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JAN JOURNAL OF ADVANCED NURSING

THEORETICAL PAPER

Spiritual crisis: a concept analysis


Laurie B. Agrimson & Lois B. Taft

Accepted for publication 19 September 2008

Correspondence to L.B. Agrimson: A G R I M S O N L . B . & T A F T L . B . ( 2 0 0 9 ) Spiritual crisis: a concept analysis. Journal


e-mail: agrimslb@uwec.edu of Advanced Nursing 65(2), 454–461
doi: 10.1111/j.1365-2648.2008.04869.x
Laurie B. Agrimson BSN RN
Graduate Student
Abstract
Department of Nursing, University of
Wisconsin-Eau Claire, USA Title. Spiritual crisis: a concept analysis.
Aim. This paper is a report of an analysis of the concept of spiritual crisis.
Lois B. Taft DNSc RN GCNS-BC Background. The term spiritual crisis has been used ambiguously in the literature,
Professor resulting in lack of clarity. A holistic approach includes spirituality in nursing care
Department of Nursing, University of of the whole person.
Wisconsin-Eau Claire, USA Data sources. Papers available online between 1998 and 2007 in the CINAHL,
Medline and PsycInfo databases were retrieved for analysis. The search engine
Google was also used to examine additional references to ‘spiritual crisis’.
Review methods. Spiritual crisis, spiritual emergency and life crisis were the terms
initially used to search each database. The search was expanded to include spiri-
tuality to draw more literature into the review.
Findings. Using Walker and Avant’s method of concept analysis, a definition of
spiritual crisis was identified. Spiritual crisis can be described as a unique form of
grieving or loss, marked by a profound questioning of or lack of meaning in life, in
which an individual or community reaches a turning point, leading to a significant
alteration in the way life is viewed. Possible antecedents include sudden acute illness
and loss of important relationships. Potential consequences may include physical
and emotional responses.
Conclusion. People with terminal illness, depression, and those who are griev-
ing losses may be at special risk of spiritual crisis. The literature suggests
an interdisciplinary approach, nurses’ self-exploration of spirituality, and
refraining from defining spirituality by religious affiliation as part of improving
practice.

Keywords: concept analysis, life crisis, nursing, spiritual crisis, spiritual emer-
gency

(Villagomeza 2005). Philosophies that emphasize the unity of


Introduction
human beings include the spiritual domain within a unified
Although holistic nursing care includes spiritual care, many whole. Nursing theories that provide direction for holistic
nurses skim over spiritual topics or leave them out entirely care include Rogers’ Science of Unitary Human Beings, the

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JAN: THEORETICAL PAPER Concept analysis of spiritual crisis

Neuman Systems Model, Parse’s Theory of Human Becom- Spirituality contributes to the sustenance of life by giving
ing, and Newman’s Theory of Expanding Consciousness individuals meaning in their lives and can sometimes keep
(Fawcett 2005). them from death by suicide (Wilding et al. 2005). Spirituality
Typically, in the United States of America, spiritual includes cognitive, emotional and behavioural components
assessment in nursing language refers to asking about (Byrne 2007) and is described as a quality that ‘strives for
religious group membership. In many cultures throughout inspirations, reverence, awe, meaning and purpose, even in
the world, religion and spirituality are inseparable and blend those who do not believe in God’ (Murray & Zentner 1989,
into a unique cultural world view. By understanding individ- p. 259). In the words of deVeber, spirituality ‘separates
ual and cultural differences in spirituality and religion, it is humans from other beings,’ and ‘is that realm of being that is
possible to reduce barriers to holistic care. concerned with the profound and ultimate questions of
Spiritual crisis is a phenomenon that can affect individuals, existence’ (deVeber 1995, p.297).
families, and societies. Former U.S. Vice President Al Gore
used the term spiritual crisis in 2007 when he spoke of a ‘new
Conceptual models
way of thinking’ to help influence people to combat global
warming. Gore stated that ‘it’s in part a spiritual crisis’ – McSherry and Smith (2007) point out that, to make sense of
‘crisis of our own self-definition – who we are’ (Caputo 2007, life events and cope with various crises, both adults and
para.3). Maxwell (2003) used the term to describe how children draw on past experiences and beliefs, including
society’s view of the universe as a ‘machine’ tends to cause religious and spiritual beliefs. Wright (2005) devised a
individuals to feel fragmented, leading to alienation and conceptual model in which life’s meaning arises from
despair, especially in some parts of the world. questioning and exploration of the interaction of suffering,
Reactions to the death of the United Kingdom’s Princess beliefs and spirituality. The Trinity Model addresses all forms
Diana were an example of a society that faced a spiritual of human suffering, where suffering is defined as ‘physical,
crisis in their shared grief. The film The Queen captured the emotional or spiritual anguish’ (p.129). Individuals who are
sense of loss as the whole nation was changed by this crisis. experiencing spiritual pain often ask, ‘Why?’ and are search-
Another profound example of a society responding to a deep ing for meaning (Byrne 2007).
spiritual crisis is the Peace and Reconciliation Movement in Victor Frankl considered that an individual can find meaning
South Africa. in life even when challenged by a hopeless situation or immense
The word spiritual and its association with religion and suffering; this statement was based on his observations and
culture are ambiguous. In the literature, spiritual crisis has experience as a concentration camp victim in World War II.
generally been used as a ‘catch-all’ phrase which could He suggested that suffering was a personal challenge to an
encompass many different phenomena. The purpose of this individual to show courage, to act decently in spite of one’s
concept analysis was to clarify and define ‘spiritual crisis’ and situation (Starck 2003) and that a person’s quest for meaning is
explore the implications for holistic nursing care. the essential motivation in life (Frankl 1984). Frankl’s Theory
of Meaning and Wright’s Trinity Model inform our under-
standing of the concept of spiritual crisis.
Background

Significance Concept analysis process

According to Hermann (2007), their spiritual needs must be A concept analysis breaks down concepts into simpler parts
met in order for people to find meaning and purpose in life. All to refine ambiguous elements and improve understanding by
people are considered naturally spiritual, and so all have distinguishing what is from what is not included (Walker &
spiritual needs (Walter 2002), including atheists and agnostics Avant 2005). The steps outlined by Walker and Avant (2005)
(Carroll 2001). Spiritual needs include: ‘the need for love, are as follows:
others, and God; the need to find meaning and purpose • Select a concept.
in life; the need to find hope for the future; the need for • Determine the aims or purposes of analysis.
forgiveness, creativity, continuity with the past; and to serve • Identify all uses of the concept that you can discover.
and worship God or a higher power’ (McEwen 2005, p. 162). • Determine the defining attributes.
Galek et al. (2005) described seven domains of spiritual needs: • Identify a model case.
belonging, meaning, hope, the sacred, morality, beauty and • Identify borderline, related, contrary, invented and
acceptance of dying. illegitimate cases.

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L.B. Agrimson and L.B. Taft

• Identify antecedents and consequences. (Spiritual Crisis Network: http://www.spiritualcrisisnetwork.


• Define empirical referents. org.uk, para.1–2). Powerful spiritual energies may
affect a person’s body and mind, causing fragmentation of
the self until the energies can be embodied (Cortright
Data sources
2000). Lukoff et al. (1998) add problems such as loss of
A review of the literature was performed using the terms faith, joining a new religious cult and questioning of
‘spiritual crisis’, ‘spiritual emergency’ and ‘life crisis’ in the religious values to the scope of meaning for spiritual crisis/
electronic databases of Google, Medline, CINAHL, PsychI- emergency.
NFO and the Philosophy and Religion database. Papers in An individual may have a ‘temporary loss of that connec-
English and published between 1998 and 2007 were retrieved tion with God’ (Penson et al. 2001, p.287), and this may
and analysed. In general, the literature available on these bring on a powerful spiritual crisis in someone with a strong
topics was sparse. The search was limited initially to peer- faith. Ventegodt et al. (2005) add that spiritual crises may
reviewed papers, but was later expanded to include non-peer occur when individuals are not quite true to themselves and
reviewed papers for the purpose of inclusiveness and under- do not lead their lives in accordance with who they really are.
standing of terms. Everything may come to a standstill. Individuals with
religious convictions may also experience internal struggles,
where good and evil may seem to be struggling for
Results
dominance. Some patients may experience profound mean-
inglessness or a death wish, which needs to be attended to
Definitions of terms
seriously (Ventegodt et al. 2005).
In the Merriam-Webster Dictionary (2004, p.692), spiritual is Grof (2007), in an interview with Jeffrey Mishlove,
defined as ‘relating to, consisting of or affecting the spirit,’ described the experience of spiritual crisis in this way:
where spirit can mean a life-giving force or animating
…there is a sense of such hopelessness that you lose the perspective
principle. Other definitions include a person’s mind or
that this is a lesson and that I’m going to come out of this different. A
feelings as separate from the body, the soul, a person’s
lot of times that will happen around what we call the ego death
nature and the true purpose of something as opposed to a
experience, where everything feels like it’s dying. And what’s
strict interpretation of its words (Oxford American Dictio-
happening in that kind of experience is that all of the old structures,
nary, 1980).
all of the old ways of being, the unsuccessful ways of being, are
Crisis is defined as ‘a turning point for better or worse in an
coming to an end, and it feels literally as though, well, this is it…
acute disease or fever,’ or ‘a decisive or critical moment’
Again, another irony is that if the person is able to open up to that
(Merriam-Webster, 2004, p.171) or ‘a time of acute difficulty
experience, to be there with the experience, that just on the other side
or danger’ (Oxford American Dictionary, 1980, p.151). A
of despair and hopelessness and dying is a whole new way of being
crisis is, by definition, something for which an individual
(http://www.intuition.org/txt/cgrof2.html).
cannot prepare, and results in being caught off guard (Spillers
2007). Spiritual distress has been defined by the North A spiritual crisis may be a unique form of life crisis, in that
American Nursing Diagnosis Association as ‘the disruption in something happens within a person, perhaps after some
the life principle that pervades a person’s entire being and stressful event, such as a death of a loved one. Suddenly, the
that integrates and transcends one’s biological and psycho- individual cannot make sense of the world around them;
social nature’ (Johnson et al. 2001, p.322). Spiritual struggles options seem out of reach, and it is as if the person ‘has hit a
have been associated with several negative outcomes such as wall and they are unable to move on’ (Ventegodt et al. 2005,
feelings of stress, depression, post-traumatic stress disorder, p. 300). A spiritual crisis may also be viewed as an existential
anxiety, guilt and having thoughts of suicide (Pargament & vacuum which is associated with despair, hopelessness, lack
Ano 2006). of life’s meaning and feelings of uselessness (Frankl 1969). A
spiritual crisis is a dilemma which can affect anyone. Nagler
(2004) suggests that the universe has tended to be viewed as
Uses of the concept
consisting of three ontological realms: matter, energy and
Spiritual crisis is described in the literature on transpersonal consciousness. Science has influenced us to view reality as
psychology as ‘a turbulent period of spiritual opening and primarily related to matter, or what can be seen and
transformation,’ where ‘a process of spiritual emergence or measured, although there is a great hunger for contact with
awakening becomes unmanageable for the individual’ the spiritual side of life. According to Nagler (2004, p. 3), a

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JAN: THEORETICAL PAPER Concept analysis of spiritual crisis

spiritual crisis occurs when either an individual or a culture is


Antecedents and consequences of spiritual crisis
trapped in an ‘outmoded or suffocating network of values
and conceptions’ in which the old paradigm or worldview is While antecedents are phenomena that must occur prior to
no longer workable, and a new paradigm has not yet been the occurrence of a concept, consequences are the resulting
born. A shift in worldview must occur in order for the crisis outcomes (Walker & Avant 2005). Possible antecedents to
to pass. spiritual crisis are sudden acute illness, loss of important
relationships, and other similar phenomena. According to
Villagomeza (2005), potential consequences of a spiritual
Attributes of spiritual crisis
crisis can be negative or positive, depending on personal
Several themes were identified in the literature concerning characteristics, spiritual coping mechanisms, and what
the attributes of spiritual crisis. The first is that a spiritual support is given. An example of an extreme negative
crisis involves profound questioning about the meaning of consequence could be suicide. Conversely, the crisis may
one’s life. Conversely, individuals who have developed an result in self-reorganization which, according to Mishel and
understanding of the meaning of their lives, recognizing the Clayton (2003), occurs when an individual evaluates
unpredictability and uncertainty, are able to see through uncertainty within their own life, and comes to an
their own false beliefs and transcend themselves to perceive understanding that uncertainty is accepted and part of
reality as it is (McKee & Barber 1999). Life crises tend to the ‘natural rhythm’ of life. A summary of antecedents,
stimulate questions about the meaning of existence (Balk attributes and consequences of spiritual crisis is given in
1999). The questioning of the meaning of life has been Table 1.
identified as important in understanding essential spiritual
needs (Frankl 1969, McEwen 2005, Villagomeza 2005,
Empirical referents
Wilding et al. 2005). Balk (1999) describes how an
individual can also face a crisis when they discover that Empirical referents are qualities or categories of measurable
they have been fundamentally mistaken about some aspect phenomena that demonstrate the presence of the concept
of their life. (Walker & Avant 2005). Villagomeza (2005) describes 50
The second attribute which defines the crisis is grief or a separate empirical referents in the conceptual analysis men-
deep feeling of loss, often as a result of disruption in tioned earlier. Examples of referents listed by Villagomeza
a person’s attachment or connection to themselves, others or are: ‘expresses being separated from usual support system;
a higher power (God). The attachment could also be to a feels separated from personal source of comfort and strength;
fundamental belief that has helped to frame the worldview of verbalizes loss of faith; verbalizes that God is unforgiving;
an individual. According to Parse (1981), p. 20, without questions meaning of own existence; expresses concern with
other people ‘one would not know that one is, or who one is’. meaning of life and death and/or belief systems; verbalizes
Macmurray (1961) echoes this, noting that identity and profound disharmony’ (p.290).
personhood are found by engaging with and encountering
others.
Model case
The third defining attribute of spiritual crisis is that it
presents as a critical moment, turning point or juncture in Debbie was a 33-year old married woman whose husband
which a person is changed by the crisis. Balk (1999, p. 485) had a history of alcohol use. This was a second marriage for
writes that, in order for spiritual change to occur, an both of them. Rick had two children from his previous
individual’s life ‘must forever afterwards be coloured by the marriage, and Debbie had a son who was 12 years old.
crisis’. Debbie was not happily married but remained married
because she was afraid of venturing out on her own. Also,
she had been brought up in a strict church that discouraged
Definition of spiritual crisis
divorce. She was employed as a nurse’s aide, while Rick was
Based on this concept analysis, the following definition of an office manager with a good income.
spiritual crisis is offered: ‘A unique form of grieving or sense Debbie’s son, Justin, was involved in a serious car accident
of loss, marked by a profound questioning of or lack of while riding with Rick to a baseball game and was fatally
meaning in life, in which an individual reaches a turning injured. Debbie was devastated.
point or juncture, leading to a significant alteration in the After the funeral, she became very depressed and
way oneself and life is viewed.’ questioned whether or not she wanted to live, and whether

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L.B. Agrimson and L.B. Taft

Table 1 Antecedents, consequences, and defining attributes of spiritual crisis

Antecedents Defining attributes Consequences

Acute situations that threaten a Grief or a deep feeling of loss Negative:


person’s sense of identity or lead to Profound questioning of the May involve physical symptoms –
an impairment in any one of the meaning of one’s life loss of energy, anxiety, depression,
following areas: A turning point, juncture or chest or abdominal pain, sensitivity to
• sense of trust in God or the world decisive moment in which noise or light, anorexia
• sense of purpose or meaning one’s life will be altered afterwards Loss of control over one’s direction
• sense of inner peace Social withdrawal
• sense of reality Frequent bouts of crying
• feelings of connectedness Decreased attention span
• sense of values Loss of control over emotions or thoughts
• ability to transcend oneself Suicidal ideation
May involve loss of an important person, Feelings of abandonment
belief system or relationship, including with Existential loneliness
oneself, others or one’s higher power Consequences are dependent on the
May involve a sudden, acute or terminal illness individual and multiple factors
Positive:
A sense of renewal or spiritual awakening
Spiritual resilience
Renewal of hope
Self-reorganization
Post-traumatic growth

she could function in her marriage. The prospect of filing


Contrary case
for divorce was difficult to imagine, not having an
adequate income to support herself. She was very anxious Bill was a 57-year old man admitted to hospital with chest
and so went to her physician and obtained a prescription pain and coronary artery disease. Diagnostic tests including
for lorazepam and sleeping pills. Two months after her an angiogram showed a partially-occluded left main coronary
son’s funeral, Debbie’s body was found by her husband at artery and one other affected vessel. Open heart surgery was
home, after an apparent overdose. In this case, she had performed and Bill was extubated within 6 hours of his
experienced the three attributes of a spiritual crisis: a major return from surgery. He maintained good spirits during his
loss; questioning the meaning of her life and a turning immediate recovery and was transferred from intensive care
point that changed her. the following day. He progressed as hoped with cardiac
rehabilitation, and was discharged to home to the care of his
wife on his fourth postoperative day. It did not appear that
Borderline case
Bill exhibited any attributes of spiritual crisis.
Janet was an 80-year old retired teacher with a history of
depression and recent diagnosis of brain cancer. She was
Discussion
raised as a Catholic and believed in the holy sacraments
and that prayer could heal her. She sincerely believed that From a relational and pragmatic approach, no single theory
if she only prayed hard enough she would overcome her can hold the absolute truth (Wright & Leahey 2005)
illness. Yet, in spite of prayer, her illness did not abate, because all knowledge is limited, complex and potentially
and she only got worse. She cried a lot during that period. fallible. Therefore, all theories must be constantly scruti-
Finally, she realized that even though she was not going to nized for possibly limiting one’s view of knowing. Also,
be cured, she was still going to be ‘with God’ and she although concept analysis is a formal exercise, a limitation
accepted that. She died a few days later after receiving last is that the product must always be considered tentative.
rites. In this case, Janet exhibited some of the character- Two individuals analyzing the same concept may reach
istics of spiritual crisis (grieving the loss of her health and different conclusions, and this is to be expected because of
her connection with God in terms of answered prayer), but changes in the meanings of words over time (Walker &
not all of them. Avant 2005). The topic of spiritual crisis, being positioned

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JAN: THEORETICAL PAPER Concept analysis of spiritual crisis

addressed, although the difference between these is important


What is already known about this topic in nursing practice.
• Assessment of spiritual wellness and needs have been
insufficiently taught to nurses.
Implications for nursing
• Spirituality has many meanings for individuals, which
creates ambiguity and causes reluctance to explore the While there has traditionally been a lack of research in this
topic. area of nursing, recent scientific evidence supports the
• A greater awareness of spiritual topics and how to benefits of spirituality for health (Villagomeza 2005). Spir-
employ spiritual care is crucial to improved patient ituality is part of what makes us human, or as Fabry (1991)
care. asserted, we have a body and a psyche, but we are our spirit.
Simmington (2004) further notes that, in a healthcare
context, clients are viewed as physical beings who happen
What this paper adds to have a soul, rather than as spiritual beings who also have a
• Spiritual crises can be experienced either at an indi- physical nature.
vidual level or by a larger community of people who In nursing studies, the loneliness of dying people is
undergo a paradigm shift in their worldview. described as a type of spiritual distress (Carroll 2001).
• Nurses can improve their ability to assess and inter- Moreover, compassion fatigue (burnout experienced by
vene with clients’ spiritual needs through a more open nurses torn between the use of technology and the desire to
definition of spirituality and by exploring their own remain compassionate) has also been identified as a type of
spiritual needs. crisis of meaning and termed spiritual crisis (Kelly 2004). If
• Spiritual crisis can be described as a unique form of we examine the concept of spiritual crisis from the perspec-
grieving or sense of loss, marked by a profound ques- tive of a response grounded in loss and grieving, it may be
tioning of or lack of meaning in life, in which a person more apparent that the topic is relevant to nursing than if we
reaches a turning point, leading to a significant alter- merely think of it in terms of religion or belief systems.
ation in the way oneself and life is viewed. There is some criticism in the literature of the attempt in
nursing to try to address spirituality without proper under-
standing of the implications. Many would argue that, as
Implications for practice and/or policy nurses tend to lack education and understanding in how to
• Nurses need to consider every individual or commu- talk to patients about their spirituality, they ought to leave
nity experiencing a significant loss as being at risk for this to religious professionals. However, Swinton (2006)
spiritual crisis. stated that nurses need to listen to the critics of spiritual care
• An individual’s spirituality should not be defined by in nursing and realize that we must enter into dialogue with
their culture or religious affiliation. other disciplines if we are to make progress in this area. It is
• A more open approach to assessing clients’ spiritual vital that nurses share information with social workers,
needs should be encouraged. religious professionals and other healthcare professionals
when they become aware that individuals are suffering
spiritually. The questions that nurses ask patients in assess-
ing their spirituality must also be expanded beyond the
within the spiritual dimension, is difficult to quantify. A typical questions about religious affiliation. Wright (2005)
diagnosis of spiritual crisis is complex and challenging, and suggests that the best way to understand suffering is to
may be problematic to discern in another individual. An examine dialogue between those who suffer and their
example of an unnoticed spiritual struggle was brought to nurses. Those who might especially benefit from an
the world’s attention after the death of Mother Teresa. Her expanded view of spirituality and ability to relate to patients
published diary revealed serious personal doubts about include those who are depressed or suicidal, those with a
whether she believed God existed, and suggested she terminal illness, and anyone grieving the death of a loved
suffered with spiritual pain for over 50 years (Johnston one or other losses.
2002). The suggestion that nurses ought to explore their own
A large body of literature on philosophy and/or religion spirituality has also been made by many authors, according
was excluded from this concept analysis, and the distinction to Carroll (2001). Being in touch with one’s own spiritual
between spirituality and religion was not specifically dimensions may be the first step in being able to recognize

 2008 The Authors. Journal compilation  2008 Blackwell Publishing Ltd 459
L.B. Agrimson and L.B. Taft

and support the spiritual nature of others. Villagomeza Cortright B. (2000) An integral approach to spiritual emergency.
(2005) proposes that assessment of spirituality could be Guidance & Counseling 15(3), 81–98.
Fabry J.B. (1991) Guideposts to Meaning: Discovering What Really
accomplished not only by direct questioning of patients, but
Matters. New Harbinger, Oakland, CA.
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Frankl V.E. (1969) The Will to Meaning. New American Library,
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Conclusion Frankl V.E. (1984) Man’s Search for Meaning: An Introduction to
Logotherapy. Beacon, Boston, MA.
Both Wright’s Trinity Model and Frankl’s Theory of Meaning Galek K., Flannell K.J., Vane A. & Galek R.M. (2005) Assessing
could add to the knowledge development of the spiritual a patient’s spiritual needs. Holistic Nursing Practice 19(2), 62–69.
dimension of individuals and communities, through the Grof C. Addiction, Attachment, and Spiritual Crisis Part II: Spiritual
concept of spiritual crisis. Framing spiritual crisis as a process Crisis With Christina Grof. [Interview.] Retrieved from http://
www.intuition.org/txt/cgrof2.html on 3 July 2007.
within the realm of suffering or coping may also illuminate
Hermann C.P. (2007) The degree to which spiritual needs of patients
further discussion and research. There has been a lack of near the end of life are met. Oncology Nursing Forum 34(1),
qualitative research in the matter of spiritual distress, but this 70–78.
would be a desirable area for additional exploration. Johnson M., Bulechek G., McCloskey Dochterman J., Maas M. &
Being spiritual is part of what makes us human, and it Moorhead S. (2001) Nursing Diagnoses, Outcomes and Inter-
should not be defined by boundaries of religion or cultural ventions: NANDA, NOC, and NIC linkages. Mosby, St Louis,
MO.
background; a more open approach is needed in order to
Johnston B. (2002). Mother Teresa’s Diary Reveals Her Crisis
apply this concept more universally. of Faith. [Electronic Article.] Retrieved from http://www.
religionnewsblog.com/1315/mother-teresas-diary-reveals-her-crisis-
of-faith on 8 September 2008.
Acknowledgement Kelly J. (2004) Spirituality as a coping mechanism. Dimensions of
Critical Care Nursing 23(4), 162–168.
We would like to thank J. Michael Orange for editorial
Lukoff D., Lu F. & Turner R. (1998) From spiritual emergency to
comments and suggestions. spiritual problem. Journal of Humanistic Psychology 38, 157–186.
Macmurray J. (1961) Persons in Relation. Faber and Faber, London.
Maxwell T.P. (2003) Considering spirituality: integral spirituality,
Funding deep science, and ecological awareness. Zygon 38(2), 257–276.
This research received no specific grant from any funding McEwen M. (2005) Spiritual nursing care: state of the art. Holistic
Nursing Practice 19(4), 161–168.
agency in the public, commercial, or not for-profit sectors.
McKee P. & Barber C. (1999) On defining wisdom. International
Journal of Aging and Human Development 49, 149–164.
McSherry W. & Smith J. (2007) How do children express their
Author contributions
spiritual needs? Paediatric Nursing 19(3), 17–20.
LBA conducted the concept analysis and drafted the manu- Merriam-Webster, Inc (2004) Merriam-Webster Dictionary, 6th edn.
Merriam-Webster, Inc, Springfield, IL.
script with direction and supervision by LBT. LBA and LBT
Mishel M.H. & Clayton M.F. (2003) Theories of uncertainty in illness.
made critical revisions to the paper. In Middle Range Theory for Nursing (Smith M.J. & Liehr P.R., eds),
Springer Publishing Company, New York, NY, pp. 25–48.
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The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientific journal. JAN contributes to the
advancement of evidence-based nursing, midwifery and health care by disseminating high quality research and
scholarship of contemporary relevance and with potential to advance knowledge for practice, education, management
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