See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/261476863

Spiritual care in nursing: A concept analysis

Article  in  International Nursing Review · May 2014

DOI: 10.1111/inr.12099

CITATIONS READS

79 5,641

4 authors, including:

Monir Ramezani Eesa Mohammadi

Mashhad University of Medical Sciences Faculty of Medical Sciences, Tarbiat Modares University
21 PUBLICATIONS   126 CITATIONS    215 PUBLICATIONS   1,890 CITATIONS   

SEE PROFILE SEE PROFILE

Anoshirvan Kazemnejad
Tarbiat Modares University
339 PUBLICATIONS   2,950 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

predictors of menopausal symptom View project

Nursing shortage View project

All content following this page was uploaded by Monir Ramezani on 21 October 2017.

The user has requested enhancement of the downloaded file.

 bs_bs_banner
Concept Analysis

Spiritual care in nursing: a concept analysis

M. Ramezani1 MSN, RN, F. Ahmadi2 RN, PhD, E. Mohammadi3 RN, PhD &
A. Kazemnejad4 MSc, 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 61, 211–219

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

Introduction Watson (2012, p. 65), ‘consists of transpersonal attempts to

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: ahmadif@modares.ac.ir.
Conflict of interest: None declared.
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, develop-
mental, cultural and spiritual needs. Accordingly, one of the

© 2014 International Council of Nurses 211

212 M. Ramezani et al.
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’ spir-
itual 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 descrip-
tions 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 recog-
nition 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 spir-
itual 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. More-
over, patients’ and healthcare providers’ perceptions of spiritual
care differ clearly (Ross 2006). Consequently, it is hard to under-
stand 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).
© 2014 International Council of Nurses
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 conse-
quences 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–peer-
reviewed journals, as well as letters to the editors and commen-
taries, 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 agree-
ment 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
Spiritual care in nursing
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)
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).
by reading each document at least for three times. At the third
time, we identified words and phrases that stood for the attrib-
utes of spiritual care. Thereafter, we arranged the identified
words and phrases in descending order according to their fre-
quency 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-Consult-
Sozialforschung, 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 environ-
ment to patients’ health (ICN 2012). Brown & Lo (1999)
© 2014 International Council of Nurses
213
Words and phrases standing Sub-attributes Defining attribute
for the attributes
Developing trust in the Therapeutic relationship Therapeutic use
nurse–patient relationship of self
Attentive listening to what Active listening
patient says
Suspending personal thoughts Being non-judgemental
and opinions
Patients’ feelings of total Unconditional acceptance
acceptance
believed that nurses’ role is not to overcome patients’ spiritual
problems; rather, nurses should provide a supportive environ-
ment 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 develop-
mental 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 profes-
sional 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 attrib-
utes, including ‘healing presence’, ‘therapeutic use of self ’, ‘intui-
214 M. Ramezani et al.
Table 2 Defining attributes of the spiritual care concept
Defining attributes Sub-attributes
Healing presence Fully caring presence, altruism
Therapeutic use of self 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’, ‘patient-
centredness’, ‘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 con-
structed 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. Identify-
ing 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
© 2014 International Council of Nurses
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 occur-
rence 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 transcend-
ent 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), spir-
itual 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 reli-
gious affiliation, religious insight and self-improvement
(Lundmark 2006) facilitate the identification of patients’ spir-
itual needs and also the provision of spiritual care. Moreover,
nurse’s professional commitment (Carson & Koenig 2008), pro-
fessional responsibility and accountability (Chan et al. 2006),
professional competency (Carr 2008), accurate sensory percep-
tion (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, psychologi-
cal adaptation and feelings of satisfaction for patients, and pro-
motion of spiritual awareness and job satisfaction for nurses
(Fig. 3). The delivery of spiritual care helps patients restore and
Spiritual care in nursing 215

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 consum-
ers. 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. Conse-
quently, human core is full of energy and human’s caring-
healing 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
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 purpose-
ful behaviours (Mayer 1992). Consequently, it stimulates
patients’ spiritual growth (Smith 2006) and promotes their spir-
itual well-being (McEwen 2005).
Another consequence of spiritual care is psychological adap-
tation (Mauk & Schmidt 2004). Spiritual care increases patients’

© 2014 International Council of Nurses

216 M. Ramezani et al.
Defining
attributes
• Transcendent • Healing presence
awareness • Therapeutic use of self
• Self-awareness • Intuitive sense
• Religious affiliation • Exploration of the spiritual
• Professional perspective
commitment • Patient-centredness
• Sensitivity • Meaning-centred
• Intentionality therapeutic intervention
• Creation of a spiritually
Antecedents nurturing environment
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), effec-
tive 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 pro-
vides 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 ref-
erents are defined to answer the following questions, ‘How we
can measure the concept?’ and ‘What are the real-world applica-
tions 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 strat-
egies (Mok et al. 2010);
© 2014 International Council of Nurses
Nurse Patient
Spiritual Healing
awareness Spiritual well-being
Job satisfaction Psychological
adaptation
Patient satisfaction
Consequences
• 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 rela-
tionship (Dell’Orfano 2002); and
• expressing unconditional love for patients (Tanyi 2002).
It is noteworthy that spiritual care has different empirical ref-
erents 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 sub-
jective 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 spir-
itual perspective, patient-centredness, meaning-centred thera-
peutic intervention and the creation of a spiritually nurturing
environment. Spiritual care happens in the context of nurses’
Spiritual care in nursing
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 rela-
tionship 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); ‘estab-
lishment 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 non-
judgemental 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 con-
tinue 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 &
© 2014 International Council of Nurses
217
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, suffer-
ing 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 defi-
nition 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 spiritual-
ity 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 con-
sidering spiritual care. We believe this study provided compre-
hensive 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 cur-
riculum 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 lan-
guages, as well as unpublished data on spiritual care and docu-
ments published prior to 1950, were not included in the
analysis.
218 M. Ramezani et al.
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 knowl-
edge can help facilitate the correction of common misconcep-
tions about, and the delivery of, spiritual care.
Acknowledgements
This study was funded by the Research Administration of
Tarbiat Modares University which deserves our gratitude. More-
over, we would like to gratefully thank Tarbiat Modares, Univer-
sity 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 meth-
odology. 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 psycho-
metric 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.
© 2014 International Council of Nurses
Carson, V.B. & Koenig, H.G. (2008) Spiritual Dimensions of Nursing Prac-
tice. 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 prac-
tice 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’ emo-
tional 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’ percep-
tions 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.
Spiritual care in nursing
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 spir-
itual 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 his-
torical 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 Pro-
ceedings, 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) Interdis-
ciplinary 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 spir-
itual 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 guide-
lines 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.
© 2014 International Council of Nurses
View publication stats
219
Sawatzky, R. & Pesut, B. (2005) Attributes of spiritual care in nursing prac-
tice. 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.