.
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Sawatzky, R. & Pesut, B. (2005) Attributes of spiritual care in nursing practice. Journal of Holistic Nursing, 23, 19–33. Smith, A.R. (2006) Using the synergy model to provide spiritual nursing care in critical care settings. Critical Care Nurse, 26, 41–47. Soeken, K.L. & Carson, V.J. (1987) Responding to the spiritual need of the chronically ill. Nursing Clinics of North America, 22, 603–611. Strang, S., Strang, P. & Ternestedt, B.M. (2002) Spiritual needs as defined by Swedish nursing staff. Journal of Clinical Nursing, 11, 48–57. Tanyi, R.A. (2002) Towards clarification of the meaning of spirituality. Journal of Advanced Nursing, 39, 500–509. Tjale, A. & Bruce, J. (2007) A concept analysis of holistic nursing care in pediatric nursing. Curationis, 30, 45–52. Walker, L.O. & Avant, K.C. (2011) Strategies for Theory Construction in Nursing. Prentice Hall, Englewood Cliffs, NJ. Watson, J. (1988) New dimensions of human caring theory. Nursing Science Quarterly, 1, 175–181. Watson, J. (2008) Nursing: The Philosophy and Science of Caring. University Press of Colorado, Boulder, CO. Watson, J. (2012) Human Caring Science: A Theory of Nursing. Jones & Bartlett, Ontario. Wills, E.M. & McEwen, M. (2002) Concept development: clarifying meaning of terms. In Theoretical Basis for Nursing, (McEwen, M. & Wills, E.M., eds). Lippincott Williams and Wilkins, Philadelphia, PA, pp. 46–68. Wilson, J. (1963) Thinking with Concepts. Cambridge University Press, New York.
Original Article
Spiritual care in nursing: a concept analysis M. Ramezani1 MSN, RN, F. Ahmadi2 A. Kazemnejad4 MSc, PhD
RN, PhD, E.
Mohammadi3
RN, PhD
&
1 PhD Student of Nursing, Department of Nursing, 2 Professor, Department of Nursing, 3 Associate Professor, Department of Nursing, 4 Professor, Department of Biostatistics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
RAMEZANI M., AHMADI F., MOHAMMADI E. & KAZEMNEJAD A. (2014) Spiritual care in nursing: a concept analysis. International Nursing Review Background: Around the world, spiritual care in nursing is a critical part of providing holistic care, but within our profession, there is a lack of certainty over the meaning of spirituality and delivery of spiritual care, including nurses thinking of spirituality as religion. Methods: We adopted the eight-step Walker and Avant’s concept analysis approach to provide a definition of the concept, searching and analysing international and national online databases. Inclusion criterion included that articles were published between 1950 and 2012 in English or Persian language. Finally, 151 articles and 7 books were included in the analysis. Findings: The attributes of spiritual care are healing presence, therapeutic use of self, intuitive sense, exploration of the spiritual perspective, patient-centredness, meaning-centred therapeutic intervention and creation of a spiritually nurturing environment. Spiritual care is a subjective and dynamic concept, a unique aspect of care that integrates all the other aspects. It emerges in the context of nurses’ awareness of the transcendent dimension of life and reflects a patient’s reality. The provision of spiritual care leads to positive consequences such as healing for patients and promotion of spiritual awareness for nurses. Implications for Nursing and Health Policy: The conceptual definition of spiritual care provided in this study can help clinical nurses, educators and nurse managers to develop and implement evidence-based health policies, comprehensive staff training programmes and practical quality assessment guidelines to try to ensure that all nurses are competent to include relevant spiritual care in practice. Conclusion: A comprehensive definition of the concept of spiritual care ensued. The findings can facilitate further development of nursing knowledge and practice in spiritual care and facilitate correction of common misconceptions about the provision of spiritual care. Keywords: Concept Analysis, Nursing, Spiritual Care, Spiritual Needs
Conflict of interest: None declared.
Watson (2012, p. 65), ‘consists of transpersonal attempts to protect, enhance, and preserve humanity and human dignity, integrity and wholeness, by helping a person find meaning in illness, suffering, pain, and existence and to help another gain self-knowledge, self-control, self-caring, and self-healing wherein a sense of inner harmony is restored regardless of the external circumstances’. Human beings have a wide range of physical, psychological, social, emotional, intellectual, developmental, cultural and spiritual needs. Accordingly, one of the
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Introduction Nurses work across the holistic domain and spiritual care is a critical aspect of care and care giving. Nursing, as defined by
Correspondence address: Fazlollah Ahmadi, Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, PO Box 14155-4838, Tehran, Iran; Tel: +98 21 82883585; Fax: +98 21 82884555; E-mail: [email protected].
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most important components of nursing care is spiritual care (Burkhart & Hogan 2008). Callister et al. (2004) believed that nursing is a spiritually driven profession that aims at improving people’s morale and nourishing their spirits. Evidence shows that patients consider nurses as a good source of spiritual information and are able to fulfil patients’ spiritual needs. Similarly, nurses are also willing to address patients’ spiritual needs (Strang et al. 2002). However, despite the increasing importance of spiritual care in recent years (Lundmark 2006), there are still ambiguities about its nature and components (Strang et al. 2002). There are different definitions and descriptions of spiritual care in nursing literature, including, but not limited to, • an effort to touch the spirit of another person (Dell’Orfano 2002), • a set of highly fluid interpersonal processes of mutual recognition of human values and experiences (Mok et al. 2010), and • an interactive and intentional process between nurse and patient aiming at enhancing patients’ spiritual well-being (Burkhart et al. 2011). These latter authors noted that this process may also result in both good and bad spiritual memories, which, in turn, can affect nurses’ spiritual well-being, both negatively and positively. Watson (2008) used the terms ‘spirit’ and ‘soul’ and referred to care as a transpersonal process between nurse and patient that has the potential for transcending the moment and expanding human consciousness and healing capacity. However, no clear consensus exists over the definition of spiritual care. McSherry & Jamieson (2011) believed that despite serious attempts made to create awareness of spirituality and spiritual care, healthcare professionals lack certainty over the meaning of spirituality and the delivery of spiritual care. Nurses usually think of spiritual needs as religious needs and consider the provision of spiritual care as a difficult nursing task. Moreover, patients’ and healthcare providers’ perceptions of spiritual care differ clearly (Ross 2006). Consequently, it is hard to understand and operationalize the concept of spiritual care in clinical settings (Smith 2006). Narayanasamy (1999) reported that sometimes nurses even ignore the spiritual aspect of care and delegate it to clergy. The increasing interest of nursing educators and other specialists in spiritual care as a subject area (Rassool 2000), in spiritual care, has made the clarification of the concept absolutely necessary. We conducted this concept analysis to provide a clear and comprehensive definition of the spiritual care concept in nursing.
Concept analysis Concept development is an essential prerequisite for the advancement of nursing knowledge (Rodgers & Knafl 2000).
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Among different strategies developed for concept development, these authors believed that concept analysis is a popular and explicit approach where the attributes of the intended concept are initially identified and the concept is differentiated from other similar concepts. Moreover, concept analysis guarantees the correct use of the intended concept in the real world (Wills & McEwen 2002). There are many different approaches to concept analysis. The determining factors in adopting an approach are the scope of interest and the aim of the analysis (Rodgers & Knafl 2000). In this study, we adopted the eight-step Walker & Avant’s (2011) concept analysis approach that seemed to be well suited to the study purpose. This is a structured, step-by-step approach frequently used in previous studies (Baldwin & Rose 2009). The eight steps of the Walker & Avant’s (2011) approach are as follows: 1 selecting a concept, 2 determining the aim of the analysis, 3 identifying all uses of the concept, 4 determining the defining attributes of the concept, 5 constructing a model case, 6 constructing additional cases, 7 identifying the antecedents and consequences of the concept, and 8 defining empirical referents. Steps 1 and 2 were explained in the Introduction. Steps 3–8 are explained below.
Data collection We searched international and national online databases such as Proquest, Ovid, ScienceDirect, PubMed, Google Scholar, Scopus, Ebrary, Sage, MEDLINE, CINAHL, Wiley, SID, Magiran, INML, IranMedex and IranDoc using key terms such as ‘spiritual nursing’, ‘spiritual care’, ‘spiritual nursing care’ and ‘spiritual needs’. The inclusion criteria were as follows: being related to the definitions, attributes, antecedents and consequences of the spiritual care concept, as well as being published in peer-reviewed journals between 1950 and 2012 either in English or Persian languages. Articles published in non–peerreviewed journals, as well as letters to the editors and commentaries, were excluded from the analysis. Initially, 520 documents were retrieved and 157 journal articles and 7 books met the inclusion criteria. We retrieved and read the full texts of all these documents. Finally, 6 more documents were also excluded, and 151 journal articles, 1 complete book and 14 book chapters were included in the final analysis. The research team had full agreement on the inclusion of these documents in the final analysis. Data analysis was performed in the same way as the textual content analysis (Rodgers & Knafl 2000). We started the process
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Table 1 An example from data analysis: the development of the ‘Therapeutic use of self ’ defining attribute of the spiritual care concept Meaning units (excerpts from retrieved documents)
Words and phrases standing for the attributes
Sub-attributes
Defining attribute
In any case, communication concerning spiritual needs should be characterized by sensitivity and based upon a relationship of trust between the patient and nurse (Labun 1988, p. 318). Three important aspects of communication pertinent to spiritual care are attentive listening, nonverbal communication and the use of presence (McSherry 2006, p. 155). Giving your complete attention to the patient or service user. Suspending your own thoughts and opinions on the subject; clearing your own head (McSherry 2006, p. 157). The listener provides an open and free interpersonal space, in which the patient and family may find total acceptance and hospitality (Puchalski et al. 2006, p. 407).
Developing trust in the nurse–patient relationship
Therapeutic relationship
Therapeutic use of self
Attentive listening to what patient says
Active listening
Suspending personal thoughts and opinions
Being non-judgemental
Patients’ feelings of total acceptance
Unconditional acceptance
by reading each document at least for three times. At the third time, we identified words and phrases that stood for the attributes of spiritual care. Thereafter, we arranged the identified words and phrases in descending order according to their frequency to determine the attributes of the concept. Finally, we categorized the attributes according to their differences and similarities to identify the defining attributes of the concept (Table 1). The MAXQDA 10 software was used for data management. MAXQDA, software for qualitative data analysis, is a registered trademark of VERBI Software-ConsultSozialforschung, GmbH, Berlin, Germany.
Identifying all uses of the concept In nursing literature, spiritual care has been recognized as the core element (Carr 2010), essential component (McEwen 2005) and the cornerstone of holistic nursing practice (Dyson et al. 1997). Spirituality is larger than other dimensions of human beings, while at the same time integrating them all together. Kelly (2002) believed that it is inside us and beyond us, makes us unique and enables us to see what is happening beyond the moment. Integrative spiritual care permeates all aspects of care in the same way that spirituality gives meaning to all aspects of life (Sawatzky & Pesut 2005). Nursing scholars such as Florence Nightingale and Jean Watson considered spiritual care as the core of nursing care (Chung et al. 2007). The Joint Commission on Accreditation of Healthcare Organizations also considers the delivery of spiritual care as a fundamental prerequisite to quality care (McEwen 2005), whereas the International Council of Nurses Code of Ethics for Nurses has also emphasized the importance of an ideal physical, social and spiritual environment to patients’ health (ICN 2012). Brown & Lo (1999)
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believed that nurses’ role is not to overcome patients’ spiritual problems; rather, nurses should provide a supportive environment for patients’ spiritual growth and well-being. In providing spiritual care, a nurse’s approach is to ‘being with’ patients not to ‘doing for’ them (Martsolf & Mickley 1998, p. 299). Accordingly, nurses provide a comfortable environment in which patients can freely express their own spiritual anguishes such as pain and discomfort, hopelessness, fear and loneliness (Lane 1987). Dickinson (1975), an early pioneer in spiritual care, believed that spiritual care includes helping people develop the virtues according to the Erikson’s developmental theory in areas such as hope, will, purpose and care. Puchalski et al. (2006) also believed that healing, and thereby spiritual care, both originate from the therapeutic relationship. Moreover, spiritual care is the use of art and intuition in nursing (Dyson et al. 1997). Lane (1987) believed that providing spiritual care indicates the true humanity and complete professional commitment of a nurse. Finally, spiritual care is based upon unconditional love for human beings and affirming the unique value of every individual and their spiritual needs and is under the influence of their cultural beliefs, physical status, thoughts, emotions and relationships (Mok et al. 2010).
Determining the defining attributes of the concept Attributes provide a profound insight about the concept of interest and differentiate it from surrounding concepts (Walker & Avant 2011) and we found that spiritual care is the unique, integrating dimension of nursing care (McSherry & Jamieson 2011; Puchalski et al. 2006). It possesses seven defining attributes, including ‘healing presence’, ‘therapeutic use of self ’, ‘intui-
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Table 2 Defining attributes of the spiritual care concept Defining attributes
Sub-attributes
Healing presence Therapeutic use of self
Fully caring presence, altruism Active listening, therapeutic relationship, being non-judgemental, unconditional acceptance Intuitive sense Sensing into one’s own being, recognizing the opportunity for spiritual conversation with patient Exploration of the spiritual Spiritual assessment, assessment of patient’s perspective sources of strength and hope, assessment of patient’s spiritual needs Patient-centredness Reflection of patient’s reality, recognizing the uniqueness of each individual patient Meaning-centred therapeutic Developing meaningful relationships, intervention instilling hope, religious intervention, complementary therapy Creation of a spiritually Respecting patient’s spiritual beliefs, nurturing environment safeguarding the ethical aspect of care, respecting patient’s cultural and religious values
tive sense’, ‘exploration of the spiritual perspective’, ‘patientcentredness’, ‘meaning-centred therapeutic intervention’ and ‘creation of a spiritually nurturing environment’ (Table 2).
Constructing a model case A model case is an example of the real-world application of the concept of interest and embodies all the defining attributes of it. A model case can be either a real-world example drawn from the literature or a hypothetical scenario constructed by the researcher (Walker & Avant 2011), such as the one we constructed in Fig. 1.
Constructing additional cases Another part of the internal dialogue is the construction of additional cases. As some defining attributes of the concept of interest may overlap with other related concepts, identifying the most representative defining attributes is very difficult. Identifying cases that do not exactly correspond with the intended concept but are similar or contrary to it in some ways helps researcher identify the most representative attributes (Walker & Avant 2011). Contrary case
The contrary case does not illustrate the intended concept (Walker & Avant 2011). In other words, the contrary case shows
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that whatever the concept of interest is, it certainly is not an instance of this case (Wilson 1963). We constructed this in Fig. 2.
Identifying the antecedents and consequences of the concept Antecedents are events that exist or happen before the occurrence of the concept. On the contrary, consequences are the results or the outcomes of the concept (Walker & Avant 2011). Antecedents
The antecedents of the concept of spiritual care are transcendent awareness, self-awareness, religious affiliation, professional commitment, sensitivity and intentionality (Fig. 3). Nurses’ transcendent awareness is an important antecedent of spiritual care (Smith 2006). By acknowledging the fact that humans are spiritual beings, nurses can identify and plan to fulfil each patient’s unique spiritual needs (Meraviglia 1999). Factors such as nurses’ spiritual awareness and evolution (Tanyi 2002), spiritual well-being and prior experience of crises and spiritual issues in their personal lives (Burkhart & Hogan 2008), and receiving education about spirituality and spiritual care during nursing education (Ross 2006) promote nurse’s awareness of the transcendent dimension of life. Nurse’s self-awareness (Carpenter et al. 2008) is the second antecedent of the concept of spiritual care. It includes nurse’s awareness of personal beliefs, attitudes, values, fears, prejudices, and critical analysis of self and personal experiences (McSherry 2006). A nurse’s religious affiliation, religious insight and self-improvement (Lundmark 2006) facilitate the identification of patients’ spiritual needs and also the provision of spiritual care. Moreover, nurse’s professional commitment (Carson & Koenig 2008), professional responsibility and accountability (Chan et al. 2006), professional competency (Carr 2008), accurate sensory perception (Clark et al. 2003; Ross 2006) and ability to understand and accept others’ feelings and behaviours are among the essential prerequisites for the fulfilment of patients’ spiritual needs. Barnum (2006) and Carpenter et al. (2008) believed that nurses’ intentionality is a kind of focused consciousness that leads to the identification of patients’ patterns and cues and the enhancement of nursing assessment. Consequences
The delivery of spiritual care leads to positive consequences such as healing, promotion of spiritual well-being, psychological adaptation and feelings of satisfaction for patients, and promotion of spiritual awareness and job satisfaction for nurses (Fig. 3). The delivery of spiritual care helps patients restore and
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After 14 years of trying to get pregnant, Sophia, a 39-year-old woman, has eventually given birth to a preterm baby eight weeks ago. Her baby has been in neonatal intensive care unit since delivery. During the last three days, Sophia has learned from nurses how to feed her baby through a naso-gastric tube (NGT). She fed her baby through NGT for two times under the supervision of a staff nurse. This morning, she independently fed her baby through a displaced NGT. Consequently, her baby aspirated the food and was re-intubated and placed on mechanical ventilation. The baby is now given nothing by mouth. A nurse is by the baby’s incubator. While reading the last shift nursing report, she carefully observes Sophia’s behaviors. Sophia, with tearful eyes and trembling hands, is standing next to the incubator while mumbling. Understanding her perfectly, the nurse puts her own hand on Sophia’s shoulder and asks her to sit on a chair next to incubator. “Sophia! Would you like to speak for a few minutes?” the nurse asks Sophia. Nodding her head to say yes, Sophia hopelessly says: “Why did it happen to me? I suffered great hardships for this baby and finally, I, with my own hands… (A short silence) This morning, when I wanted to feed my baby, I followed all instructions nurses provided me in the previous days; why I did not pay attention to that sign on NGT? I think God wants to show me that I am not worthy of being a mother”. Nodding sadly Sophia tells the nurse, “I feel terribly anxious; I feel that my dreams will turn into nightmares. I wanted you to tell me the truth. Will my baby survive this crisis?” The nurse puts her hand on Sophia’s hand and looks her in the eye and answers, “To tell you the truth, your baby’s condition is critical; however, my colleagues are doing their best for your baby. Rely on God; all events are within the will of God. Thank God this problem occurred at hospital. Sure, the situation could have got notoriously dangerous if it had happened at home. When your baby recovers from this accident, feed him with the utmost care”. Sophia tells, “Would it be possible for me to cuddle my baby again?” The nurse leaves the room and brings a photo album from the nursing station. There are lots of photos of babies that doctors had given them a little, if any, chance of survival. Photos had been taken after obtaining consent from babies’ parents. Parents had been informed about the purpose of taking such photos. The nurse says, “However, these babies miraculously survived and were discharged from hospital”. The nurse reflectively pauses at some photos, while remembering and sharing her memories of caring for them. Looking at these photos, Sophia smiles and questioningly looks at the nurse’s eyes and says, “It seems that you are right; all events are within the will of God. I had been disappointed too soon. I try to do whatever I can for my baby”. The nurse replies, “Your current decision makes me truly happy. Can I help you?” Sophia says, “I feel I need my spouse and my mother to be here with me and my baby; it will be a great moral support for me. I want to see them but I cannot leave my baby”. The nurse guarantees that she will ask head-nurse to let Sophia’s spouse and mother to be with her.
Fig. 1 A constructed model case of the concept of spiritual care.
Karen, a 17-year old teenager, was admitted to the emergency room last night after an unsuccessful suicide attempt. After reading the nursing report and medical records, the nurse takes Karen’s medications to her room. Karen does not pay attention to the nurse. The nurse puts the medication on the table in front of Karen and says, “I know that you have experienced a difficult situation. If I had been in your shoes, I might have committed suicide too. These are your medications. Take them”. The nurse stays with Karen to make sure that she takes her medications and then leaves the room.
Fig. 2 A constructed contrary case of the concept of spiritual care.
maintain the integrity of their body, mind and spirit (Chung et al. 2007), and gives them internal energy and strength (Carr 2008). Accordingly, it can realize patients’ healing potential (Martsolf & Mickley 1998). Watson (1988) believed that during caring transaction, care providers and care consumers affect each other. She also believed that human caring process field of energy is greater than that of care providers and care consumers. This energy is a part of human consciousness process that originates from a person and becomes a part of his/her life history and a part of the larger complex pattern of life. Consequently, human core is full of energy and human’s caringhealing consciousness can accelerate the healing process and release individual’s internal strengths through creating a greater field of energy. Moreover, spiritual care encourages the hoping
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abilities of patient (Mayer 1992); gives real meaning to their lives (Mok et al. 2010); results in transcending beyond physical boundaries (Martsolf & Mickley 1998); fosters harmony and relationship with self, God and others (McEwen 2005); helps patients find meaning in the illness experience – a meaning that is congruent with the real meaning of life (Kelly 2002); strengthens confidence and belief in the supreme being (Soeken & Carson 1987); helps re-ordering of life priorities (Mok et al. 2010); and promotes the development of meaningful purposeful behaviours (Mayer 1992). Consequently, it stimulates patients’ spiritual growth (Smith 2006) and promotes their spiritual well-being (McEwen 2005). Another consequence of spiritual care is psychological adaptation (Mauk & Schmidt 2004). Spiritual care increases patients’
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Defining attributes
• Transcendent awareness • Self-awareness • Religious affiliation • Professional commitment • Sensitivity • Intentionality
Antecedents
• Healing presence • Therapeutic use of self • Intuitive sense • Exploration of the spiritual perspective • Patient-centredness • Meaning-centred therapeutic intervention • Creation of a spiritually nurturing environment
Nurse
Patient
Spiritual awareness Job satisfaction
Healing Spiritual well-being Psychological adaptation Patient satisfaction
Consequences
Fig. 3 Antecedents, attributes and consequences of the concept of spiritual care.
spiritual knowledge and coping skills (Narayanasamy 2001) and helps them effectively cope with the critical situations of life (Cavendish et al. 2006). Other positive consequences of spiritual care include greater reality acceptance (Mok et al. 2010), inner peace (McEwen 2005), reality-based peace (Mayer 1992), alleviation of anxiety (Carson & Koenig 2008), alleviation of depression (Mauk & Schmidt 2004), alleviation of psychological distress (Meraviglia 1999), enhanced resiliency (Smith 2006), optimism in stressful situations (Brown & Lo 1999), effective stress management (Battey 2009), increased self-control (Martsolf & Mickley 1998) and self-confidence (Meraviglia 1999), and reclaim a self-concept (Mattison 2006). Moreover, spiritual care provides patient satisfaction (Rieg et al. 2006), improves nurses’ spiritual awareness (Narayanasamy 2001), gives meaning and purpose to nurses’ professional life and provides them with job satisfaction (Rieg et al. 2006).
Defining empirical referents The last step of concept analysis is defining empirical referents for the defining attributes of the concept. In fact, empirical referents are defined to answer the following questions, ‘How we can measure the concept?’ and ‘What are the real-world applications of the concept?’ Empirical referents are directly related to the defining attributes of the concept, not to the entire concept itself. Additionally, they are clearly related to the theoretical underpinnings of the concept (Walker & Avant 2011). Based upon the reviewed literature, empirical referents of spiritual care included, but not limited to: • helping patients develop their personal spiritual coping strategies (Mok et al. 2010);
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• helping them re-establish relationships with self, family, friends and the supreme being (McEwen 2005); • encouraging self-care (Chung et al. 2007); • supporting patients and their family members’ spiritual and religious practices (Carpenter et al. 2008); • emphasizing the positive aspects of situations (Mauk & Schmidt 2004); • considering the uniqueness and individuality of each patient (Clark et al. 2003); • respecting the personal dignity of each patient (Callister et al. 2004); • listening to patients actively (Govier 2000); • creating and promoting confidence in the nurse–patient relationship (Dell’Orfano 2002); and • expressing unconditional love for patients (Tanyi 2002). It is noteworthy that spiritual care has different empirical referents in different contexts, situations and cultures. Therefore, defining other empirical referents of the concept requires further qualitative studies.
Discussion The aim of this study was to provide a clear and comprehensive definition of spiritual care. We found that spiritual care is a subjective and dynamic concept that demonstrates the unique aspect of care and integrates all the other aspects. We also found that it has seven defining attributes, including healing presence, therapeutic use of self, intuitive sense, exploration of the spiritual perspective, patient-centredness, meaning-centred therapeutic intervention and the creation of a spiritually nurturing environment. Spiritual care happens in the context of nurses’
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awareness of the transcendent dimension of life and reflects a patient’s reality. It has many positive consequences for patients – such as healing, promotion of spiritual well-being and psychological adaptation – and for nurses – such as promotion of spiritual awareness and job satisfaction for nurses. In the nursing literature on spiritual care, great emphasis has been put on the word ‘presence’. Words and expressions such as ‘pervasive physical-mental-spiritual presence’ (McSherry 2006); ‘being with patient when needed’ (Puchalski & Ferrell 2010); ‘conscious intention to appreciate the connection of the moment’ (Barnum 2006); ‘displaying a caring attitude and behavior’ (Mok et al. 2010); ‘immersion in the human beings’ conditions’ (Lane 1987); ‘being partner with patients in the midst of their pain’ (Puchalski 2001); partnership in patients’ experience of loneliness, anxiety and suffering (Carson & Koenig 2008); ‘empathy’ (Lundberg & Kerdonfag 2010); ‘showing patients great kindness and compassion’ (Carson & Koenig 2008); and ‘expressing unconditional love for patients’ (Narayanasamy 2001), all carry the meaning of ‘presence’. Based upon the sub-attributes of presence, we used the phrase ‘healing presence’ to describe the nature of presence in spiritual care. Spiritual care also embodies a complex interpersonal relationship between nurse and patient (Burkhart et al. 2011). The characteristics of this relationship are as follows: ‘creation and promotion of confidence in relationship’ (Tanyi 2002); ‘establishment of professional boundaries in relationship’ (Puchalski & Ferrell 2010); ‘transference of healing energy form nurse to patient’ (Carr 2008); ‘honesty in relationship’, ‘use of useful communication skills’; ‘establishment of eye contact’ (McSherry 2006); ‘attention to the power of speech in the promotion of healing’ (Carson & Koenig 2008); and ‘showing sensitivity to patients’ non-verbal signals’ (Rieg et al. 2006). Based upon these characteristics, we used the phrase ‘therapeutic relationship’ to describe the nature of nurse–patient relationship in spiritual care. Moreover, scholars referred to ‘therapeutic use of self ’ as a main attribute of the concept of spiritual care (Rieg et al. 2006). In the current study, we enhanced the clarity of the concept by identifying the sub-attributes of this attribute which included active listening, therapeutic relationship, being nonjudgemental and unconditional acceptance. This attribute reflects how a nurse uses self as a channel for giving patients hope and energy (Soeken & Carson 1987) to promote their well-being. Evidence shows that spirituality provides a dimension in nursing care in which patients and their family members continue to explore meaning in real-life situations. The aim of this exploration is the assessment of relationships and situations that give patients a sense of worth and a reason to live (Tjale &
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Bruce 2007). We found that the dimensions of this exploration included spiritual assessment, assessment of patient’s sources of strength and hope, and assessment of patient’s spiritual needs. These dimensions constitute the ‘exploration of the spiritual perspective’ defining attribute of spiritual care. Moreover, in Nursing Interventions Classification, a great emphasis has been put on the stimulation of spiritual growth (Smith 2006). The findings of the current study revealed that by respecting patients’ spiritual beliefs and cultural and religious values and emphasizing the ethical aspect of care, nurses can create a nurturing environment that facilitates patients’ spiritual development. In addition, our findings revealed that nurses’ spiritual care interventions are meaning-centred and therapeutic. The aim of these spiritual care interventions is to mobilize person’s inner healing resources. Moreover, spiritual care provides answers to fundamental questions about the meaning of life, pain, suffering and death. Finally, the conceptual definition of spiritual care we propose includes the art of ‘being with’ patients and helps to develop the current nursing theories in the area of spiritual care. This definition implies that spiritual care is not interchangeable with religious or psychosocial care.
Implications for nursing and health policy We argue that given the ever-increasing importance of spirituality in health care, undertaking policy reform to ensure patients’ spiritual needs are fulfilled is crucial. An important aspect of health policy reform in many countries concerns staff training programmes for developing healthcare professionals’ knowledge and skills in the area of spiritual care. As knowledge plays an important role in designing and implementing appropriate health care, evidence-based policy making is needed when considering spiritual care. We believe this study provided comprehensive definition of and clear evidence about the concept of spiritual care in nursing. Consequently, policy makers can use the findings of this study for designing effective health policies in the area of spiritual care. On the contrary, the findings of this study can guide nursing policy makers in revising nursing curriculum and developing a spiritually centred curriculum, as well as spiritual care quality assessment guidelines and instruments.
Limitations In this study, we only included documents published in English or Persian languages. Accordingly, documents in other languages, as well as unpublished data on spiritual care and documents published prior to 1950, were not included in the analysis.
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Conclusion In this study, we reviewed nursing literature to analyse different understandings of the concept of spiritual care and thereby identified the attributes, antecedents and consequences of the concept. As nurses’ perception of spiritual care affects the quality of spiritual care, the findings of this study can promote the development of nursing knowledge in this area. This knowledge can help facilitate the correction of common misconceptions about, and the delivery of, spiritual care.
Acknowledgements This study was funded by the Research Administration of Tarbiat Modares University which deserves our gratitude. Moreover, we would like to gratefully thank Tarbiat Modares, University Department of Interlibrary Loan and Article Delivery, for helping us retrieve the full texts of the articles and books.
Author contributions MR, FA, AK and EM: Study design and conceptualization. MR, FA, AK and EM: Data collection. MR, FA, AK, and EM: Data analysis and interpretation. MR, FA, AK and EM: Manuscript writing. FA, AK and EM: Study supervision.
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