Learning Objectives

1. Explore the concept of spirituality
   
2. Analyze the difference between spirituality and religiosity.
   
3. Discuss results of existing spirituality research.
   

Introduction

A growing interest in spirituality has given rise to applying the term to all sorts of phenomena and experiences. The conceptual ambiguity is due in large part to the abstractness of the construct itself and the reader-inferred sub-concepts identified in the literature. Spirituality is a component of all people, a human experience, universal, and thus uniquely experienced and interpreted by each person. Beliefs about spirituality affect interpretations of life, from birth to death, from self-worth to one's life philosophy. Van Kaam (1966) reports that human experiences “cannot be measured or experimented with, they are simply there and can only be explicated in their givenness” (p. 187). If spirituality has to do with aspects of human nature and “fundamental matters, with our lives at their deepest, with what counts most for us, it cannot be segregated from any aspect of our existence” (Wagner & Wagner, 1988, p. 15). McSherry & Draper (1998) states that the literature demonstrates spirituality as a part of human nature that cannot be seen in isolation.

A person's spirituality is therefore of concern to health care professionals due to its universality. Health care professionals need to understand the spiritual dimensions. If definitions and assessments of spirituality vary depending on the author's specific field and/or training, then these inconsistencies do not promote clarification for the provider. Health professionals have the opportunity to experience the “vernacular spirituality, an appreciation of the sacred in the ordinary” (Moore, 1994, p. 215) for themselves and in their patients.

Background

Webster's Random House College Dictionary (1992) defines spirituality as “the quality or fact of being spiritual, incorporeal or immaterial nature. Pertaining to the spirit or soul, as distinguished from the physical nature, of or pertaining to the spirit as the seat of the moral or religious nature; of or pertaining to sacred things or matters; religious” (p. 1291). Spirituality lacks a precise theoretical-conceptual definition and has been subject to increasing speculations regarding its nature (Goddard, 1995). Burkhardt (1989) suggests that spirituality however has no antecedents being a ‘thing-in-itself'. A holistic care approach in assessing a client is critical to providers, because it will include spirituality. According to the Random House Webster's College Dictionary (1992) Holistic is a term coined by J. C. Smuts and defined as an approach to health care, “in which isolated symptoms or conditions are considered secondary to one's total physical and psychological state” (p. 639).

The psychiatrist Frankl (1984) states that meaning is the primary motivation in life and that this meaning of one's life is characterized by self-transcendence. The popular literature references to spirituality are about the values and meanings of people's lives and the mind/body interaction. One example of a popular author and speaker on spirituality is Myss. According to Myss (1977), spiritual traditions make reference to the seven levels, or chakras, of power mentioned in scriptures; and that the seventh chakra deals, along with others, with the spiritual dimension. “As institutional religion loses ground, spirituality is gaining momentum, a spirituality that is more universalist in orientation than the creeds that preceded it” (Myss, 1997, p. 86). A physicist, straddling science and popular literature is Capra, who developed a holistic paradigm of science and spirit. He views “the concept of human spirit…as the mode of consciousness in which the individual feels connected to the cosmos as a whole” (1982, p. 412). The psychiatrist C. G. Jung mourns the loss of man's awareness of “the helpful medieval view that man is a microcosm, a reflection of the great cosmos in miniature…by virtue of his reflecting consciousness” (Jung, 1958, pp. 72-73). He further states, that without effort and suffering man will keep from reflecting on his inner reality and that the churches' approach fails individuals, because an “elementary axiom of mass psychology (is), that the individual becomes morally and spiritually inferior in the mass” (Jung, 1958, p. 68). Thomas Moore is a psychotherapist, philosopher and theologian known for his writings on the soul. According to Moore (1994), spirituality transcends all particulars of the concrete world and is necessary for human life.

The literature is sparse on spiritual development, partly due to the difficulties in definition (Lovecky, 1998). “Discussions of spirituality also may range in focus from discussions about religion to discussions about self-actualization” (Lovecky, para. 14). To Lovecky (1998) “the seeking of the transcendent may be an experience of connection to something larger than oneself, to nature, the universe, or as an inner experience of wonder and awe” (para. 4), stating children are capable of this experience as well as adults are. Gifted children show a greater development potential earlier than the mental age of 12 (para. 38), and Lovecky (1998) suggests the formation of a spiritual paradigm or theory that includes children's spirituality, a paradigm that will acknowledge that spirituality is a life-long process. Maslow linked needs of people “based upon circumstance and achievement as much as on age” (Barnum, 1996, p. 46) and would support such as paradigm. In 1971, Maslow added a top tier to his famous hierarchy of needs, called ‘transcendence', to reflect his further insight into human needs (Barnum, 1996). Fowler (1981) identified seven stages of faith development recognizing faith as a universal human phenomenon rather than as religious faith. His stages were developed based on research with individuals ranging in age from 3 – 84 years.

Ferrer (2001) cautions that a participatory vision of human spirituality cannot occur via Western Worldview, since the West favors certain spiritual paths over others. He suggests the distinction made by evaluating the “emancipatory power for self, relationships, and world” (para. 64), which could open a spiritual universalism that can be cultivated independently of worldview. Spohn (1997) argues the importance of the connection between ethics and spirituality, reporting that spirituality has a direct connection to morality and identity. He concludes that spirituality is one source for ethics, and that spiritualities bring their practitioners in touch with meaning. Ruiz (1997) shares his Aztec spirituality, describing it as a way of life and a way for their Aztec society to conserve the spiritual knowledge and practices. Their knowledge is a means toward self-actualization and transcendence. The Dalai Lama (2000) reflects that the Buddhist sees meditation as a spiritual discipline, demonstrating another perspective of spirituality. In 1938 Holmes (1997) wrote that spiritual experience is realizing that all are bound together in one complete Whole, and that this spirituality springs from within the person. So far, every source supports a spiritual universalism. Ferrer (2001) cautions to assure the inclusion of all the various ways of the sacred in order to fully understand spirituality.

Religion reflects on metaphysical assumptions and beliefs including the elements of faith and hope. Similar to Puritan Spirituality are the Spiritual Exercises developed by Ignatius of Loyola in the early 1500's (Armstrong, 1993). These exercises emphasize self-examination and mysticism. The course is still used by Catholics and Anglicans. Ignatius stated that emotions that came “from God were peace, hope, joy and an elevation of mind” (as cited in Armstrong, 1993, p. 284).

The medical literature details the relationship between religion and medicine, as well as the impact of spirituality on health, illness, and healing. Koenig (2002) is a prolific writer addressing the spiritual needs of patients, from the religious perspective. Koenig (2002) states that the physician, upon learning that the patient is non-religious, should stop the spiritual interview and ask about the patient's coping with illness and what gives life meaning and purpose, about cultural beliefs and social resources, as well as their relationship to the sacred or transcendent. Koenig sees spirituality emanating from religion, but he acknowledges spiritual needs of a ‘non-religious' patient. Anandarajah & Hight (2001) offer the following comprehensive definition of spirituality that reflects the majority of the medical literature:

Spirituality is a complex and multidimensional part of the human experience. It has cognitive, experiential and behavior aspects. The cognitive or philosophic aspects include the search for meaning, purpose and truth in life and the beliefs and values by which an individual lives. The experiential and emotional aspects involve feelings of hope, love, connection, inner peace, comfort and support. These are reflected in the quality of an individual's inner resources, the ability to give and receive spiritual love, and the types of relationships and connections that exist with self, the community, the environment and nature, and the transcendent (e.g. power greater than self, a value system, God, cosmic consciousness). The behavior aspects of spirituality involve the way a person externally manifests individual spiritual beliefs and inner spiritual state (p. 83).

Northrup (1994) confirms that spirituality is separate from religion. Her message is that our culture controls our inherent spirituality via religion and that women are split from their daily spirituality. In 1994 an Integrative Medicine program was founded by Weil (Integrative Medicine Program Page), which moves medicine towards considering the patient as a whole person consisting of mind, spirit, and community, as well as body. This occurred twelve years after Dossey (1982) wrote about the conceptual crisis of medical science, encouraging Western doctors to abandon the mechanical model of the human body. Dossey (1982) encouraged the total integration of the spiritual and the physical domains. Physicians agree that spirituality plays an important part in medical care (Astrow, Puchalski, & Sulmasy, 2001; Ellis, Campbell, Detwiler-Breidenbach, & Hubbard, 2002; Levin, Larson, & Puchalski, 1997). Charles (2001) states that of the nation's 135 medical schools, 65 now offer courses in religion, spirituality, and medicine. No similar statistics were located for nursing schools. Dossey (2000) reports that Nightingale may have defined nursing as a profession and as scientific, but her message directs nurses to integrate all aspects of nursing, including the spiritual one. Koenig (2002) acknowledges that the connection between religion and medicine is not as old as the connection between religion and nursing. He suggests that the person that takes primary responsibility for the patient should perform the spiritual history, that “nurses, who often do their own spiritual assessments, should be aware if the physician has already completed one and proceed tactfully (and vice versa)” (p.37). Though large numbers of medical schools address spirituality in their education, nursing schools are lagging behind and need to catch up in order to provide worthy team members. All health professionals need the spirituality education to work together with ministers as a team to integrate this aspect of care. Groer, O'Connor, & Droppleman (1996) state that spirituality is a neglected dimension in curricula, though most nursing programs address spiritual needs of clients. They developed a course to enable students to understand holism. Support for formal spiritual education for nurses is widely promoted (Donley, 1991; Kuuppelomäki, 2001; Leetun, 1996; McRoberts, Sato, & Southwick, n.d.; McSherry, 1998; Rothrock, 1994; Wensley, 1995).

Perspectives of spirituality

The essence of spirituality can be understood by identifying the underlying core values of different cultures and worldviews. Leininger (1991) and Martsolf (1997) emphasize the importance of cultural sensitivity and education towards religiosity and spirituality. Acknowledging different cultural and religious perspectives can also show sensitivity. This can be demonstrated, for example, by refraining from the Christian ‘BC' and ‘AD' designation for centuries, and instead using ‘BCE' (before the common era) and ‘CE' (common era) (Armstrong, 1993). Engebretson (1996) reports on assumptions that may bias views of spirituality and could contribute to misdiagnosis based on three Western worldviews (monotheism, dualism, and interpreting transcendence to mean connecting with spiritual entities beyond the self).

Possessing an awareness and knowledge of one's own spirituality will promote spiritual care. General agreement exists among scholars that providers need to develop awareness about their own spirituality in order to effect spiritual care in their patients (Dossey, Keegan, & Guzzetta, 2000; Leetun, 1996; Nagai-Jacobson & Burkardt, 1989; Taylor, Highfield, & Amenta, 1994; Wilt & Smucker, 2001). Dossey (1998) developed a spiritual assessment tool to assist nurses in their self-evaluation, while Burkhardt & Nagai-Jacobson (2002) published a book to demonstrate how providers can nurture their own spirituality. Patients have a right to their individuality and unique perspective. Providers can gain guidance from ethical principles to guide spiritual care in an ethical way (Kozier, Erb, Berman, & Burke, 2000). Spiritual care involves doing as well as being (Dossey, Keegan, & Guzetta, 2000), and the degree of being is directly associated with the provision of doing (Taylor, Highfield, & Amenta, 1999).

Burkhart & Twadell (2001, para. 3) present the importance of the philosophical perspective of spirituality: the realist, who believes in a physical being having a spiritual component, and the existentialist, believing in spiritual beings having a human experience. Spirituality and spiritual are coupled with a variety of terms in the literature, resulting in overlapping or contradicting meanings. Examples are: the use of spirituality when religiosity is intended, spiritual relationships, spiritual dimension, spiritual care, spiritual well being, spiritual needs, spiritual perspectives, spiritual distress, and spiritual problem. The term “spiritual problem - Code V62.89” (American Psychiatric Association, 1994, p. 765) was approved for use by clinical therapists to assist in differentiating religious from spiritual problems. McGlone (1990) defines religion as “a belief in and commitment to certain doctrines and practices prescribed by ministers…(while) spiritual pertains to a state of being in relationship with God” (p. 78). She notes that illness can actually be a cure for ‘time famine', allowing us to focus on spiritual concerns. A provider has to avoid equating spirituality with religiosity since this would deny the spiritual dimension (Mansen, 1993).

Stoll (1979) and Piles (1990) emphasize the need to distinguish between the psychosocial dimension and the spiritual dimension. A common understanding of spirituality would allow providers to clearly communicate about spiritual care (Emblen, 1992; Widerquist, 1991). On the other hand, Moya & Brykczynska (1992) state that spirituality and spirit, by definition, are indescribable. Spirituality is described as a process by Mansen (1993) rather than an outcome, and she promotes the development of the intuitive knowledge of spirituality.

Goddard (1995) contrasts spirituality and religiosity and then uses principles of logic to re-conceptualize spirituality as ‘integrative energy'. Jack (1997) describes spirituality as “the motivating force in the self that gives a sense of meaning and purpose to life” (p. 227). A review of qualitative studies (Walton, 1996) found that connectedness to self, others, nature and a higher power defined spiritual relationships. Martsolf & Mickley (1998) reviewed the literature and found that the meaning of spirituality remains amorphous due to the various world-views among authors; nevertheless, they yielded the following attributes: 1) meaning, 2) value, 3) transcendence, 4) connecting, and 5) becoming. Their article provides the researcher and practitioner with additional theoretical understanding. Meraviglia's (1999) critical analyses arrived at prayer and the meaning of life as the empirical indicators for spirituality, while distinguishing it from religiosity. The concept analyses on spiritual perspective by Haase et al. (1992) declared spirituality to be the antecedent, which was enabled by life experiences, wisdom, and love. They defined the attributes to be connectedness, belief, and creative energy, yielding the outcomes of purpose and meaning, values to guide conduct, and self-transcendence. The authors choose spiritual perspective, instead of spirituality, because their analyses showed that the perspective between individuals was the variance.

Self-transcendence in adults was separated out from spirituality in research by Reed (1991a, 1991b). Her research demonstrated a direct relationship between self-transcendence and mental health. Reed (1991a) defined self-transcendence as “an expansion of self-boundaries and an orientation toward broadened life perspectives and purposes” (p. 64). Groer, O'Connor, & Droppleman (1996) state that 75% of the holistic healthcare literature equates spirituality with a personal philosophy of meaning.

The concept of spirituality can also be seen in the context of art. A museum collection displays examples of expressions of spirituality in their medieval or renaissance art works, a time when art and spirituality were synonymous. Art promotes spiritual healing in a variety of ways (Bailey, 1997). Each culture and each religion manifests spirituality in its own theology and way of life. These cross-cultural beliefs have implications for health professionals.

Concept of spirituality defined

The definition used by Anandarajah & Hight (2001), reviewed earlier, is truly complete and precise although lengthy. The information gathered from theoretical literature demonstrate these core values:

1. Meaning and purpose in life (making sense of life, see Frankl, 1984, p. 121, reflecting cultural notions),
   
2. Transcendence of self (expanding self-boundaries, see Reed, 1991a, p. 64),
   
3. Connecting to self, others and God/Life Force/Environment/Absolute, and
   
4. Reflecting/knowing (how one knows, one's awareness of self in the cosmos, see Capra, 1982, p. 412.).
   

Anandarajah & Hight's definition (2001) promotes the least ambiguity. By changing the first sentence, the concept will be universal, and, by adding to the behavior aspect measurable consequences from the literature, the concept will be more complete. The resulting unifying definition is offered below:

Spirituality is the unifying and integrating essence creating an indivisible whole between mind, body, and soul. Although unobservable and unmeasurable it is nevertheless real, being experienced in the secular and the sacred, in the profound and the mundane. It has cognitive, experiential and behavior aspects. The cognitive or philosophic aspects include the search for meaning, purpose and truth in life and the beliefs and values by which an individual lives. The experiential and emotional aspects involve feelings of hope, love, connection, inner peace, comfort and support. These are reflected in the quality of an individual's inner resources, the ability to give and receive spiritual love, and the types of relationships and connections that exist with self, the community, the environment and nature, and the transcendent (e.g. power greater than self, a value system, God, cosmic consciousness, Absolute). The behavior aspects of spirituality involve the way a person externally manifests individual spiritual beliefs and inner spiritual state (e.g. altruism, idealism, awareness of the tragic, values, sacredness of life, mission, a sense of trust in life, one's place in the cosmos, a gratitude for all experiences of living).

Assessment of spirituality

Spiritual assessment discerns a patient's level of spiritual well being. The process of the spiritual assessment differs from the standard medical or nursing assessment, in that a provider has to look beyond the physical to underlying spiritual meanings (Wilt & Smucker, 2001). A lack of time by 87.1% of respondents in a study by Piles (1990) was the stated cause of non-assessment by providers. Assessing a patient's spirituality can occur during daily patient care and/or via an assessment tool. Another option is to use a practice model that incorporates the spiritual domain, such as the Dungan Model of Dynamic Integration (Dungan, 1997). Various instruments exist, from many different disciplines. Frank-Stromborg & Olson (1997) list the following quantitative tools for spiritual needs, such as the Spiritual Health Inventory, Spiritual Perspective Scale, and Serenity Scale. They list the Hess's Spiritual Needs Spiritual Needs Survey, Stoll's Guidelines for Spiritual Assessment, and the Reed Interview Schedule, as qualitative tools to measure spiritual needs. The Spiritual Well-Being Scale and Moberg's Indexes of SWB measure spiritual well-being, while the Patient Spiritual Coping Interview measures spiritual coping (Frank-Stromborg & Olson, 1997).

Spirituality cannot be isolated from the human nature (Mc Sherry & Draper, 1998; Van Kaam, 1966; Wagner & Wagner, 1988). Therefore, spirituality might be inferred from multiple indirect observations, such as visible expressions or consequences of behavioral aspects. These aspects can demonstrate the intent or attitude to the observer or be self-reported to the interviewer. Hall (1997) questions if spirituality can be captured with an instrument. An instrument to measure aspects of spirituality needs to address both the religious and the psychosocial components in the tool design and specify the aspect and the population investigated (Frank-Stromborg & Olsen, 1997). The most promising scale found is the Spiritual Involvement and Beliefs Scale (SIBS), designed to be applicable across religious traditions. It is in a 26-item, Likert-type format, with very good instrument reliability and validity, high internal consistency (Cronbach's alpha = .92), and strong test-retest reliability (r = .92), and avoids cultural-religious bias and assessment of both beliefs and actions (Hatch, R., Burg, Naberhaus, & Hellmich, 1998). This would be the choice instrument available at this time, since the indicators confirm the underlying principles of the concept definition offered earlier.

Spirituality in the practice setting

“At the core of holistic modalities are spirituality and healing” (Dossey, 1998, p. 45). Yet Ross (1994) reports how delivery of spiritual care is hindered by the lack of an agreed upon definition of spirituality. One method for communicating support to nurture spiritual health is touch (Estabrooks & Morse, 1992). Being fully present or ‘being with' is one aspect of demonstrating caring for clients with spiritual needs, and a caring attitude is the requisite to nurture spiritual health (Burkhardt, 1989; Newshan, 1998; Pettigrew, 1990). Pettigrew (1990) defines the elements of being present to another, as giving of self in the present moment, being available with all of the self, listening with the full awareness of the privilege of doing so, and being there in a way that is meaningful to another person. The four essential components of being present are client vulnerability, silence, invitation, and privilege (Pettigrew, 1990). Time is the greatest barrier to giving spiritual care (Wilt & Smucker, 2001). Presence however can be practiced during short intervals, though requiring intense and focused energy (Osterman & Schartz-Barcott, 1996). Burkhardt (1998) encourages the reintegration of spirituality into health care via the telling of one's story, prayer, and by being able to differentiate healing and curing.

Table 1 Literature Supported Findings

Literature supported findings:

• Evidence of spiritual universalism.
  
• A need exists to understand the nature of spirituality and its unique expression in individuals.
  
• A need for distinction between spirituality, religion, and the psychosocial dimension, as well as the awareness of the effect of one's worldview.
  
• The existence of various definitions of spirituality possibly inhibits holistic care.
  
• The existence of a link between spirituality and caring, morality, intuition, and ethics.
  
• Spirituality affects health, healing, and illness.
  
• Quality of life includes spiritual elements.
  

Lifespan:

• Spirituality is a life-long process.
  
• Spirituality takes on new meaning for the aged and terminally ill.
  
• Empirical research validates that clients' spiritual needs increase during critical life events.
  
• Empirical research validates the ability to increase spiritual well being.
  

Education:

• Providers need to be educated about spirituality to address client spiritual concerns.
  
• Education needs to address the provider's own spirituality awareness.
  
• Spirituality education is neglected in nursing curricula yet widely supported in the literature.
  
• Literature offers strategies for undergraduate spiritual education.
  
• Providers declare lack of spirituality knowledge an obstacle to performing spiritual care.
  

Culture:

• Essence of spirituality requires understanding different cultures, religions, and worldviews.
  
• Empirical research demonstrates differences of spirituality in cultures.
  
• Spiritual care to be provided in a multi-cultural, multi-religious setting.
  

Self:

• Providers have a responsibility for their ongoing spirituality education.
  
• Providers have a responsibility for awareness and knowledge of their own spirituality in order to effect spiritual care in their clients.
  
• Spiritual assessment tools exist for self-evaluation
  
• Books exist to guide providers' nurturance of their own spirituality.
  
• Self-awareness affects the relationship of the provider and the client.
  

Note: Adapted from “Survey of literature on spirituality,” by L. Manning, 2003, Unpublished manuscript, University of Colorado at Colorado Springs, 24-27.

Conclusion

Providers need to agree on a concept of spirituality, this complex and abstract aspect of the human, in order to create meaning and understanding to enhance a client's well being. This author is offering a definition for a unifying understanding amongst providers. Providers also have to create the momentum for basic medical and nursing education to include a course on spirituality. Alternatively, though less effective, to interweave the concept into all taught subjects. Providers should also encourage spiritually grounded organizations. Organizations have to respond by giving their people the tools and environment by developing structures that promote this spiritual work (Bazan & Dwyer, 1998). This is also possible via the implementation of care models that includes spirituality (Dungan, 1997) and the provision of continuing education in spirituality for their staff.

In order to serve all of man, providers have to understand spiritual needs as one expression of the human person. An expression that is universal und uniquely experienced and interpreted by each person, regardless of religious affiliations and beliefs or lack thereof. The increased interest in providing holistic care to clients is encouraging. There is meaning, guidance, beauty, and fulfillment in the intent of all the religions of humanity. Religion is a necessity for a majority and assists in nourishing the spirit. The resurgence of interest in spirituality among the health professions, as well as the public, and the slow shift in worldview in this country, permit a glimpse of the direction in which the health professions are moving.

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