Spirituality is an evolving concept that has significance in relation to bodily health. It is also considered an aspect of health. Gone are the days when spirituality was limited to the esoteric; it has now been deemed to have practical applications, such as in nursing care. There is extensive literature about the connection between spirituality and its influence on health and well-being (Puchalski, 2001; Koenig & Cohen, 2002; Chaves & Gil, 2015; Ebrahimi et al., 2017). Furthermore, strong spirituality has been linked to resilience (Koenig, 2012). Thus, it would be remiss not to incorporate the spiritual component in the practice of nursing care, which considers the holistic care of the person to be its goal. Yousefi and Abedi (2011), in their study, posit that real and complete healthcare can only be possible through sensitivity to the patient’s spiritual needs.
The concept of spirituality has gained increasing interest from researchers. Although it has significance in the healthcare profession in general, the spiritual component is still most often associated with nursing care (Timmins & McSherry, 2012). History would show that even in the past or ancient forms of nursing, patient care was always holistic, including both spiritual and religious care. This may be because caring is an important component of nursing practice. Although some measure of care is to be expected in other forms of healthcare, it can be said that in nursing, the nurse takes a more active and invested role in their patient’s well-being as their task is not just to diagnose or dispense, but to provide holistic care. This is also an important factor to consider as to the rationale of developing a Spiritual Nursing Care Theory. Spiritual care is compatible with nursing care as patient care is more than just the medical aspect of nursing. The nurse has to meet not just the medical needs of the patient but all aspects which deal with the patient’s well-being. Not only is it demanded from nurses by nature of their profession, but studies would show that they are also well-suited for the task.
In a study that compared how doctors and nurses provided emotional care, it was found that the respondent doctors would reassure their patients by continuing clinical care and explaining the curative nature of the treatment. Furthermore, they believed that they could not reassure patients if they discussed the latter’s fear with them. In contrast, nurses relied on psychological and social skills, often being open and discussing patients’ concerns with them, this being their way of providing reassurance and emotional support (Forsey et al., 2013).
Furthermore, the majority of the international literature and studies have supported the increasing importance of spiritual care and recognize it as an important component of nursing care that is well-rounded and holistic (Koenig, 2012; Chaves & Gil, 2015; Ebrahimi et al., 2017). The concepts of spirituality, spiritual needs, and spiritual well-being have also been discussed and defined in various studies. Fisher defines spirituality as a “personal quest for understanding answers to ultimate questions about life, about the meaning and about relationships that are sacred or transcendent” (Fisher, 2011). Meanwhile, according to a study by Guerrero-Castaneda and Flores (2017) on spiritual nursing care as perceived by older persons, older people make use of spirituality and religiosity to find a sense of life amidst all of the radically developing circumstances brought about by advancing age. (Narayanasamy et al., 2004) identified specific spiritual needs of older persons, including religious beliefs and practices, absolution, seeking connectedness and comfort, and healing or looking for meaning and purpose. Spiritual Well-Being was defined as the “ability to experience and integrate meaning and purpose in life through a person's connectedness with self, others, their environment, or a power greater than oneself and the totality of circumstances that would lead a person to say that his life is going well” (Fisher, 2011).
It can thus be inferred that studies generally agree that spirituality is a state of being of a person; however, there is still an evident lack of consistency in the definition of spirituality (Timmins et al., 2015). In addition, while there have been studies conducted to investigate the spiritual needs of aged persons in residential homes and those at the end of life stage in intensive care units (Erichsen & Büssing, 2013), there is unexplored potential in studying their spiritual well-being. According to the National Health Service Scotland (2009), all healthcare staff, caregivers, and families could provide spiritual care. However, there is also a significant lack of literature concerning the three-way relationship between the nurse, the patient, and his or her family as current studies on spiritual nursing care tend to be general and broad. In light of all of these, there seems to be a great need to address these huge gaps in nursing literature related to Spiritual Nursing Care. For these reasons, the researcher wanted to develop a Spiritual Nursing Care Theory.
In this study, the author wanted to explore another perspective that considers the interconnection of the healthcare provider, specifically the nurse, the family, and the patient himself or herself. There has yet to be a formalized framework of Spiritual Nursing Care in the Philippines despite its importance. Developing such a framework is significant because compared to traditional forms of healthcare which make use of equipment and facilities that may not be available, spiritual nursing care requires only the competency of the healthcare provider, specifically the nurse, in giving spiritual care. As of now, spiritual needs are considered only a small component of the holistic needs of a person. However, the author argues that the concepts of spirituality, spiritual needs, and spiritual well-being, which have been studied in previous literature, can all be interconnected in one formal theoretical framework. One way of understanding spirituality is the perception of a person on the importance of or how strong his or her spiritual practices or beliefs make up a part of his life. Spiritual needs are specific needs that must be addressed by the healthcare provider, in this case, the nurse, so that the patient can attain meaningful well-being, or be more specific, spiritual well-being. When spiritual needs are satisfactorily addressed, spiritual well-being is achieved and contributes to holistic health care. The author posits that spiritual well-being is as important as physical, emotional, and mental health, which deserves due consideration.
This paper was meant to explore the patient’s understanding and perception of the concept of spirituality, the influence of the cultural elements of the patient’s external environment on the practice of spiritual nursing care, as well as the competencies of the nurse in providing spiritual care, and its link to attaining spiritual well-being for the patient. The eventual aim of this paper was to develop a comprehensive, holistic, and spiritually inclusive nursing care framework, which values the importance of each stakeholder. This paper can be of help to patients, the family, nursing practitioners, scholars, learners, and curriculum planners who may decide to incorporate spiritual nursing care as a part of the curriculum and the nursing profession as a whole. It would serve to add to the minimal knowledge of spiritual nursing care within the Philippine context.
The theory proposed in this paper on spiritual nursing care was conceptualized through the deductive form of reasoning. Deductive reasoning is the systematic and logical process whereby a conclusion is reached based on the concurrence of multiple premises that are generally assumed to be true (Sternberg, 2009). According to Creswell and Plano Clark (2007), utilizing deductive reasoning by the researcher would involve the researcher working from the ‘top down’ starting with a theory to hypothesis and then to data to add to or contradict the theory.
The deductive method is used to construct a deductive axiomatic system or theory. The essence of an axiomatic approach as used in the field of logic and mathematics is that a group of statements, called propositions, are derived through the use of deductive logic applied to another more fundamental set of statements serving as basic assumptions, also known as axioms. Axioms represent the foundation statements in a deductive system. Meanwhile, a concept is defined as representing views or descriptions of some aspect of the real world. A concept of something is not the same as the thing itself (Lambert, 1973).
Finally, a theory is a set of logically related statements, including some law-like basic assumptions having testable implications, are an explanation and description of some concept. All theories are deductive systems. Kerlinger (1973) defines a theory as a set of interrelated constructs or concepts, propositions, as well as a systemic view of phenomena through specifying relations among variables with the objective of explaining and predicting such phenomena. Theories are those which knit together observations (Thompson, 2005).
The Spiritual Nursing Care Theory was developed following a deductive axiomatic approach. Within the framework of nursing theories and models, the author also used an empirical quantitative approach in her theory generation (Jacox, 1974) in developing the Spiritual Nursing Care Theory. The researcher identified the phenomena that she wanted to investigate within her field of study, specified, then classified concepts used when describing these phenomena. A broad topic in the field of nursing was chosen, specifically in gerontology, which was of interest to the researcher and which had the potential for further study. The topic chosen was the role of spirituality in nursing care. The next step was to research and gather related literature on the selected topic. The researcher then developed propositions on how two or more concepts are related. To elaborate, by identifying patterns among the studies made by prominent scholars in the field, the researcher was able to single out statements that were generally accepted to be true (axioms) to serve as a starting point for deducing and inferring other truths which would be the building blocks of the theory (propositions). The researcher then linked propositions to each other in a systematic way to come up with the theory.
Walker and Avant (1995) identified four levels of nursing theories, which include practice theories, mid-range theories, grand theory, and metatheory. The term ‘grand theory’ is an alternative term to ‘model’. In contrast to grand theories, which do not easily find an application and are furthermore broad and abstract, mid-range theories are more restricted in their focus. Mid-range theories are also abstract, but only moderately so. Moreover, they are composed of measurable variables. The Spiritual Nursing Care Theory developed is an example of a mid-range theory that specifies how the propositions, and the concepts of spirituality, spiritual needs, spiritual well-being, and spiritual nursing care are related to each other, but which propositions remain measurable. The Spiritual Nursing Care Theory may also easily be applied in actual nursing practice.
The related literature in the succeeding discussion was gathered to formulate the premises to base the more specific propositions, which made up the foundation of the proposed theory on Spiritual Nursing Care.
Results and Discussion
Five axioms were generated after thoroughly reviewing the literature and studies and were used as a basis for generating the two propositions, which served as the framework for the development of the Spiritual Nursing Care Theory. The connection between spirituality and health has been the subject of study since time immemorial. In the past, and even until now, the caring for the body and the spirit was done by the same person acting as both therapist or counselor and religious leader (Fradelos et al., 2014). Spirituality is linked to the human spirit and is an important component of human existence (McKee & Chappel, 1992). Many people consider their spirituality and religion as a crucial part of their existence. Spirituality also serves as a source of support and contributes to people’s well-being, and helps them cope with everyday struggles (Purdy & Dupey, 2005).
Health professionals also recognize the part spirituality plays in healthcare (Monareng, 2012). Monareng, in her study, goes on to state that it is the holistic perspective on human functioning and in nursing which demands that nurses take into account aspects of spirituality when they provide nursing care (Monareng, 2012).
Studies exploring spirituality from a holistic approach revealed that patients use religious or spiritual beliefs and practices to cope with suffering such as illness and stress (Koenig, 2012). One of the findings from Koenig (2012) was that religious people tend to spend less time in the hospital. He then claims in his study that healthcare providers, including nurses, have an obligation to the patient to include the patient’s religious beliefs in their care and incorporate their faith (spirituality) in promoting healing. The nature of nursing is to care, and thus it would make sense for nurses to have a more direct hand in attending to the spiritual needs of patients.
Various studies also show that people who are more spiritual have better adaptive capabilities. They tend to adapt more quickly to health complications compared to their counterparts, who are less spiritual (Strandberg et al., 2007). Levin et al. (1996) meanwhile explored connections between spiritual beliefs and practices and health. His findings are corroborated by studies that revealed the many ways spirituality can prevent illness and promote well-being, such as by positively impacting physical health, lessening the risk of disease, and influencing responsiveness to treatment (Baker et al., 2015).
Holistic approaches in healthcare take into consideration all aspects of the individual, and his or her needs, including mental, social, and spiritual needs. Research regarding spirituality suggests that meeting patients’ spiritual needs has a positive contribution to their adaptation to illness and improving rehabilitation (Levin et al., 1996). Based on the literature mentioned above (Purdy & Dupey, 2005; Strandberg et al., 2007; Koenig, 2012; Baker et al., 2015), it can be said that every person has holistic needs, which may include spiritual needs (Axiom 1).
As people grow older, some tend to contemplate more on matters of mortality and spirituality (Axiom 2). Researchers posit that the natural process of aging comes with it the consciousness that life will eventually end. This creates a context where older adults are more accepting of deepening their understanding of their mind, body, or spirit (Atchley, 1999).
Spirituality is a complex and abstract subject with many perspectives. It is something that touches all people in different degrees. By sex, various studies have suggested that females are more spiritual than males. The same study revealed that people with higher educational attainment tend to be less spiritual than those who finished lower levels. Furthermore, this same study demonstrated that spirituality decreases as income levels increase. As for health status, some studies indicate that religiosity or spirituality appears to positively correlate with physical health (Ellison & Levin, 1998). While patients and their families have different understandings and degrees of spirituality, individual nurses also have different levels of spirituality. Nurses are primarily trained in the physical and nursing care of the patient; however, their levels of spirituality can also impinge positively on their care of the older person. Other studies have also shown how providing spiritual care is influenced by multiple factors, including the spirituality of the healthcare provider and their understanding of the spiritual practices of the patients (Schleder et al., 2013). A study by Kisvetrová et al. (2013) found that nurses living in a predominantly secular country would tend to see themselves as non‐religious and, as a consequence, therefore, believe that providing spiritual/religious care was not something they were likely to do. Thus, what the literature would show is that nurses are indeed aware of the concept of spiritual care or spiritual nursing; however, they may differ in their interpretation and how they administer such care because of their differing understandings of spirituality. Therefore, it helps to understand that people have different understanding and levels of spirituality (Axiom 3).
Internal and external environment contributes to a person’s spirituality (Axiom 4). People can find meaning in life in different ways and through different avenues (Eckersley, 2005). People would often have many things which are important to them, such as their family, friends, career, hobbies, interests, and desires. All of these are avenues through which people can find meaning in life.
People can also find spirituality in their connection with their nation or ethnic group since spirituality is one of the deepest forms of interconnection. There is a link between interconnectedness and physical well-being. For example, it was found that socially isolated people five times likelier to die compared to those who have strong ties with their family, friends, and or community (Berkman & Glass, 2000).
In addition, empirical studies would show that health cannot be reduced to just an organic and natural objective process, but rather is connected to the experiences of individuals and groups, which are in turn related to the cultural characteristics of a society (Minayo, 2006).
The literature affirms that healthcare practices vary depending on a person’s culture and that culture is the basis for their explanations for their suffering and illness, their search for meaning in these occurrences, treatment choices, and life reevaluation (Mello & Oliveira, 2013). In 1996, the World Health Organization (WHO), as well as the United Nations Educational, Scientific and Cultural Organization (UNESCO), recognized the importance and significance of cultural aspects in international health (Mello & Oliveira, 2013). The two international organizations stated that health care, which includes nursing care, and culture should be approached in a way that integrates the two from the perspective of benefiting individuals and countries (Mello & Oliveira, 2013).
Based on the above literature, it can be seen how the internal and external environment of a person, both his socio-cultural and physical environment, can influence his spirituality.
Holistic nursing care includes spiritual care (Axiom 5). Taylor (2002), as cited in Monareng (2012), defines ‘spiritual nursing care’ as those activities that facilitate and provide for a healthy balance between the bio-psychosocial and spiritual aspects of the person, and thus contributing to a sense of wholeness and overall well-being. To adequately address the concerns of their older patients, nurses must be knowledgeable of their patient’s spiritual needs, meet these needs and contribute to maintaining their patient’s positive spirituality. The concept of spirituality has gained researchers’ interest in recent years. Although spirituality is present in general healthcare literature, the spiritual component of healthcare is still mostly associated with nursing care (Timmins & McSherry, 2012). Even in the oldest forms of nursing, patient care was said to be holistic and included spiritual and religious care as well. During the Byzantine era, the patients in the hospitals received physical and spiritual care (Papathanasiou et al., 2013). In addition, theories of nursing recommend a holistic model for healthcare. It has already been substantiated that patient care cannot be and should not be one-dimensional but should be holistic and composed of all aspects such as the biological, psychological, social, and spiritual dimensions (Papathanasiou et al., 2013). Florence Nightingale, who can be said to be the founder of modern nursing, introduced important elements necessary for the healing process. Some examples included the environment, touch, light, scents, music, silent reflection, and even birds. Each of those elements helped the patient connect with others, with nature, and with the divine (Nightingale, 1860).
Holistic care may be defined as a comprehensive model of caring and is the heart of nursing (Strandberg et al., 2007; Albaqawi et al., 2021). Holistic care is built upon the principle of holism which puts forward the idea that for people, the whole is greater than the sum of its parts. In addition, mind and spirit both affect the body (Tjale & Bruce, 2007). Holistic care then is that care that recognizes that the patient is a whole. Furthermore, it acknowledges that there is interdependence and interconnection between and among the patient’s biological, social, psychological, and spiritual dimensions. Holistic care, being a comprehensive model of caring, includes the following components – education, self-help, medication, complementary treatment, and communication (Morgan & Yoder, 2012).
Holistic care is also applied in nursing. In the context of holistic nursing, the patient’s attitude, opinions, emotions, thoughts, and even culture and spiritual beliefs and practices are factored in the care plan and are considered essential to the recovery, happiness, satisfaction, and well-being of the patient (Selimen & Andsoy, 2011).
From the axioms generated, the following ideas were put forward as propositions to form the backbone of the theory on Spiritual Nursing Care. The first proposition posited states that the meaning of spirituality differs from person to person (Proposition 1).
The second proposition posited is that the patient’s spiritual well-being is influenced by the nurse’s spiritual competence as well as the patient’s internal and external variables (Proposition 2).
Spiritual Nursing Care Theory
The theory being proposed in this paper on Spiritual Nursing Care states that every person has holistic needs, which may include spiritual needs that must be satisfied for the person to attain spiritual well-being. The theory forwards that in order to achieve spiritual well-being and for the person’s spiritual needs to be satisfied, what is required is the triumvirate interconnection among the nurse, the external environment, and the spiritual nursing care which may be provided by the nurse as the healthcare provider and the significant others or family as part of the external environment.
The Spiritual Nursing Care theory claims that spiritual needs are part and parcel of the totality of needs of the patient; it is not lesser than any other need. They should be considered and dealt with holistically and accorded great weight. The theory postulates that satisfaction of spiritual needs contributes to the overall well-being, as it may contribute to the improvement of the physical and emotional well-being of the patient (Bangcola, 2019). Thus, it is assumed that people who find themselves spiritually satisfied would have a more positive attitude towards healing, both emotionally and physically, and are therefore more responsive to healthcare interventions.
The schematic diagram of the theoretical framework for this study was based on the work of the author, the Spiritual Nursing Care theory, which proposed that holistic care for patients is composed of three interlocking factors that contribute to the satisfaction of the patient’s spiritual needs to attain spiritual well-being: the external environment which includes the nurse as the healthcare provider, and which necessitates that he or she must have enough spiritual competency to provide spiritual nursing care; the culture of the patient’s family or significant others; and at the center is the spiritual nursing care itself.
Figure 1 illustrates the Spiritual Nursing Care Framework, which involves the tripartite relationship between the nurse as the healthcare provider, the family as providers of support, and the patient having spiritual needs.
The theoretical framework is composed of four components: (1) spiritual nursing care, (2) the nurse’s spiritual competency, (3) the cultural background of the patient, both as part of the external environment, and (4) the patient’s spiritual needs.
The Spiritual Nursing Care theory proposes that patients have spiritual needs as part of their holistic needs. When these needs are satisfied, they will have a more positive attitude towards healing and thus are more responsive to healthcare interventions which may be manifested in their satisfaction with the spiritual nursing care provided by the nurse. The trust between the nurse and the patient will help in the nursing aspect by creating an atmosphere of rapport between the nurse and the patient, thereby making the patient support the decisions of the nurse when it comes to the spiritual aspects of nursing care. As illustrated in the above schematic diagram, there must be trust between the nurse and the family members of the patient also because they both act as a healthcare provider and support system for the patient.
Furthermore, there must be trust since the nurse is expected to provide spiritual nursing care, which must be sensitive to the patient’s needs and the cultural background of the patient’s family. This, in turn, will help make the patient’s family trust that the spiritual nursing care provided by the nurse will redound to the benefit of the patient. On the part of the nurse, as a healthcare provider, he or she must have spiritual competency in order to address the spiritual needs of his or her patient adequately. Competence refers to a set of traits and characteristics which form the basis for optimal performance. In other words, spiritual competency then is that defined set of attitudes, knowledge, and skills in the domains of spirituality that every nurse should have to effectively and ethically practice nursing, regardless of whether or not they consider themselves spiritual or religious.
There must be congruence between the nurse’s spiritual competency and the spiritual nursing care to be provided in order to satisfy the patient’s spiritual needs. As defined in nursing, culturally congruent practice is that application of evidence-based nursing, which is in line with the preferred cultural values and practices, beliefs, and worldview of patients (Marion et al., 2016). Therefore, the spiritually congruent practice would be nursing which is sensitive to the preferred spiritual or religious beliefs of the patient and his or her significant others. Meanwhile, spiritual competence is the process wherein nurses demonstrate congruent spiritual practice. In other words, the nurse needs to be spiritually competent in providing spiritual nursing care that is congruent with the patient’s spiritual needs.
In whatever healthcare setting, the nurse is likely to have patients with culturally diverse beliefs and practices concerning their own health, wellness, and illnesses. This is where the interaction between the nurse and the external environment (socio-cultural) would also be essential. Not only must the nurse provide culturally sensitive spiritual nursing care, he or she must also provide spiritually congruent nursing care. There may be instances where the personal belief system of a nurse may not match those of his or her patient. In this instance, there may be a conundrum since the nurse may have difficulty relating to his or her patient, which in turn may hinder the nurse from providing adequate spiritual care. Hence, it is necessary for the nurse to interact with the external environment of the patient or his family to be more specific. This is because, in the family setting, most persons develop and form their values and belief systems as influenced by their socio-cultural background.
Meanwhile, the family members may not be expected to have the same spiritual competence as the nurse as they are already in a unique position of being the primary and fundamental emotional support of the patient. What is required is that they be sensitive to the spiritual needs of the patient and assist them as much as they are able. They should also assist the nurse in understanding how best to satisfy the spiritual needs of the patient and handle any confusion the nurse may have as to specific cultural and religious practices, as the family members are likely to come from the same socio-cultural environment as the patient.
It is only with the nurse’s spiritual care competence that is congruent with the nursing care provided and is sensitive to the cultural background of the patient’s family, which would complete the holistic spiritual nursing care provided to the patient. It is through this three-way symbiotic relationship that holistic spiritual nursing care may be perfected. If the nurse is able to provide optimum physical, pharmacological and spiritual assistance to the patient and the family environment delivers spiritual guidance, then the patient can attain positive health status within his given physical illness or bodily condition.
The essence of spiritual nursing care is the understanding that spirituality can mean different things to different people, especially considering the physical and socio-cultural environment. The Spiritual Nursing Care theoretical framework involves three groups: the patient, the nurse, and the family or significant others as part of the external environment. It is also composed of three components: the nurse’s spiritual care competence, the cultural elements of the external environment, and the spiritual nursing care, the intersection of which directly influence the satisfaction of the patient’s spiritual needs.
The higher the spirituality or how much the patient believes himself to be faithful, the higher the impact the corresponding faithfulness of his significant others would impact him. In providing holistic nursing care that includes spiritual care, there must be congruence between the nurse’s spiritual competency as well as the spiritual nursing care provided to meet patients’ spiritual needs. In other words, the spirituality inclusive nursing care provided would be the practical application of the nurse’s spiritual competency, the former’s effectiveness in meeting the patient’s spiritual needs to attain spiritual well-being, being directly influenced by how competent the nurse may be.