Nursing Assignment

NURSING THEORY AND CONCEPT DEVELOPMENT OR ANALYSIS

Towards clarification of the meaning of spirituality

Ruth A. Tanyi BSJ RN BSN MSN FNPCandidate

Registered Nurse, Orthopedics and Spine, Regions Hospital, Saint Paul, Minnesota, and Abbott Northwestern Hospital

Minneapolis, Minnesota, USA

Submitted for publication 20 July 2001

Accepted for publication 31 May 2002

Background

Rhetoric about spirituality and the human search for spiritual

answers has been part of history for many years, and spiritual

care has been part of nursing history since ancient times

(Narayanasamy 1999c). Humans have a profound need to

understand their spirits (Freeman 1998), which is the core of

human existence and �the most elusive and mysterious

constituent of our human nature� (Macquarrie 1972, p. 43),

because being spiritual is part of being human (Wright 1998,

Cairns 1999). In the last few decades, there has been a

resurgence of spiritual discourse, as scientific-based

approaches are not fully able to address many fundamental

human problems such as persistent pain (Sundblom et al.

500 � 2002 Blackwell Science Ltd

Correspondence:

Ruth Tanyi,

1547 Marion Street,

Apt # 207,

Saint Paul,

MN 55117,

USA.

E-mail: [email protected]

TANYI R A (2002)TANYI R.A. (2002) Journal of Advanced Nursing 39(5), 500–509

Towards clarification of the meaning of spirituality

Background. Rhetoric about spirituality and nursing has greatly increased, as sci-

entific-based approaches are not fully able to address many human problems, such

as persistent pain. Despite the renewed interest and growing literature on spiritu-

ality, there is no consensus on a definition of this concept. There is also ambiguity on

how this concept is incorporated into nursing practice, research, and education.

Aim. This paper aims to contribute toward clarification of the meaning of spiri-

tuality in relevance to health and nursing today through a conceptual analysis

process.

Methods. Information was obtained through dictionary definitions and electronic

database searches of literature on spirituality spanning the past 30 years. The

criteria for selection included scholarly articles and books with a definition of

spirituality, and research studies that investigated the meaning of spirituality to

individuals’ health. A total of 76 articles and 19 books were retrieved for this

analysis.

Findings. Spirituality is an inherent component of being human, and is subjective,

intangible, and multidimensional. Spirituality and religion are often used inter-

changeably, but the two concepts are different. Spirituality involves humans’ search

for meaning in life, while religion involves an organized entity with rituals and

practices about a higher power or God. Spirituality may be related to religion for

certain individuals, but for others, such as an atheist, it may not be.

Conclusion. In order to provide clarity and enhance understanding of this concept,

this analysis delineates antecedents, attributes, constructed case examples, empirical

referents, and consequences of spirituality. A proposed definition of spirituality

emerged from this process, which may be applied broadly. Implications for nursing

practice, education, and research are discussed.

Keywords: spirituality, concept analysis, meaning, self-transcendence, faith, hope,

clarification, connectedness, nursing

1994). Furthermore, people are searching for peace, mean-

ingful lives, and connections (Walsh 1999), and are seeking

answers to increased societal and cultural problems such as

violence (Thoresen 1999). Additionally, people are increas-

ingly frustrated by the impersonal managed health care

system in the United States of America (USA) and are looking

elsewhere for answers to their health concerns (Gundersen

2000).

Despite a renewed interest in spirituality, there is no

consensus on a definition of this concept (Dyson et al. 1997,

Martsolf & Mickley 1998, McSherry & Draper 1998,

George et al. 2000) due to its subjective and personal nature

(Cawley 1997, Miller & Thoresen 1999). The purpose of this

analysis is to attempt to clarify the meaning of spirituality in

relation to health and nursing, in order to enhance commu-

nication and influence how nurses might incorporate this

concept into practice, education, and research. The con-

ceptual analysis strategy offered by Walker and Avant (1995)

is used as the conceptual framework.

Concept analysis

According to Chinn and Kramer (1999), a concept is �a

complex mental formulation of experience� as perceived in

the world (p. 54, 1999). Walker and Avant (1995) state that

concept analysis is used to describe and examine a word and

its usage in language and nursing literature; that is, to

determine what the concept is, and what it is not. It is also

useful to clarify ambiguity of a concept in literature, scholarly

discussions, and in practice when multiple definitions are

present. Furthermore, concept analysis may yield precise

operational definitions, defining attributes and antecedents,

and provide new tools for theory and research development,

or may be used for evaluating established tools. Clinically,

concept analysis is useful in the process of formulating and

evaluating nursing diagnoses (Walker & Avant 1995).

Walker and Avant’s (1995) iterative steps of concept

analysis include: the selection of a concept; the aims of the

analysis; all the various uses of the concept; the defining

attributes of the concept; the model case that epitomizes the

concept; the other cases that are related or different from the

model case; the antecedents and consequences of the concept;

and the empirical referents of the concept. The first two

processes have already been described.

Walker and Avant (1995) assert that the defining attributes

of a concept may allow one to develop case examples of what

the concept is or what it is not. Cawley (1997) argues that

using this framework and the attributes of spirituality to

develop a contrary case that exemplifies none of the compo-

nents of spirituality is problematic, because spirituality is a

phenomenon common to all humans. Since a contrary case of

spirituality seems problematic, this author uses a man-made

robot in a contrary case in lieu of a human being. This

framework has also been criticized for having a positivist

paradigm (Rodgers 1989). In spite of these criticisms, this

framework is useful to this author because of its step-by-step

and iterative approach of analysing a concept, thereby

facilitating an in-depth analysis. Furthermore, this frame-

work has been used by others who have analysed this concept

(Meraviglia 1999).

Aim of the analysis

Concepts range on a continuum from those that may be

directly measured to those that are abstract and indirectly

experienced. The more abstract a concept, the less it becomes

directly measurable (Chinn & Kramer 1999). On this

continuum, spirituality may be placed on the more abstract

end because of its intangible and subjective nature. Hence, it

is easy to see why there has been prolonged ambiguity on

how the concept is defined and incorporated into nursing

research, practice, and education. This analysis therefore

aims to contribute toward clarification of the meaning of

spirituality with relevance to health and nursing today.

Literature review

Following Walker and Avant’s (1995) recommendation, an

initial definition of spirituality was obtained from the Oxford

English Dictionary (1989), which yielded numerous defini-

tions of the key word spirit, and the word form spiritual (see

Tables 1–3). The various dictionary definitions are consistent

with the premise that spirituality is a multidimensional

concept.

Further information about spirituality was obtained by a

search of literature on spirituality spanning the past 30 years.

Database searches were done using CINAHL, Biomedical

Collection, Nursing Collection, Health Star, Medline, Psy-

Info, Clinical Psy, Cancer Lit, ATLA Religious Index, and

Social Work Abstracts. The criteria for selection included

scholarly articles and books with a definition of spirituality,

and research studies that investigated the meaning of spiri-

tuality to individuals’ well-being and health. A total of 76

articles and 19 books were retrieved for this analysis. Based

on articles reviewed, spirituality is understood by the author

to be a multidimensional concept without an agreed upon

definition.

Despite the lack of a consensual definition, many nursing

authors (Burkhardt 1989, Reed 1991, Emblen 1992, Dossey

et al. 1995, Harrison 1997, Relf 1997) include these

Nursing theory and concept development or analysis The meaning of spirituality

� 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(5), 500–509 501

elements: transcendence, unfolding mystery, connectedness,

meaning and purpose in life, higher power, and relationships

in their definitions of spirituality. Furthermore, some nurse

theorists have defined and included spirituality in their

models. For example, Neuman’s (1989) systems model

describes spirituality as an innate variable that is a compo-

nent of an individual’s basic structure, facilitating optimal

wellness, health, and stability. In Watson’s theory (1989)

spirituality is described as a possession of human beings,

enabling self-awareness, heightened consciousness, and pro-

viding the strength to transcend the usual self.

Spirituality and religion are words used interchangeably; in

order to clarify the meaning of spirituality, a distinction

between these two words is warranted. Some authors

(LaPierre 1994, Horsburgh 1997, Thoresen 1998, Walsh

1999) agreed that religion involves an organized entity, such

as an institution with certain rituals, values, practices, and

beliefs about God or a higher power. Religions also have

definable boundaries and may provide guidelines to which

individuals adhere (Walsh 1999). It is argued that humans’

search for meaning and purpose in life may be lost due to

adherence to religious practices and beliefs (Cawley 1997,

Miller & Thoresen 1999). Although some individuals may

express their spirituality through religious values, rituals, and

beliefs (Stoll 1989), it is contended that belonging to a

religion does not automatically mean one is or will be

spiritual (Long 1997).

Conversely, many authors acknowledge that spirituality

involves an individual’s search for meaning in life, whole-

ness, peace, individuality, and harmony (Burkhardt 1989,

Fitzgerald 1997, Tloczynski et al. 1997, Walsh 1999,

O’Leary 2000), and is a biological, and integral component

of being human (Heyse-Moore 1996, Narayanasamy 1999a,

Wright 2000). Spirituality is also described as a way of being

(Macquarrie 1972, Ellison 1983); an energizing force that

propels individuals to reach their optimal potential (Goddard

1995, 2000); a meaningful and extensive way of knowing the

world (Dawson 1997); and is expressed through several

personal mechanisms such as meditation and music appreci-

ation (Stoll 1989, Aldridge 1998). While spirituality may be

related to religion for certain individuals, for others it may

not be (Oldnall 1996, Dyson et al. 1997). For example, the

spirituality of an atheist (one who denies God’s existence) or

an agnostic (one who is unsure of God’s existence) may

be centred on a strong belief in significant relationships,

Table 2 Definitions of spiritual

Spiritual

Of or pertaining to, affecting or concerning, the spirit or higher

moral qualities...

Applied to material things, substances, etc...

Of, belonging or relating to, concerned with, sacred or ecclesiastical

things or matter...

Standing to another, or to others, in a spiritual relationship...

Devout, holy, pious; morally good; having spiritual tendencies

or instincts...

Appropriate or natural to a spirit...

Of or pertaining to, emanating from, the intellect or higher

faculties of the mind...

A spiritual or spiritually minded person...

Matters which specially or primarily concern the church

or religion...

Source: The Oxford English Dictionary, 2nd edn., (1989, pp. 257–

258).

Table 1 Definitions of spirit

Spirit

The animating or vital principle in man...

The breath of life...

Incorporeal or immaterial being...

The soul of a person...

The disembodied soul of a deceased person...

A supernatural, incorporate, rational being or personality usually

regarded as imperceptible at ordinary times to the human

senses...

The spirit of God...

The disposition, feeling, or frame of mind with which something

is done...

A person considered in relation to his character or disposition...

The prevailing tone or tendency of a particular period of time...

The immaterial intelligent or sentiment element or part of a

person...

The emotional part of a man...

Liveliness, vivacity, or animation in persons...

Vital power or energy...

Vigour or animation of mind...

Strong alcoholic liquor...

To infuse spirit, life, ardour, or energy into a person...

To invest with a spirit or animating principle...

To instigate or promote...

Source: The Oxford English Dictionary (2nd ed.) (1989, pp. 251–

255).

Table 3 Definitions of spirituality

Spirituality

The body of spiritual or ecclesiastical persons;

That which has a spiritual character;

The quality or condition of being spiritual;

An immaterial or incorporeal thing or substance;

The fact or condition of being spirit or of consisting of an incorporeal

essence.

Source: The Oxford English Dictionary, 2nd edn., (1989, pp. 259).

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self-chosen values and goals instead of a belief in God. These

beliefs may become the driving force in the lives of these

individuals (Burnard 1988). For certain individuals, for

example, Christians and Muslims, spirituality is directly

related to religion (Rassool 2002). This direct relationship is

evidenced in the theological literature, as some authors

directly linked spirituality to religion. As such, it is described

in relation to Jesus Christ and is �God-based� (Chirban et al.

1996, p. 39, Clinton 1997).

The Judeo–Christian spirituality has been advanced by

nursing authors such as Bradshaw (1994). Bradshaw main-

tains that spiritual care is embodied in the nurse’s respect for

patients’ dignity, display of unconditional acceptance and

love, honest nurse–patient relationships, and the fostering of

hope and peace. In this context, Bradshaw (1994) espouses

that the spiritual dimension of nursing care is rooted in the

Judeo–Christian tradition. However, Narayanasamy (1999b)

expresses that Bradshaw’s stance on spirituality may limit

spiritual care to Christian patients only.

Notwithstanding the generally accepted notion that spir-

ituality is an inherent component of humans (Heyse-Moore

1996, Benjamin & Looby 1998, Wright 2000), nonreligious

individuals also have spiritual needs pertaining to the search

for meaning and purpose in life (Burnard 1988). From the

above distinction between spirituality and religion, this

author agrees with others (Narayanasamy 1993, Miller &

Thoresen 1999, Walsh 1999) that spirituality is a much

broader concept than religion.

The literature further suggests that meaning and purpose in

life, connectedness, inner strength, self-transcendence, and

belief are important components of spirituality. Self-trans-

cendence is described as reaching beyond personal bound-

aries and attaining a wider perspective, which facilitates

finding meaning in life’s experience (Coward 1996). Research

studies have shown how self-transcendence, connectedness,

belief, inner strength, meaning and purpose in life add to the

meaning of spirituality. For example, Woods and Ironson’s

(1999) study of 60 medically ill patients’ spirituality and

religiosity revealed that patients’ beliefs and connections to a

higher power, themselves, or others promoted a sense of

hope. Moreover, their beliefs facilitated empowerment, a

relaxed state, and a sense of well-being, which influenced

their recovery.

Jirojwong et al. (1994) studied 125 Thai women’s percep-

tions of the aetiology of cervical cancer and use of health care

providers. Their findings showed that spiritual beliefs have a

strong influence on how individuals perceive the cause of an

illness. Some participants, who were predominately Bud-

dhists, believed that their spiritual beliefs such as Karma

(previous behaviours) caused them to become ill. Moch’s

(1998) qualitative study of 20 women with breast cancer

showed that the participants identified meaning and purpose

in their lives through connectedness with the environment,

self, and others. Hall’s (1998) qualitative study of 10 adults

with advanced human immunodeficiency virus (HIV) revealed

that being spiritual promoted meaning and purpose in life,

hopefulness, self-transcendence, and decreased anxiety about

death. The participants’ connections to a higher power,

families, and communities shaped the way they perceived

their disease, and provided the impetus for them to transcend

beyond suffering.

Rozario’s (1997) phenomenological study of chronically ill

and disabled individuals (n ¼ 35), and autobiographers

(n ¼ 14) revealed that participants found meaning in life

and made sense of suffering when they embodied a sense of

spiritual awareness. This awareness made them hopeful, and

their connection to a higher power provided a source of

support in their lives. Other studies have concluded that

being spiritual can help people cope with the stressors

and uncertainties associated with illnesses (Landis 1996,

Baldacchino & Draper 2001, Tuck et al. 2001). Researchers

who have examined levels of spirituality and health suggest

that higher levels of spirituality may promote well-being and

health (Kaczorowski 1989, Tloczynski et al. 1997, McBride

et al. 1998a, Brome et al. 2000). From these studies, one

could assume that spirituality is a powerful resource that can

ameliorate suffering during illness, thereby fostering peace

and the ability for individuals to harness the mystery of the

unknown with positivism and grace.

Unfolding experiences such as the loss of significant

relationships may facilitate creation of spiritual awareness

and transformation (Martsolf & Mickley 1998). According

to Benjamin and Looby (1998) �spiritual development is the

process of growth strengthened by one spiritual experience

after another, which ultimately leads to spiritual transforma-

tion� (p. 95). Spiritual transformation is evidenced when one

embraces a new and broadened perspective in life and

transcends beyond difficulties (Benjamin & Looby 1998).

Because life’s experiences may facilitate spiritual awareness

and transformation, some believe that anyone has the

potential to experience spiritual growth, but at different

levels (Long 1997, Chilton 1998).

Some authors purport that spiritual awareness may lead to

negative consequences such as inner conflict and guilt, if life’s

experiences cause individuals to struggle between religious or

spiritual beliefs, self-chosen values, beliefs, or goals that guide

their lives (Carson 1989, Horsburgh 1997). But it appears

from the literature as if spiritual awareness and transforma-

tion may catalyse a positive sense of self-perceived good

health. The following studies exemplify some of the benefits

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� 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(5), 500–509 503

of spiritual transformation. Young et al. (2000) study of

spirituality on individuals’ (n ¼ 303) negative life events and

psychological adjustment suggests that being spiritual may

help one maintain a healthy psychological well-being. Having

a spiritual orientation decreased the effects that negative life

events, such as divorce, had on participants’ levels of

depression or anxiety.

Walton (1999) studied 13 individuals’ perceptions of

spirituality’s influence on their recovery from acute myocar-

dial infarction. Spirituality provided the participants with

peace, hope, strength, and a sense of well-being, which

facilitated their recovery. Other benefits of spirituality

indicated by research include a restored sense of well-being

and recovery from psychological conditions, such as sexual

abuse, substance abuse, and homelessness (LaNae &

Feinauer 1993, Shuler et al. 1994, Kennedy et al. 1998,

Brome et al. 2000).

Some authors believe that understanding spirituality is

necessary to the provision of spiritual care. Burnard (1988)

asserts that nurses with strong spiritual beliefs would better

address individuals’ spiritual needs, as they may be less

threatened by others’ beliefs and values. Murray & Zentner

(1989) maintain that nurses who have experienced spiritual

awareness and transformation are better equipped to address

patients’ spiritual needs. Others (Long 1997, Chilton 1998,

Chiu 2000, Govier 2000) have espoused the importance for

nurses to understand their own spirituality in order readily to

assist others. However, it is argued that providing spiritual

care is not contingent upon nurses’ understanding of their

spirituality (Carson 1989). Although nurses may not be able

to address specific spiritual concerns, several authors (Carson

1989, Montgomery 1996, Golberg 1998, Greasley et al.

2001) agree that spiritual care in a broader sense may still be

provided by nurses’ ability to provide compassionate care,

maintain close relationships with patients, and offer them-

selves to patients (presence).

Defining attributes

The next step of a concept analysis is to define the critical

attributes of the concept examined. Critical attributes are

characteristics of the concept that appear repeatedly in the

literature, and may help clarify how the concept is used

(Walker & Avant 1995). Attributes of spirituality include:

belief and faith, connectedness, inner strength and peace.

Belief and faith could entail believing in a higher power or

God. It could also entail believing in significant relationships,

self-chosen values/goals, or believing in the world without

acknowledging God (Burnard 1988, Carson 1989). Inner

strength and peace come from having faith and a belief system.

The component connectedness is described in the literature

as how well one is connected to oneself, a supreme purpose

or meaning, a higher power, or significant relationships

(Bellingham et al. 1989, Golberg 1998, Newshan 1998).

According to Stoll (1989), connectedness has vertical and

horizontal components. The vertical component involves a

person’s relationship with a higher power or God and the

horizontal component is one’s relationships with others, the

environment, and the self. Connectedness may be expressed

through activities such as prayer, presence, or physical touch

(Dossey 1996, Golberg 1998). It is contended that connect-

edness may lead to a deeper meaning in life (Bellingham et al.

1989). Conversely, a lack of connection is discussed in the

literature as a source of estrangement, loneliness (Bellingham

et al. 1989), and to spiritual pain and or distress (Heyse-

Moore 1996). From these attributes, it can be inferred that

spirituality entails some form of a belief system.

Case examples

According to Walker and Avant (1995) case examples are

used to promote further understanding of the concept. These

case examples include (1) model cases: constructed stories

designed from clinical experiences with patients, or actual

nonconstructed examples �from real life� (p. 42) that include

all the defining attributes of the concept and absolutely

exemplify it; (2) borderline cases: examples of the concept

that contain some but not all of the defining attributes; and

(3) contrary cases: examples of what the concept is not,

defined as the complete absence of the defining attributes.

Constructed model case

Bina is a middle-aged female admitted to the hospital for

complications from four miscarriages. She is despondent, and

refuses to eat or take medications. She expresses a strong

belief in God, which gives meaning to her life, but she is

angry and thinks God is punishing her. Bina tells Evelyn,

the nurse, that she is afraid her husband might divorce her

because of his desire for a child. Bina also believes mother-

hood is a supreme value that will give meaning and purpose

to her life, and is a significant reason for her being; this value

is threatened. Evelyn listens attentively while holding Bina’s

hand. She asks Bina if she would like to see a psychologist,

and she accepts. Bina expresses happiness for connecting with

Evelyn.

Six weeks after her discharge from the hospital, Bina sends

Evelyn a letter explaining that counseling helped her establish

a new value and belief about motherhood. She plans to adopt

a baby within the next 2 years. Her reconnection with God,

her value, and belief have renewed her sense of faith, purpose,

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504 � 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(5), 500–509

and meaning in life. She expresses a heightened sense of

beauty, joy in life, and peace with her husband. This new

sense of being has given Bina the strength to overcome her

fears and sadness. She spends a few minutes each day

meditating in order to connect with her self.

This is a model case as it exhibits all of the attributes of

spirituality as highlighted in the literature. It demonstrates

believing and having faith in a higher power, significant

relationships, and personal values and beliefs. It further

underscores how a belief system and connection with others

can promote inner strength and peace. In the process, Bina

experiences spiritual transformation, which enables her to

transcend her difficulties. This model case therefore contains

all the elements identified as critical attributes of spirituality.

Constructed borderline case

Mary comes to the clinic with complaints of general mal-

aise, loss of appetite, and insomnia. Her laboratory tests,

history, and physical examinations are normal. Susan,

the admitting nurse suspects emotional problems. Mary

expresses sadness about her failed marriage, increased

loneliness, no strength to move on, and no support from

anyone. She questions the value she once had for marriage,

and does not believe anyone can help her. Mary’s love for

her husband, respect, and value for her marriage gave

meaning to her life, but since the divorce life has been

meaningless. She expresses her uncertainty about God’s

existence and no longer finds meaning in her work as a

social worker. Susan listens attentively and empathizes with

Mary; the two women express their sense of connection.

Mary states that she feels blessed to have met Susan

whose compassion has given her strength. One month later,

Mary presents at the clinic with the same complaints, and is

admitted to the hospital because she is suicidal.

This is a borderline case as it exhibits some of the critical

attributes of spirituality, but not all. Mary, who feels

disconnected from everyone and herself before meeting

Susan, experiences a connection with Susan. The connection

gives Mary immediate short-term strength but does not add

meaning to her life. Mary’s shattered belief in marriage is still

unresolved, and she has no other belief system to sustain her.

Her hatred for life continues and she still finds no meaning in

her work. Mary remains hopeless and faithless. Thus, she

returns to the clinic with the same complaints, plus suicidal

ideation.

Constructed contrary case

Humans are different from physical objects because of our

spirits, which provide the force for individuals to transcend

the self, think independently, and interact freely (Macquarrie

1972). In light of this difference, a man-made robot is used to

exemplify a contrary case of spirituality.

There is a robot exhibited in a museum in a mid-western

American city. The robot is programmed to walk up to a

guest every 10 minutes and welcome him or her to the

museum. Thereafter, the robot rings a bell for the museum

manager to further assist the individual. The robot’s interac-

tions are limited to shaking the guests’ hands and ringing a

bell. One day, a woman falls in the museum. The robot,

which is only programmed to greet guests, does nothing, even

though the woman screams for help. The robot is unable to

interact independently with the woman or express empathy.

After a few minutes, the woman gets up, yells at the robot for

not ringing the bell, then leaves the museum.

This is a contrary case, as it demonstrates none of the

critical attributes of spirituality. The robot is not human and

therefore is unable to independently and freely interact, and

connect with humans. The robot does not posses the spirit,

which is an inherent component of humans. It cannot have a

belief system, and is unable to initiate and maintain mean-

ingful relationships. The robot cannot have the faith or inner

strength that may be present from having some form of belief

system. A nonhuman lacks all of the core attributes of

spirituality, therefore only a nonhuman can be used in a

contrary case of spirituality.

Antecedents and consequences

Antecedents are events that must be present before the

occurrence of a concept, and consequences are incidents that

emerge as a result of a concept (Walker & Avant 1995).

Antecedents to spirituality as delineated from the literature

include life and spirit. In this paper life is described as the

period of time from conception, birth, to death. Pivotal life

events such as illnesses may provide the impetus for spiritual

awareness and growth (Haase et al. 1992, Meraviglia 1999).

Spirit is an inherent aspect of human beings, and it is the

core of human existence. The consequences of spirituality as

delineated from the literature are: a sense of hope and peace,

love and joy, meaning and purpose in life, self-transcendence,

and a sense of spiritual, psychological, physical health and

well-being (Burkhardt 1989, Haase et al. 1992, Meraviglia

1999). Other consequences may include guilt and inner

conflict about one’s values and beliefs (Carson 1989).

Empirical referents

Empirical referents are external measures of a concept

grounded in the real world. They are useful for instrument

development in research, and clinically they may assist

practitioners to clearly discern the presence of a concept

(Walker & Avant 1995). No single definite external measure

Nursing theory and concept development or analysis The meaning of spirituality

� 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(5), 500–509 505

of spirituality emerged from the literature, but the most fre-

quently used empirical referent is the spiritual well-being

scale (SWB) by Paloutzian and Ellison (1982).

This tool has 20 items with a Likert-type response format

measuring religious well-being (RWB) and existential well-

being (EWB). Ten items on the scale measure one’s relation-

ship with God (RWB), while the other 10 items measure one’s

sense of purpose, meaning, and satisfaction in life (EWB).

This tool has been found to have high reliability and validity

(Paloutzian & Ellison 1982). Many researchers have

attempted to measure spiritual well-being in adults by using

this scale (Kaczorowski 1989, Crigger 1996, Landis 1996,

Zorn & Johnson 1997, Coleman & Holzemer 1999, Tuck

et al. 2001). In order to understand what spirituality means

to different individuals, researchers have examined the

concept using a qualitative design (Guillory et al. 1997, Hall

1998, Chiu 2000, Mattis 2000).

Clinically, many spiritual assessment tools are available to

assist nurses in addressing patients’ spiritual concerns. For

example, the JAREL spiritual well-being scale is a 21-item

Likert-type format assessment tool designed to clinically

assess individuals’ spiritual concerns and strengths. Responses

range on a continuum from strongly agree to strongly

disagree about various attributes of spirituality (Hungelmann

et al. 1996). Dossey et al. (1995) offer a 55-item spiritual

assessment tool assessing: meaning and purpose in life,

interconnectedness, and inner strength. In primary care

settings, the spirituality pictorial charts developed by

McBride et al. (1998b) provide a quick, easy, and nonintim-

idating method of assessing spirituality. The spirituality

pictorial charts are assessment tools, which contain questions

that may be used to assess individuals’ spiritual practices and

experiences. The spirituality charts have been found to have

high reliability and validity (McBride et al. 1998b).

These tools are useful clinically because the findings may

facilitate communication of patient’s spiritual needs, thereby

increasing nurses’ understanding of patients’ spiritual per-

spectives and concerns. This author believes that this

increased understanding may facilitate the provision of

individualized spiritual care. These tools may also provide

the nurse with an additional diagnostic tool that incorporates

patient’s belief systems (Dossey et al. 1995, Hungelmann

et al. 1996, McBride et al. 1998b).

Discussion

Spirituality: proposed definition

This analysis has been a complex and challenging process

heralded by frustration at reaching a proposed definition of

spirituality. As stated earlier, this paper aims to contribute to

the clarification of spirituality, and not to provide a definite

overall definition of spirituality due to the subjective nature

of the concept. Nonetheless, a proposed definition of spiri-

tuality emerged in the process; however, further research is

needed to determine its usefulness.

Spirituality is a personal search for meaning and purpose in

life, which may or may not be related to religion. It entails

connection to self-chosen and or religious beliefs, values, and

practices that give meaning to life, thereby inspiring and

motivating individuals to achieve their optimal being. This

connection brings faith, hope, peace, and empowerment. The

results are joy, forgiveness of oneself and others, awareness

and acceptance of hardship and mortality, a heightened sense

of physical and emotional well-being, and the ability to

transcend beyond the infirmities of existence.

Nursing implications

Understanding the spiritual dimension of human experience

is paramount to nursing, because nursing is a practice-based

discipline interested in human concerns. Although it is

relevant for nurses to provide spiritual care, research has

suggested that nurses encounter many barriers providing this

care, such as insufficient academic preparation, lack of

postacademic training, inadequate time and staffing, and

lack of privacy to counsel patients (Narayanasamy 1993,

McSherry 1998). Spiritual care is also hindered by some

nurses’ perception that spiritual care is a religious issue

best addressed by hospital chaplains (Narayanasamy 1993,

Narayanasamy & Owens 2001). Optimistically, research has

revealed that many nurses can recognize patients’ spiritual

needs (Narayanasamy 1993, McSherry 1998).

It is proposed that the inclusion of spiritual care education

in nursing education would increase nurses’ knowledge,

understanding, and provision of spiritual care (Narayanasamy

1993, Long 1997, Narayanasamy 1999b, Narayanasamy &

Owens 2001). While this author acknowledges the impor-

tance of spiritual care education, it can be argued that nursing

actions, such as the use of spiritual assessment tools (Dossey

et al. 1995, Hungelmann et al. 1996, McBride et al. 1998b)

that do not require much time, privacy, or academic

preparation are measures that may overcome some of the

barriers impeding spiritual care. In using these tools, nurses

may select questions that are suitable for different patients;

however, caution should be taken not to upset some patients

with certain questions (Harrison 1997).

Because relationships may be hindered when one is

consistently dehumanized (Walton 1996), developing a

trusting, respectful, and mutual nurse–patient relationship is

R.A. Tanyi

506 � 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(5), 500–509

essential in order for spiritual assessment and intervention to

be effective (Labun 1997). Interpersonal quality care by

nurses (ability to display compassionate care toward the

patient), has been discussed as a critical element of spiritual

care. Research has suggested that maintaining a caring

relationship can be transcending, fulfilling, and rewarding

to the patient and the nurse (Montgomery 1996, Greasley

et al. 2001, Narayanasamy & Owens 2001).

Further suggestions for spiritual assessment and interven-

tion include:

• Initiating spiritual discourse with patients, as appropriate,

in a calm and reassuring atmosphere during admissions to

hospitals, long-term care facilities, or at clinic visits. For

example, patients may be asked to describe their source of

hope and strength, or what they find most meaningful.

Such broad questions may provide the nurse with infor-

mation about the patient’s spiritual perspectives; whether it

is religious-based or not (Stoll 1979). Because it is imper-

ative for nurses to remember that non-religious individuals

also have spiritual needs (Burnard 1988), attempts should

be made to avoid questions that may favour a particular

spiritual perspective (for example, asking patients to state

their denomination).

• Acceptance and respect of patients’ spiritual and cultural

practices, beliefs, and values;

• Attentively listening to patients and directly observing for

indications of spiritual cues (for example, photographs of

loved ones, rosary, etc.) and practices (e.g. prayer or

meditation); these may provide nurses with significant in-

sights about patients’ spirituality (Carson 1989, McSherry

1998, Narayanasamy & Owens 2001);

• Remaining non-judgemental and open-minded to patients’

situations;

• Consulting with other health care professionals, as neces-

sary, to initiate the appropriate spiritual counseling.

Through these actions, nurses may begin to understand

patients’ spiritual perspectives, and enhance optimal holistic

health care.

Conclusion

This paper has attempted to contribute toward clarifying the

meaning of spirituality. Humans are spiritual beings. The

spirit – the core of human existence – is fundamental to all.

Spiritual awareness and transformation can occur given

certain circumstances in life, thus a spiritual perspective that

transcends devastating life experiences may lead to peaceful

resolutions. The nature of nursing practice places nurses in

key positions to foster peaceful resolutions in patient’s lives

by assisting them with their spiritual needs.

Acknowledgements

I would like to thank M. Cecilia Wendler, RN, PhD, CCRN,

Associate Professor of Nursing, University of Wisconsin-Eau

Claire, for her invaluable assistance and encouragement during

each step of this manuscript. And a special thank you to De Ann

Lancashire, Metropolitan State University, St Paul, Minnesota,

for proof reading several versions of this manuscript.

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