Keywords

Literature review; Spirituality; Nursing care

Introduction

Holistic nursing is defined as caring about the physical, psychological, social, and spiritual aspects of the whole person. Because spiritual care is a part of holistic nursing, Ross systematically reviewed 47 articles related to spiritual nursing research from 1983 to 2005 and identified five categories: nurses, patients and caregivers [1], nurses and patients and caregivers, nursing education, and instrument developing. Following the review by Ross and Pike systematically reviewed 45 spiritual articles from 2006 to 2010 and identified that the majority of spiritual care studies focused on chronic illness and pain, alcoholism, dementia and psychological care, palliative care, and cancer care. Continuously, this article is to review literature from 2011 to 2015 on spiritual care in nursing using CINAHL. The keywords “systematic review,” “spiritual care,” and “nursing” were used to search the Cumulative Index to Nursing and Allied Health Literature (CINAHL) database. Initially a total of 19 articles were identified. After excluding studies by Ross and Pike [1,2], one unrelated to spiritual care, four that were not systematic reviews, and one Spanish article, finally 11 systematic reviews were reviewed. The literature review revealed six categories: the definition of spirituality, concept analysis of spiritual care, spiritual assessment, spiritual care on the clinical setting, ethical issues and nursing education.

Definition of Spirituality

One article investigated the definition of spiritual care. Reinert and Koenig systematically reviewed 20 articles about the definition of spirituality in the CINAHL and MEDLINE databases from 2007 to 2011 and identified that the majority of the definitions of spirituality were inconsistent and contaminated by the concept of mental health [3]. They suggest that it is preferable to define spirituality with religious involvement, particularly for intrinsic religion, to distinguish the definition of spirituality from the concept of mental health in nursing research. Furthermore, they recommended the mixed method for the quantitative and qualitative spiritual studies in nursing, because it can provide consistent findings for the measurements and enable the exploration of individualized spiritual experiences. Finally, they proposed that future nursing research should focus more on the effectiveness of spirituality involving intrinsic religion for health outcomes, rather than nursing practice, and develop a distinct spiritual care program for each clinical setting.

Concept Analysis of Spiritual Care

Two articles conducted the concept analysis of spiritual care. Petersen conducted a concept analysis of spiritual care for a child with terminal-stage cancer [4], and a literature search was conducted from inception to the end of 2012 by using the CINAHL, ATLA, and PubMed databases. Results identified six attributes: assessing spiritual needs, assisting the child to express feelings, assisting the child to find meaning, aiding the child to find hope, helping the child to be remembered, and strengthening the relationship of the child with others. Existential questions and spiritual distress were the antecedents. The consequences comprised a peaceful death, spiritual growth, a trust relationship, and strengthening end-of-life care. Although spiritual care is a crucial part of holistic nursing care, the gaps in knowledge and nursing practice prevent children with cancer at the end of life from obtaining appropriate spiritual care.

Ramezani et al. used keywords such as “spiritual nursing,” “spiritual care,” “spiritual nursing care,” and “spiritual needs” to systematically review different information systems such as ProQuest, Ovid, ScienceDirect, PubMed, Google Scholar, Scopus, Ebrary, Sage, MEDLINE, CINAHL, Wiley, SID, Magiran, INML, IranMedex, and IranDoc and identified 151 articles and seven books that fulfilled the inclusion criteria [5]. They conducted a concept analysis of spiritual care by using the 8- step approach of Walker and Avant and identified the following attributes of spiritual care: healing presence, therapeutic use of self, intuitive sense, exploration of the spiritual perspective, patient-centeredness, meaning-centered therapeutic intervention, and creation of a spiritually nurturing environment. The antecedents of the concept of spiritual care are transcendent awareness, self-awareness, religious affiliation, professional commitment, sensitivity, and intentionality. The delivery of spiritual care leads to positive consequences such as healing, promotion of spiritual wellbeing, psychological adaptation, feelings of satisfaction for patients, promotion of spiritual awareness, and job satisfaction for nurses.

Spiritual Assessment

One article described spiritual assessment. Draper conducted an integrative review of spiritual assessment and identified three categories: generic, quantitative [6], and qualitative approaches and conducted a metasynthesis of all approaches. The author recommends that spiritual assessment should start from a generic model such as the FICA model [7,8]. F refers to the faith and beliefs of the patients. I imply the importance of the faith and beliefs in patients’ lives. C addresses whether patients are participating in a spiritual or religious community. A indicates whether patients would prefer that healthcare professionals address the issues in their health care. Following assessment by using the generic model, the author suggests that spiritual needs should be further assessed according to four categories and 22 domains under the references of Hodge and Horvath and Monod et al. [9,10]. The four categories were 1) meaning, purpose, and hope; 2) relationship with God; 3) spiritual practice, religious obligation, and interpersonal connection; and 4) professional staff interaction. The first category included the three domains of hope, outlook, and purpose and meaning. The second category included the five domains of loving God, punishment, sense of harmony, universality, and inspiration. The third category included the five domains of spiritual activities, religion, sense of harmony, community, and giving and receiving love. The fourth category included the nine domains of fulfillment, happiness, identity, life satisfaction, self-esteem, well-being, sense of wholeness, peacefulness, and spiritual well-being.

Spiritual Care on the Clinical Settings

Four articles examined spiritual care on the clinical settings. The content of spiritual care in clinics included cancer patients and palliative care. For cancer patients, Oh and Kim systematically reviewed the abstracts and full-text articles in databases including PubMed and Cochrane Library and excluded duplicated studies and those not fulfilling the inclusion criteria [11]. They retrieved 6321 references and selected 15 articles investigating the effects of spiritual interventions in patients with cancer by using meta-analysis and identified interventions that had significant, but moderate, effects on the spiritual well-being, meaning of life, and depression in cancer patients. Specifically, analysis of subgroup data revealed that the existential and religious interventions exerted significant moderate effects on the meaning of life and spiritual well-being of cancer patients. Nevertheless, they identified that the evidence of the aforementioned findings was weak because of mixed study methods with heterogeneity; however, they strongly recommend that evidence-based spiritual care training can improve nurses’ competency of spiritual care and patients’ spiritual well-being.

For palliative care, two articles examined spiritual care on the palliative care settings: one described life review and the other the quality of life. For life review, Jenko, Gonzalez, and Seymour defined life review as the process of systematic and structured recalling of past experiences with the purpose of finding meaning [12], and effective therapeutic listening as a specific skill for nurses to engage in the life review process. Keall et al. conducted a comprehensive search of PubMed, MEDLINE, Web of Science, CINAHL, Scopus, and PsycINFO to identify manual therapeutic life review interventions for existential and spiritual domains of palliative care patients with prognoses of 6 months or fewer [13]. They identified 1768 articles and selected 14 articles that fulfilled the inclusion criteria. However, only eight interventions were found to be efficient treatments: legal activities, life review, meaningcentered group psychotherapy, adaptation of meaning, forgiveness therapy, meaning-making intervention, meaning of life intervention, and outlook intervention. These interventions were practiced for a period ranging from days to months and consisted of one to eight sessions (15-160 minutes per session) for palliative care patients before their deaths. These interventions required little to comprehensive training with a manual.

For the quality of life, O’Quinn and Giambra used the patient, intervention, comparison intervention [14], and outcomes of interest (PICO) format of question formulation to search articles related to pediatric and palliative care, quality of life, and life-limiting illness and evidence-based studies from 1999 to 2011 in the databases of Cumulative Index to Nursing, CINAHL, and MEDLINE. Two studies identified that the quality of life of children at the end of life and their family members could be improved by palliative care services in comparison with the control group; however, resulting in a low grade for the evidence.

Ethical Issues

One article evaluated nursing ethics in spiritual care. Polzer Casarez and Engebretson used keywords such as “ethics,” “spirituality,” “spiritual care,” “religion,” “clinician,” and “health” to search for articles related to ethics in spiritual care in the databases of CINAHL, Nursing Reference Center, PsychINFO, PubMed, Scopus, and Sociological Abstracts [15]. They also conducted a thematic analysis and identified four themes: ethical concerns of omission and commission, the situations in which healthcare providers prefer to offer spiritual care, and skills for integrating spiritual care. The ethical concerns of omission included the lack of beneficence for offering holistic care. The ethical concerns of commission implied that healthcare professionals forced and overstepped their abilities in providing spiritual care. The situations in which healthcare providers prefer to offer spiritual care included when patients were in terminal stages or when they requested spiritual care. For healthcare professionals, the strategies to integrate spiritual care were listening, remaining neutral, and sensitive to spiritual issues.

Nursing Education

Two articles evaluated spiritual care in nursing education. Tiew and Creedy searched for keywords such as “spirituality,” “spiritual care,” “nursing students,” “perceptions,” and “attitudes” from 1990 to 2010 in CINAHL and identified 126 articles [16]. However, only 48 articles met the inclusion criteria; 20 were retained after reviewing the abstracts, and finally, eight articles were retained following the comprehensive reading of the full text of studies that focused on the impact of spiritual content, spiritual education models, or teaching strategies from the nursing students’ spiritual perspectives. They identified that the majority of studies used homogenous samples and focused on Judeo-Christian beliefs; Asian samples were lacking. Therefore, the concept of spirituality was mainly defined from a Western perspective originally. In addition, the majority of the studies measured the outcomes of students’ understanding of spirituality and spiritual care after they took various spiritual courses, but the barriers influencing their practice of spiritual care were not included.

Lewinson, et al. systematically reviewed 622 articles from the BNI, CINAHL, and MEDLINE databases and selected 28 articles that met the inclusion criteria [17]. They found that nurses realized their lack of knowledge regarding the skills in the area of spirituality and spiritual care and had a desire to be educated in such an area. They also recommend that nurses require appropriate education and teaching content and strategies on spiritual care to fulfill duties associated with holistic nursing care. In addition, more studies on spiritual care in preregistered nursing education are required to develop theory-practice integration for spiritual care.

Discussion

The literature review of 11 systematic reviews or evidencebased papers revealed six categories: the definition of spirituality, concept analysis of spiritual care, spiritual assessment, spiritual care in the clinical setting, ethical issues, and nursing education. For the definition of spirituality, Pike suggests distinguishing between the definition of spirituality and religion [2]. However, Reinert and Koenig suggest that the definition of spirituality should include intrinsic religion, which would be a consistent measure of the spiritual variable [3].

For the concept analysis of spiritual care, Pike recommends clarifying whether spirituality involves life meaning [2], ultimate concern, and relieving suffering. Except for the individual spiritual needs, while Petersen conducted a concept analysis of spiritual care for a child with terminal-stage cancer and identified one attribute as strengthening the relationship of the child with others [4]. Additionally, Ramezani, et al. identified the concept analysis of spiritual care in terms of the practice skills as healing presence [5], therapeutic use of self, intuitive sense, exploration of the spiritual perspective, patient-centeredness, meaning-centered therapeutic intervention, and creation of a spiritually nurturing environment.

For spiritual assessment, McSherry, et al. developed a scale for assessing the spiritual care competency of nurses that had high reliability and validity [18]. Rather than nurses, Draper suggests that a generic model of the FICA [7,8] should be used to initially screen the spiritual status of patients [6], and that spiritual needs of patients should be further assessed according to four categories: 1) meaning, purpose, and hope; 2) relationship with God; 3) spiritual practice, religious obligation, and interpersonal connection; and 4) professional staff interactions [9,10].

For spiritual care on the clinical settings, regardless of the previous literature or the current review, the majority of studies were qualitative studies that focused on the cancer and palliative settings. However, Pike mentioned that spiritual studies have focused on chronic illness, pain, alcoholism, dementia, and psychological care [2]. In addition, Reinert and Koenig recommend the mixed method for quantitative and qualitative studies on spiritual care [3], because it could provide consistent findings for spiritual care and enable the exploration of individualized spiritual experiences. Furthermore, the manual therapeutic life review interventions for existential and religious domains of palliative care patients has been validated as evidence-based interventions for spiritual care [13]. Jenko, et al. recommend that effective therapeutic listening is a specific skill for nurses to engage in the life review process [12]. Finally, assessment of spiritual well-being is a central part to the evaluation of the quality of life for the patients [19].

For ethical issues, Pike only addressed the ethical issue of spiritual care from the perspectives of patients [2], but the nurses’ point of view. However, for the ethical issues of spiritual care, Casarez and Engebretson identified themes including the omission and commission of spiritual care and situations and strategies for which healthcare providers offer spiritual care [15]. Ethical issues were more comprehensively addressed in the current study than in previous literature.

For nursing education, Ross reported that the role of spiritual care in nursing education was unclear [1], and Pike addressed the lack of a common language in nursing education [2]. In addition, Tiew and Creedy proposed that the majority of spiritual care studies in nursing education used homogenous samples and focused on Judeo-Christian beliefs [16], and they reported a lack of studies involving multicultural populations. Considering the ambiguous and biased information on spiritual care in nursing education, Lewinson, et al. recommend that nurses require appropriate education and teaching content and strategies on spiritual care to fulfill duties associated with holistic nursing care [17].

Conclusion and Suggestions for Future Studies

This article provides some conclusions and suggestions about the following six categories: the definition of spirituality, concept analysis for spiritual care, spiritual assessment, spiritual care on the clinical settings, ethical issues, and nursing education. First, rather than concentrating on clarifying the definition and concept of spirituality and spiritual care, additional studies should conduct concept analysis of spiritual care for different patient groups such as patients with psychiatric disorders or the elderly population. Moreover, there is a need to conduct a concept analysis of the ethical role of spiritual care in nursing. Second, spiritual care should be assessed from generic to specific aspects, and this study suggests developing comprehensive assessment steps for spiritual care in nursing. Furthermore, except for cancer and palliative settings, studies on spiritual care should be expanded to other clinical care settings such as psychiatric or geriatric units. In addition, nursing researchers should apply the manual therapeutic life review interventions for existential and religious domains as the evidence-based interventions for spiritual care in the different care units to generalize the validity of these spiritual interventions. Furthermore, the mixed method should be used to study spiritual care in nursing both for obtaining consistent findings and exploring the patients’ unique spiritual experiences. Finally, spiritual care in nursing education should emphasize the content and strategies of teaching spiritual care with cultural sensitivity, particularly for effective therapeutic listening as a specific skill for nurses to engage in the life review process, using evidencebased interventions for spiritual care.

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