M A K I N G S E N S E O F SP I R I T U A L I T Y

doi: 10.1111/j.1365-2702.2006.01351.x

Putting a puzzle together: making spirituality meaningful for nursing

using an evolving theoretical framework
Denise Miner-Williams

PhD, RN

Social Science Researcher, University of Texas Health Science Center, San Antonio, TX, USA

Submitted for publication: 4 July 2005

Accepted for publication: 6 July 2005

Correspondence:
Denise Miner-Williams
University of Texas Health Science Center
9063 Schoenthal Rd
Garden Ridge
San Antonio, TX 78266
USA
Telephone: 210-651-9835
E-mail: dminerwilliams@satx.rr.com

Journal of Clinical Nursing 15, 811821

Putting a puzzle together: making spirituality meaningful for nursing using an
evolving theoretical framework
Aims and objectives. This paper addresses the need for a practical understanding of
spirituality in nursing by means of a generic definition of spirituality, an emerging
theoretical framework, and some general practice guidelines.
Background. Spirituality is being addressed more frequently in nursing literature,
but there is still lacking a professional understanding of the phenomenon that is
useful as a basis for practice and research.
Conclusion. The history of spirituality in nursing is recognized, and then its role in
peoples and patients lives, health and healing is examined. Spirituality is clarified
through its various definitions in the literature, and identification of component
concepts: connectedness, meaning, transcendence, values and beliefs, energy and
emotion. A working definition and the concepts are brought together into a
framework. Guidelines for how to incorporate spirituality into practice are presented.
Relevance to clinical practice. With this understanding of spirituality by means of a
clarifying definition, a theoretical framework and six general guidelines, nurses may
be better equipped to incorporate spirituality into their practice. This will fulfil
professional and accrediting mandates and, more importantly, provide more
holistic, ethical and balanced care for patients.
MINER-WILLIAMS D (2006)

Key words: connectedness, meaning, spirituality, theory, transcendence

Introduction
A minister once stated (LaPierre 1994) that when he
graduated from seminary and became a pastor, he was
expected to deal with spirituality, yet no one ever told him
exactly what it was. This is not a unique issue concerning
spirituality. Nearly a decade later, Chiu et al. (2004) stated
that spirituality is a universal human phenomenon, yet
confusion and incomprehension of the concept (p. 406) is
ever-present. Spirituality is frequently discussed without a
clear understanding of what it actually is. Even in LaPierres
(1994) article explicating a model for spirituality, the
definition was noticeably absent.
Nurses today are being mandated by professional and
regulating organizations (American Holistic Nurses Associ
2006 Blackwell Publishing Ltd

ation 2005, Joint Commission on Accreditation of Healthcare Organizations 2005) to incorporate spiritual assessment
and interventions into their practice. In addition, it is
postulated that failing to incorporate spirituality in nursing
care, by not addressing the spiritual needs of patients, is
unethical (Pettigrew 1990, Wright 1998). However, many
nurses will express difficulty with understanding what spirituality is, or how it relates to nursing, never mind how to
assess and implement it. The purpose of this paper is to
present an understanding of spirituality: to look at its role in
nursing and health, to define it and identify its essential
components, and to put it into a framework that may make
it more accessible for nurses to internalize and then to
incorporate into their practice. It is an attempt to put pieces
of a puzzle together to see better the picture of the puzzle.
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D Miner-Williams

Nursing history is steeped in a spiritual background, from

ancient times to the beginnings of modern nursing (OBrien
1999, Taylor 2002). Florence Nightingale, besides being the
leader in modern aspects of physical care of the patient, had
spiritual underpinnings for her understanding of both life and
nursing. She reasoned that if nature is the manifestation of
God, then co-operating with nature, by facilitating healing, is
co-operating with God (Macrae 2001). The dawn of empiricism brought with it a de-emphasis on the importance of
spirituality and a sense of reductionism developed. The belief
that spirituality was the sole or primary determinant of health
evolved into the perception of the separation of the spirit of a
person from the health of the person. Indeed, that thought
persists.

Current views of spirituality

Over the past two decades literature related to spirituality
indicates a rising interest within both the general public and
among patients. According to Mueller et al. (2001), surveys
both of the general population and of patients have consistently found that more than 90% of people believe in a higher
being. A CNN poll of 1002 people revealed that 82% believe
in the power of God to improve the course of illness (Wallis
1996). Further, some patients want spirituality incorporated
into their health care treatment. In a survey of 203 inpatients,
77% wanted physicians to consider spiritual needs, and
94% regarded spiritual health equal to physical health (King
& Bushwick 1994). Among 177 patients surveyed in a
pulmonary outpatient clinic, 66% indicated they would
welcome an inquiry from their physicians about their
spiritual or religious belief if they became gravely ill (Ehman
et al. 1999). In a qualitative study of 10 Christian patients
with a variety of illnesses, recipients of spiritual nursing care
welcomed such care, identifying positive outcomes from it,
including reduced anxiety, comfort, hopefulness and coping
(Conco 1995).
Increasing reports in the literature cite spirituality as
having a role in health and healing. Mueller et al. (2001)
conducted an extensive review of published studies, metaanalyses, systematic reviews, and subject reviews that examined the association between religious involvement and
spirituality and health. Most studies found that religious
involvement and spirituality are associated with better health
outcomes. In the 1970s Herbert Benson, a cardiologist, began
promulgating the notion that the mind influences physical
functioning of the body. He subsequently developed the
relaxation response (Benson & Stark 1996), a method of
relaxing the mind in order to produce certain physiological
changes. This idea of the mind producing physical response is
812

increasingly accepted in medical community. His work has

further progressed to recognizing that it is more than the
mind that affects health; there is a strong spiritual connection. His conclusion of this is strong enough that he has
stated that people are wired for God (p. 196). Sherwood
(2000) noted the interest nurses and patients have in how
spiritual well being affects both the health care experience
and healing.
There remains skepticism of a direct relationship between
spirituality and healing, however. Dusek et al. (2002) noted
the concerns of the medical community in accepting the
reported beneficial effects of one type of spiritual healing,
that of intercessory prayer. Roush (1997), in a profile of
Herbert Benson and his research in mind-body work and
intercessory prayer, interviewed a number of scientists, and
reported their description of such research to be quixotic,
embarrassing or worse (p. 357). Yet such research continues
among prominent researchers and is being funded.
Even for those health professionals who have faith in a
deity and believe in an active role of spirituality in healing,
there is a reluctance to admit this publicly. An anecdotal
situation is of an oncologist who told the patient who was
unexplainably going into a remission of an inoperable
cancer, that he knew it was Gods direct intervention. He felt
he could not write that in the medical record, however.
Instead, he used the explanation of the remote physical
possibilities that may have caused the turnaround. OHara
(2002), in his examination of the question of the role of
prayer and spirituality in health care, addresses the considerable evidence (p. 42) of a positive association of spirituality
with health benefits and the reluctance of the medical
community to integrate this into practice. He concluded that
the reluctance stems from the manner of examining spirituality and prayer using reductionist thought rather than
looking at it as the context of holistic health.

Defining spirituality
The question remains, however: what exactly is spirituality?
Spirituality has been discussed since the earliest of times, and
many hundreds of philosophies have explored this phenomenon. It is universal in that every human being experiences it,
but it encompasses so many factors and permeates so much of
life, that each experience is individual. Seaward (2004)
expresses well the depth of the subject when he stated that
descriptions such as the human spirit has been described as a
gift to accompany one through life, an inner drive housed in
the soul, and even a living consciousness of a divine-like
presence within us (p. 148) are poetic and profound, but
dont bring us closer to understanding of spirituality. Indeed,

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Making sense of spirituality

Making spirituality meaningful

its depth and profoundness may make it beyond the human

vocabulary to describe, or even beyond the human capacity to
adequately understand. Yet, since it rests at the core of our
essence, we continue to strive to do so. Within the health care
context we do so because of the understanding of the one-ness
of mind-body-spirit, and therefore the impact of spirituality
on health. However, Narayanasamy and Owens (2001) stated
that the literature cites lack of clarity among nurses as to the
nature of spiritualityand role ambiguity (p. 447) as
barriers to the provision of spiritual care in nursing.
A sample of various definitions of spirituality is found in
Table 1. Narayanasamy (1999) lends a unique perspective of
an understanding of spirituality with a biological basis, while
Parse, in keeping with her Human Becoming theory of
nursing, offers a vague, more searching definition. Reed
(1992) defined spirituality as a positive, empowering aspect

of being human, apparently an unspoken assumption of

many other authors. Spirituality is so encompassing and
meaningful, that each description of it is unique, but all
contain similarities. Some definitions include more facets or
concepts than others. Only with reflection can one begin to
ascertain a fullness of its meaning.
Sufficient commonalities or convergence of concepts from
the different definitions arise to give one an understanding of
its essence. Spirituality is the essence of being human (Merton
1967, Vaillot 1970, Colliton 1981, Amenta 1986, Rolheiser
1999, Dossey & Guzetta 2000, Burkhardt & Nagai-Jacobson
2001, Taylor 2002). In a generic sense spirituality is defined
as the transcendent (OBrien 1982, Reed 1992) quest for
meaning (Merton 1967, Colliton 1981, Amenta 1986,
Greasley et al. 2001) and happiness Lama (2002); an
integrative energy (Goddard 1995).

Table 1 Select definitions of spirituality

Stoll (1989)

OBrien (1982)
Amenta (1986)

Reed (1992)

Goddard (1995)
Cunningham & Eagan (1996)
Pargament (1997)
Parse (1998)
Meraviglia (1999)

Narayanasamy (1999)

Burkhardt and Nagai-Jacobson (2000)

Dossey et al. (2000)

Sellers (2001)
OHara (2002)

Is my being, who I ammotivated and enabled to value, worship, and to communicate with
the holy, the transcendent p. 6. Involves vertical (transcendent relationship) and horizontal
dimensions (experiences of relationship with God through ones beliefs, values, interactions with
self, others and nature)
That dimension of a person that is concerned with ultimate ends and values; that which inspires in
one the desire to transcend the realm of the material p. 88
The spiritual is the self, or I, the essence of personhood, the God within, that part which
communes with the transcendent. It is that part of each individual which longs for ultimate
awareness, meaning, value, purpose, beauty, dignity, relatedness, and integrity p. 117
The propensity to make meaning through a sense of relatedness to dimensions that transcend the
self in such a way that empowers and does not devalue the individual. This relatedness may be
experienced intrapersonally (as a connectedness within oneself), interpersonally (in the context
of others and the natural environment), and transpersonally (referring to a sense of relatedness
to the unseen, God, or power greater than the self and ordinary resources) p. 350
Integrative energy
The inner dimension of the person, the deepest core, where a person experiences ultimate reality;
the dimension of human experience which enriches our ordinary existence
A search for the sacred
Quieting, while moving beyond the immediate
The experiences and expressions of ones spirit in a unique and dynamic process reflecting faith in
God or a supreme being; it is connectedness with oneself, others, nature, or God; and an
integration of the dimensions of mind, body, and spirit p. 24
Spirituality is rooted in an awareness which is part of the biological make up of the human
species. Spirituality is present in all individuals and it may manifest as inner peace and strength
derived from perceived relationship with a transcendent God or an ultimate reality or whatever
an individual values as supreme p. 123124
The essence of our being which permeates our living in relationship, infuses our unfolding
awareness of who and what we are, our purpose in being, and our inner resources; and shapes
our life journey p. 91
A unifying force of a person; the essence of being that permeates all of life and is manifested in
ones being, knowing, and doing; the interconnectedness with self, others, nature, and God/Life
Force/Absolute/Transcendent p. 7
The motivating force that searches for meaning and purpose in life through connectedness p. 241
A fundamental dimension of personhood, animating the way people think, act, and live and
creating a unitive integration of the intrapersonal, interpersonal, and transpersonal dimensions
of being p. 42

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However, while the definition of spirituality may be

generic, there is no generic spirituality as it is manifested in
people. Spirituality is always rooted in a particularity of some
sort (Cunningham & Eagan 1996). Malinski (2002) stated
that ultimately, spirituality is what people say it is for them,
personally (p. 284). A modified view is that spirituality, as
the essence of being human, is integrative energy and the
transcendent quest for meaning and happiness, but it is the
expression of ones spirituality that is individual and
personal. For example, one may have Buddhist spirituality,
or a God-based but not religion-affiliated spirituality, or
perhaps a spirituality rooted in nature. Each person must find
their own means of expressing their spirituality.
The question of spirituality oftentimes arises concerning
atheists, a small but vocal minority of people. Atheists share
in the universally human experience of spirituality. Atheists
have spirituality in their essence of being human, of
channelling their integrative energy, and their experience of
journeying to find meaning in life. Their expressions of their
spiritualities do not, however, include a connectedness with a
deity.
Any discussion of spirituality must consider the relationship of spirituality and religion. A common misconception is
that the two are synonymous. However, although there is an
overlap, religion and spirituality are two separate constructs
and are not interchangeable (Emblen 1992, Dyson Cobb &
Forman 1997, Malinski 2002). Religion, often centrally
concerned with spirituality, is primarily a social phenomenon
that is, in addition to its spiritual component, also characterized by non-spiritual (e.g. social and cultural) concerns and
goals (Miller & Thorenson 2003). The two constructs
overlap for those people for whom religion is the means of
expressing spirituality. There are non-overlapping aspects of
the constructs. This is evidenced by the observations that
some very spiritual persons do not practice religion, and some
people engaged in religious practices are not very spiritual.
When religion becomes simply a required or desired behaviour in of itself, it ceases to become an expression of
spirituality. That many people identify spirituality and
religion as being closely related, however, is a reflection of
the strong proclivity of a majority of people to express their
spirituality by engaging in faith, whether it be an individual
relationship or an organized, communal connection with
God. Those who deny a distinction are often theists speaking
within the context of their belief that the transcendent quest
is only of God.
MacLaren (2004) identified a distinction between secular
and religious spirituality. This is in concurrence with the
understanding presented here of a generic spirituality and one
grounded in a particular experience (of religion). This is
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helpful, but she muddied the water a bit by stating that some
religions deny a distinction between religion and spirituality
and, in the example she gave, failed to note that this
distinction is only within a specific religious context. It is
imperative that the nurse be able to discern spirituality in its
context. It is also important to meet each person individually,
realizing that even though the person may state that they
belong to a certain religion, it does not necessarily mean they
believe in or adhere to all the tenets of that religion.
Care that must be taken to understand the perspective of
any discussion of spirituality. With the understanding that
spirituality is the essence of being human and engaging in the
transcendent quest for meaning, one must ascertain the
wholeness inherent in the phenomenon. OHara (2002) aptly
describes this by elucidating that spirituality, as the fundamental dimension of personhood, defines context and not
content. Spirituality, then, must be understood as part of the
holistic vision of the persons health, and not simply as just
another dimension of the person. The ability to understand
something, however, is sometimes limited when viewed only
in its wholeness. If one can grasp an identity with smaller
aspects of the whole, one can appreciate the whole better. We
can admire the beauty of an exquisitely cut diamond in the
entire stone. However, to better appreciate it, we tend to look
more intently at the cuts and sides to it. So, too, will we
appreciate the phenomenon of spirituality by examining its
inherent concepts, realizing that it is only by their interrelatedness can we begin to understand the whole. It is seeing
the picture of the puzzle by examining its pieces and putting
them together.

Pieces of the puzzle

Being a very complex phenomenon, there are numerous
dimensions or concepts associated with spirituality (see
Table 2). Chiu et al. (2004) conducted an integrative review
of the concept of spirituality with a sample of 73 research
articles published in the health literature between 1990 and
2000. Their analysis revealed four themes within the conceptual definitions of spirituality and attributes for two of the
themes. In addition, five dimensions were culled from operational definitions, which were usually not consistent with
conceptual definitions. The four themes were consistent crossculturally in the few culture-specific studies that were available.
Goldberg (1998), in a concept analysis of spirituality, listed
eight phenomena emerging from the spirituality literature.
Meraviglias (1999) analysis of spirituality identified antecedents, attributes, outcomes and related concepts. LaPierre
(1994), a cleric, identified six factors from his readings and
experience.

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Making sense of spirituality

Making spirituality meaningful

Table 2 Examples of pieces of the spirituality puzzle

Authors

Terms used

The pieces

Chiu et al. (2004)

Four themes with three attributes of the first theme, Existential (spiritual experience, meaning/purpose in life, hope)
four of the second
Connectedness (with self, others, nature and higher being)
Transcendence
Power/force/energy
Meraviglia (1999) Two antecedents
Life, spirit
Four attributes
Faith, connectedness, integration, unique and dynamic process
12 outcomes
Meaning, purpose, hope, self-transcendence, spiritual well being,
psychological well being, love, trust, creativity, religiousness,
health and physical well being
Eight related concepts
Religion, religiosity, spiritual dimension, spiritual aspect, spiritual
perspective, spiritual component, spiritual subsystem, spiritual
domain
Goldberg (1998)
Eight phenomena
Meaning, presenting, empathy/compassion, giving hope, love,
religion/transcendence, touch, healing
Dyson et al. (1997) Three key elements
Self, others and God
Five emerging themes articulated
Meaning, hope, relatedness, beliefs and expressions of spirituality
in the context of the elements
LaPierre (1994)
Six factors
Journey, encounter with transcendence, community, religion,
mystery of creation and transformation

From these and similar works, commonalities of concepts,

or pieces, of spirituality are established. The difficulty is that
different authors include different combinations of the pieces,
difference in terminology of the pieces (such as terms,
concepts, elements and phenomena) and different ways of
relating the pieces. There is a gap in bringing the common
pieces together in a meaningful way to give direction for
nurses to incorporate spirituality in nursing practice. To
address this problem, each of these pieces will be briefly
discussed then brought together in a theoretical framework.

Connectedness
A large body of literature acknowledges connectedness, a
special type of relationship, as spirituality, or as a component
of spirituality (Stoll 1989, Leininger 1997, Burkhardt &
Nagai-Jacobson 2000, Chiu 2000, Sherwood 2000). Connectedness is often viewed as being with oneself, with others,
with nature and/or with a deity/Higher Being. Hungelmann
et al. (1985) defined harmonious interconnectedness as the
unifying construct for all the categories derived from their
qualitative study of spiritual well being. Stoll (1989) conceptualized spirituality as relationship of two dimensions of
connectedness: the vertical (with God, the transcendent) and
the horizontal (experiences of relationship with God through
ones beliefs, values, interactions with self, others and nature).
Connecting is the essence of spirituality in Burkhardt and
Nagai-Jacobsons qualitative work (2000). They wrote of
connecting with ones inner self and physical self, with

nature, others and God, of connecting through rest and

recreation, breathing, rituals and story. This sense of
connecting is also described as being harmonious (Hungelman et al. 1985, Burkhardt 1989).
Pargament (1997) considers spirituality towards God as
the primary focus of our spiritual being, with other connectedness stemming from this focus. Indeed, there seems to be a
certain restlessness of spirit in search of meaning in life that
leads to connectedness with something greater than self.
Augustine of Hippo stated that the heart is restless until it
comes to rest in God (Outler 1955). Meraviglia (1999)
concluded that connectedness provides the discrepancy in the
theoretical literature of spirituality. She described the theological literature as emphasizing connectedness as with God,
the psychology literature that of connectedness within oneself, the sociological literature with others and the nursing
literature coming from each of these perspectives.

Meaning
The quest for meaning and happiness emerges as a prominent
theme in discussions of spirituality and of being human.
Rolheiser (2001) described it as:
at the deepest root, each of us aches for significance, meaning,
uniqueness, preciousness, immortality and to have in our lives a great
love and great beauty. This ache is congenital, incurable and
obsessive. We are, as Plato said, fired into life with this divine
restlessness in us (p. 131).

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Frankl (1963) described meaning in life as the principle

motivation in life, giving one a sense of purpose and
worthiness. The role of meaning in spirituality is found
through research. Hall (1998) evidenced this in a study with
persons with HIV. She found three themes in the role of
spirituality, two of which were about purpose and meaning,
and the third about it giving a frame for life. Burkhardt
(1994) revealed through her study with women that
spirituality shapes and gives meaning to life through
relationships. This study is consistent with Meragvilias
(1999) critical analysis of the literature, in which she
determined meaning to be an outcome of spirituality. It is
also consistent with Waltons (1996) concept analysis of
spiritual relationships. LaPierre (1994) spoke of spirituality
in terms of a journey in search of meaning and Hungelmann
et al. (1996) as a search for meaning and purpose in life.
The Lama (2002), in his treatise on the meaningful life,
begins by describing this as inner happiness. These descriptions of outcome vs. quest are not incompatible as spirituality is viewed as gaining meaning but never experiencing it
in its fullness.
The search for meaning in life is found in questions raised
by alterations in health that biological science cannot answer;
questions such as, Why am I ill? Why must I suffer? Willis
(2000) relates an Okinawan proverb about meaning and
suffering: Pain makes you think. Thought makes you wise.
Wisdom makes pain bearable.

be guided by intellect, arise from within a person and

become an element of being. Dolan (1993), identifying
seven categories or archetypes of values, stated that these
values are root sources of the expression of spirituality.
Congruence of values and beliefs with feelings and behaviour is involved in spirituality. Hungelmann et al. (1996)
see this congruency with values and practice as a property
of spiritual well being. Bellingham et al. (1989) stated that
such congruence is necessary in order to achieve connectedness with oneself.
Tanyi (2002) conducted a concept analysis of spirituality,
which led her to state that spirituality entails connection to
beliefs and values, which give meaning to life and bring faith,
hope, peace and empowerment. This connection results in
joy, forgiveness, well being and the ability to transcend.
Martsolf and Mickley (1998) stated that values, or cherished
beliefs and standards, are an attribute of spirituality. Anandarajah and Hight (2001) saw spirituality, a part of the
human experience, as having cognitive, experiential and
behavioural aspects. They demonstrated the difficulty of
trying to artificially categorize the different pieces of
spirituality by first placing the beliefs and values by which
an individual lives within the cognitive aspect of spirituality.
However, emotions, part of the experiential aspect, were seen
as being reflected in the transcendent, which includes ones
value system.

Energy and emotions

Transcendence
Transcendence is another concept of spirituality, viewed as
either an essential component (LaPierre 1994, Chiu 2000)
or as an indicator of spirituality (Reed 1992). Chiu et al.
(2004) cite it as one of four themes in their integrative
review of research concerning spirituality. Elkins (1999), a
psychologist, offers four ways to begin a spiritual journey.
One of these is prayer, a facet of faith, which is a sense of
connection to a transcendent dimension. Goddard (1995)
approached spirituality from a philosophical analysis and
uniquely found the transcendent to be a logical accident or
an attribute that is compatible with the essence of spirituality but need not necessarily accompany it. A divergent
view is voiced by Dyson et al. (1997) who completely
omitted any reference to transcendence in their discussion of
spirituality.

Values and beliefs

A variety of understandings of the relationship of values and
beliefs with spirituality are found. Beliefs, although they can
816

Energy is a concept of spirituality. Goddard (1995) described spirituality as an integrative energy. This is gleaned
from her review of definitions stating spirituality pervades,
unites and directs all human dimensions, (p. 810) constituting the internal locus of health. Miller and Thorensen
(2003) stated that the notion of being concerned with lifes
most animating and vital principle (p. 27), which gives life
or energy to the human person, is one of two themes
dominating the concept of spirituality. The other is transcendence. Rolheiser (1999) wrote of the fire that burns
within us (p. 7), with the channelling of that fire being our
spirituality.
Emotions, such as love, peace, sense of well being, hope,
forgiveness and beauty, are inconsistently addressed. Some
describe them as attributes of spirituality (Hungelmann et al.
1985, 1996). Other authors cite them as outcomes of
spirituality (Meraviglia 1999, Walton 1999, OConnor
2001, Touhy 2001). Negative emotions such as guilt and
fear are sometimes associated with spirituality, mostly in the
context of religion. Often this is a misunderstanding of
religion rather than the religion itself that is the cause.

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Making sense of spirituality

Making spirituality meaningful

transpersonally (a relatedness to the unseen, God or power

greater than the self and ordinary resources p. 350). Dossey
and Guzetta (2000) similarly address spirituality as the
interconnectedness with self, others, nature and God/Life
(p. 7). It is important to point out that it is not simply
relationship, but the transcendent connectedness within
relationship involving an integrative energy that is the
manifestation of the spiritual.
Manifestation of spirituality by behavioural means may
also take place in interactions with others and in a practice of
religion. Not all interactions or religious practice are necessarily spiritual, however. It is only when the behaviour is
meaningful in a positive way and involves an energy that it
may be considered as such.
The framework addresses the generic understanding of
spirituality, which allows for the possibility of its different
expressions. As addressed above, people will have a basic
reference to their experience of spirituality. People with Godbased or theist spiritualities will view the connectedness with
deity, or their relationship with God, as the primary
perspective or driving force of their spirituality. For example,
for Christians connectedness with God as the focus of
spirituality is what drives the life-journey, the connectedness
with self, others and nature as well as the religious activities
and behavioural interactions with others. Others may focus
on the integrative energy within self, or with their relationship with others in experiencing spirituality. Note that one
can and does have plenty of interactions with other that are
not spiritual in nature, but they always have the potential to
become so (Walton 1996). That potential happens when one

Putting the pieces together: a theoretical

framework
An evolving theoretical framework for spirituality is illustrated in Figure 1, in which the pieces, or concepts from the
literature, are put together so that one may see the puzzle of
spirituality as a whole. The assumptive base of spirituality is
that it is the essence of being human. It is then defined as both
integrative energy and the transcendent quest for meaning/
happiness. It is the search, which ultimately leads to health
and alleviation of suffering. Health is defined as wholeness, a
unity and harmony of body, mind and spirit. It is not to be
confused with simple physical wellness, and therefore can
co-exist with disease. Suffering, sometimes also described as
spiritual distress (OBrien 1999), is integrally connected with
spirituality as a journey seeking meaning (Moore 1992).
Connectedness with God and with others can alleviate
suffering for many people (OBrien 1999, Lama 2002).
A person manifests their spirituality, mediated through
their values and beliefs, by relational and/or behavioural
means. Relational manifestation of spirituality is found in the
connectedness of relationship. This framework identifies
connectedness with self, with other and with a deity. Other
is defined as all that is in the world that is outside of oneself:
people, animals and nature. As evidenced in the emphasis on
connectedness in the literature, this experiential aspect is the
most significant. Reed (1992) describes how this connectedness or relatedness to dimensions that transcend the self may
be experienced intrapersonally (a connectedness within oneself), interpersonally (in the context of others and nature) and

Person

Values,
Beliefs

Personal Manifestation

Integrative energy

Relational
Connectedness
with self
with other
with deity Love, hope,
peacefulness,
forgiveness,
comfort

Health;
Alleviation of
suffering

Behavioral
Religion
Interaction with others

Transcendent quest for meaning/purpose/happiness

Spirituality
Figure 1 Model of spirituality.

The essence of being human

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instills the element of transcendence, that is, when one

recognizes the awe, experiences the numinous in the relationship to make the spiritual connection. Although western
traditions may see the quest or journey as being a search for
meaning, some eastern traditions may focus more on the
quest itself rather than a search for answers.

Making the puzzle useful

As a recap, spirituality has been examined in terms of
definition and of identifying pieces comprising its complexity,
fitting the concepts together in a theoretical framework. The
role spirituality plays in the lives of people and of patients
have briefly been touched upon. There is considerable
evidence indicating the positive associations of spirituality
and health, making it an important issue for nursing. The
challenge lies in interfacing spirituality with nursing care in
everyday practice. To do that the nurse must be at ease with
spirituality in two respects. The first is in understanding
spirituality, and what it means to be human and how
meaningful events, such as a change in the course of ones
health, can affect someone. The nurse must also work upon
becoming whole and at ease with him or herself (Goddard
1995, OBrien 1999, Burkhardt & Nagai-Jacobson 2001).
Spirituality in nursing involves caring for the patient in need
of physical care or information as well as the person within
the patient. Naden and Eriksson (2002) refer to this as
blending the art of nursing with caring science.
It can be construed that nurses can both provide spiritual
nursing care and can provide nursing care spiritually. There
are some specific measures nurses can take. Referring to the
theoretical framework, the nurse recognizes that spirituality,
the essence of being human, can incorporate meaning,
connectedness, and perhaps some physical behaviour such
as religious practices, all emanating from cherished beliefs
and values. In clinical practice, the nurse seeking to assess or
be aware of the spiritual status of patients, must be open to
cues from the patients about what gives meaning and
happiness to or integration of their lives, whats important
to them, how this illness/need for healthcare fits into their
lives, where their connections are, as much or more so than
direct questions about such matters. Cues may be subtly
available in conversation or in the physical evidence of a
religious article sitting out or by the visitors and how they
interact. Sometimes the spiritual needs of a patient may be
blatantly obvious as when she painfully cries out, Why is this
happening to me?
Although answering questions on a standardized assessment form such as, What are your values or beliefs? and
What is your religious preference? may meet accreditation
818

requirements for spiritual assessment, if done routinely and

impersonally it misses the spirit of the requirement in
every respect! Few people are able or willing to discuss
with an impersonal stranger such matters as values, beliefs
and spirituality. A meaningful assessment or attending
to the spirit would more likely include asking such
questions as, How are your spirits today? Or How does
this hospitalization affect you and your family? Most
importantly, the manner of the nurse must indicate that the
nurse is truly interested in the person, not in filling out a
form.
Ultimately, each nurse must become comfortable with a
means of eliciting a spiritual assessment that works the best
for her or him (OConnor 2001). One suggestion is to use a
two-tiered approach (Burkhardt & Nagai-Jacobson 1985) in
which the nurse pursues an in depth attending to the spirit
only after ascertaining indicators of spiritual distress.
In providing spiritual nursing care, actions can be taken
and words said that can touch the spirit of the person. A
personal kindness, appropriate touch, taking the effort to
listen to what the patient is truly saying, offering to call a
chaplain, appropriate sharing of oneself, or recognizing the
importance of the significant visitors are all examples of
care that can be given that addresses the spirituality, or
enhances that which is meaningful or energy-giving to the
patient.
The manner in which a nurse cares for the patient also has
the potential to reach out and minister to the spirit of the
patient. The nurse administers nursing care spiritually
through a caring human relationship characterized by the
art of being present, of listening, of respecting and supporting
the values, beliefs, and important connections, and, most
importantly, of giving of self (Sellers 2001). Even the most
technical tasks can be undertaken with an attitude that
acknowledges and respects the person within the patient. Eye
contact, if culturally appropriate, communicating a genuine
interest, and accepting the patient even when values are
different from the nurse are ways of contributing to a caring
manner that enhances the patient spiritually. The manner in
which one provides care does not require any extra time on
the nurses part, which is of great benefit to the over-tasked
nurse.
Some nurses, once they understand what spirituality is, will
find that they are spiritual in their care, but have never named
it as such. Goldberg (1998), in a literature review, found that
spirituality, as a concept was not very meaningful to nurses in
their everyday work. Yet she also noted that much of their
nursing care incorporated elements identified in the literature
as spiritual care. The nurses (and probably patients) simply
did not recognize it as such.

2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 811821

Making sense of spirituality

The nurse must be perceptive to understand when

spiritual needs are beyond his or her care and when
referrals are appropriate, as well as when a patient doesnt
care to have certain areas, especially those of a religious
nature, addressed. Care must be taken to document
spiritual needs and plans to address them, including
making chaplain referrals.
In education, nurses can use this framework as a guide for
instructing students (and practicing nurses) on the essence of
spirituality, and its role in nursing. It is also important to
understand ones own spirituality in order to be effective as a
nurse in providing holistic care. Research indicates that the
spirituality of the nurse was the best single predictor of a
positive attitude toward integrating spiritual care into practice (Taylor et al. 1999). The seed for this point must be
planted early in nursing knowledge formation. A nurse who
understands spirituality and experiences spiritual development will not avoid or give platitudes to the patient who asks
angrily why he had to be the one to be afflicted with this
illness or if she is going to die. It is understood that this
patient is expressing spiritual distress in the search for
meaning. The nurse is not expected to have the answers to
life, but to respect the search, remaining present for and with
the patient in the search. Connecting with patients is
transformational for both the patient and the nurse (Sherwood 1997).
As a summary, the following are general guidelines to assist
in making spirituality meaningful in ones practice:
1 Spirituality in nursing requires a confluence of the two
conceptual approaches of providing spiritual care and
providing care spiritually. Nurses should acquire competence with both.
2 The meaning in a patients life is part of their spirituality,
which is manifested through connections and behaviours,
governed by their values. In seeking to understand and
honour these, nurses assist both patients and themselves in
their spiritual journeys.
3 Spirituality is related to, but not the same as religion.
Offering to make a referral to a chaplain may or may not
be enough to meet even a religious persons spiritual needs.
4 Patients may or may not want to have their spiritual needs,
particularly religious ones, addressed openly. It is up to the
nurse to discern and respond to patients to meet these
needs. To ignore them is unethical.
5 Providing care spiritually is caring for the person in addition to caring for the patient. Therefore, most often, it need
not take up extra time in a busy day.
6 Nurses are more likely to provide nursing care spiritually
when they themselves are comfortable with their own
spiritualities.

Making spirituality meaningful

With this understanding of spirituality by means of a

clarifying definition, a theoretical framework, and six general
guidelines, nurses may be better equipped to incorporate
spirituality into their practice. This will fulfil professional and
accrediting mandates and, more importantly, provide more
holistic, ethical and balanced care for patients.

Contributions
Study design: This work presents a mid-level theory of
spirituality and health with a clarifying framework. Data
collection and analysis: Not applicable and manuscript
preparation: The author wishes to thank the kind contributions of GS and EJT in their reviews of this manuscript.

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