hr. J. Nurs. Srud., Vol. 32, No. 5, pp. 457 468, 1995
Copyright Q 1995 Elsevier Science Ltd
Prmted m Great Britain. All rights reserved
The spiritual dimension: its
importance to patients’ health,
well-being and quality of life and its
implications for nursing practice
L. ROSS (n&e WAUGH), B.A., R.G.N., Ph.D.
Research Fellobv, Department cf Management and Social Sciences, Queen Margaret College, Cierwood Terrace,
Edinburgh EHl2 8TS, U.K.
Abstract-The spiritual dimension is described and is interpreted as the need
for: meaning, purpose and fulfilment in life; hope/will to live; belief and faith.
As the spiritual dimension is important for the attainment of an overall sense
of health, well-being and quality of life (referred to as the health potential) and
as illness and hospitalisation can precipitate spiritual distress, patients’ spiritual
needs should be addressed. The nurse’s role in spiritual care is discussed with
reference to the nursing literature.
The author’s interest in the subject of spiritual care was stimulated following an encounter
with a terminally ill patient. Having been asked if she would like a passage read to her from
the Bible lying on her locker, the change in this woman’s expression was remarkable.
Instead of lying sleeping, or staring blankly into space, her eyes widened, she strained to
raise her head, smiled and attempted to speak for the first time in several months. Later,
just before she died, she expressed how much this, together with prayer, had meant to her.
She had a spiritual need which she wanted to be met. This profound and moving experience
suggested to the author that the spiritual dimension could have a considerable influence on
a patient’s quality of life. It was with the desire to discover more about the relationship
458 L. ROSS
between the spiritual dimension and the individual’s health potential that the literature was
reviewed and a doctoral study conducted.
Description and definition of the spiritual dimension
The need for spiritual integrity is a basic human need (O’Brien, 1982). Chambers dic-
tionary defines the “spirit” as: the vital principle; the soul; a breath of wind; essence; chief
quality; that which gives real meaning (MacDonald, 1972). In the nursing literature, the
spiritual dimension is described in a multiplicity of ways:
it strives for meaning and purpose in existence (Dickinson, 1975; Henderson, 1973;
Piepgras, 1973; Travelbee, 1971);
it strives for transcendence beyond the here and now in search of some higher power or
God (however defined by the individual)/something greater than self (Fish and Shelly,
1978; Henderson and Nite, 1978; Martin and Carlson, 1988; O’Brien, 1982; Stallwood-
it inspires, motivates and hopes, directing the individual toward the values of love, truth,
beauty, trust and creativity (Dickinson, 1975; O’Brien, 1982; Stall, 1979; Travelbee,
From the above definitions, the spiritual dimension would appear to be a complex phenom-
enon. It has been regarded as the central “artery” which permeates, energises and enlivens
all other dimensions of an individual and around which all values, thoughts, decisions,
behaviours, experiences and ultimate concerns are centred (Brewer, 1979). As such it has
been described as the mainstream of life (Dickinson, 1975; Stoll, 1979; Yura and Walsh,
1982) and it has been suggested that without spiritual well-being the other dimensions, i.e.
the biopsychosocial, can never function or be developed to their fullest capacity and hence
the highest quality of life is unattainable.
From the descriptions and definitions given it would appear that the spiritual dimension
is a dual concept consisting of both vertical and horizontal elements. The vertical element
could be considered to encompass the transcendental, i.e. the individual’s relationship with
a power beyond self (referred to hereafter as “God”) or the individual’s value system. The
horizontal element could be thought of as an outworking of the vertical in the individual’s
lifestyle and relationships with self, others and environment.
The definition which probably best captures and summarises the spiritual dimension is
that of Renetzky (1979) who defines it in terms of its three component parts namely:
(1) the “power within man” giving “meaning, purpose and fulfillment” to life, suffering
(2) the individual’s “will to live”;
(3) the individual’s belief and faith in self, others and God.
Evidence for the influence of the spiritual dimension on the health potential
Support for the influence of the spiritual dimension on the individual’s health potential
is presented by considering each component of the spiritual dimension in turn, as defined
THE SPIRITUAL DIMENSION 459
Meaning and purpose
According to Yura and Walsh (1982, p. 90):
“the greatest task of human kind is to determine the meaning of life”
Other authors (Autton, 1980; Colliton, 1981; Frankl, 1959) regard search for meaning
as a universal trait which is essential to life itself. Jung and Peck (McClymont et al., 1986)
postulate, respectively, that meaning is necessary for the maintenance of ego integrity and
for the prevention of restlessness and deterioration in old age. According to Burnard (1989)
and Frank1 (1959), spiritual distress results when there is an inability to invest life with
meaning and is characterised by feelings of emptiness and despair. Research studies also
highlight the importance of meaning in life for health and well-being.
Simsen (1985) found that medical and surgical patients demonstrated a need to find
meaning in their illness and hospitalisation. Kobasa (Martin and Carlson, 1988) reported
fewer negative stress symptoms in individuals who were committed to and found meaning
in their work, and Antonovsky (1979) and Frank1 (1959) reported survival, minimal
psychological damage and even strengthening of character in holocaust victims who had
managed to maintain a sense of meaning and purpose in their lives throughout their
ordeal. Furthermore, out of 1000 cases in his clinical experience (he does not detail the
selection of the sample), Renetzky (1979) found that as the degree of meaning, purpose
and fulfilment increased, so did the role of religion and the degree of healthy self love. A
decrease in the “void” (sense of emptiness) equated with an increase in spiritual well-being.
Will to lire
The will to live and hope are closely linked. Hope has been regarded as a major motivator
of behaviour, acting as a powerful life force, producing vitality and liveliness in life (Dubree
and Vogelpohl, 1980). There is considerable documented evidence that without hope, death
can result. For example, both animal and human studies show that prolonged and repeated
exposure to events which are not life threatening but are unavoidable, and over which the
individual has no control, produces helplessness/hopelessness. The end product of this is
frequently death. Such instances include voodoo death and concentration camp experiences
(Frankl, 1959; Seligman, 1974). It is because of its often drastic effects that helplessness/
hopelessness has been appropriately termed as “passive suicide” (Limandri and Boyle,
1978, p. 79).
The importance of hope to life can be seen, not only in death caused by its absence, but
also in healing produced by its presence. Evidence for the positive effects of hope has been
observed by clinicians. Both Renetzky (1979) and Swaim (1962) reported that the greater
the will to live, the greater the chance their clients had of overcoming illness.
A different type of evidence which reports non-verifiable events illustrates the positive
effects of hope. For example, Gardner (1983) and Tari (1978) document numerous instances
of miraculous events such as healing of the deaf and blind and raising of the dead, where
hope and also faith in God were central.
Beliqfund,faith in sev, others and God
Renetzky (1979) reported his observation over 30 years working as a sociologist that the
will to live and the degree of meaning, purpose and fulfilment were increased significantly
when belief in God existed. Renetzky (1979) concluded that the factor above all else which
460 L. ROSS
appeared to influence the individual’s spiritual well-being, and hence their state of health
and quality of life, was belief in God.
Other studies have indicated the influence of belief and faith on health. O’Brien (1982)
noted that patients who possessed a positive religious perspective on life adapted more
readily to the stress of haemodialysis. Martin and Carlson (1988) reported the findings of
two studies which indicated the therapeutic effect of faith in reducing pulmonary oedema,
need for antibiotic therapy and intubation. However, Martin and Carlson (1988) questioned
these findings given the biased samples used and absence of tests to determine statistical
significance. Although further research would be helpful to test these observations, it would
appear that the optimum health potential can be attained when meaning, purpose and
fulfilment in life, a will to live and belief and faith in self, others and God exist.
Illness and hospitalisation as spiritual encounters
Healthy people can initiate action to meet their own spiritual needs. Illness and/or
hospitalisation may, however, prevent individuals from having their spiritual needs met or
fully met and may, therefore, prevent them from obtaining their optimum health potential
(Fig. 1). It may be that the experience of illness/hospitalisation causes some people to face
loss of control for the first time in their life. As Granstrom (1985, p. 42) stated:
1. When a healthy individual feels in
control of his/her life, h&he may
not be forced to seek meaning
beyond self, therefore, in the event
forced to real& that he/she is not
in total control of his/her life
motivated to seek a centre of
control outside self (i.e. God).
Less likelihood of spiritual
needs being fulfilled.
An individual who has a centre of
control outside self (i.e. God) may
be caused to question his/her
nlationship with God because of
the experience of physical illness.
4. Hospitalisation and the experience
of physical illness will mean that
the= are likely to be fewer
resources available to the
individual from which hir
spiritual needs can be satisfied,
e.g. s/he will be physically unable
to attend church etc.
May feel isolated from normal
support system and therefore
likelihood of spiritual need
being fulfiied. I
I Spiritual need -
Increased chance of expetiencing spiritual distress
Adverse effects on overall state of health
(Fish and Shelly. 1978. McGilloway & Donaolly. 1977)
Fig. 1. Ways in which illness and/or hospitalisation can precipitate spiritual distress.
THE SPIRITUAL DIMENSION 461
“Many individuals do not seriously search for the meaning and purpose of life but live as if life will
go on for ever...Often it is not until the crisis, illness...or suffering occurs that the illusion (of security)
is shattered...Therefore, illness, suffering... and ultimately death, by their very nature become
spiritual encounters as well as physical and emotional experiences.”
For many patients, therefore, spiritual care will be a necessary part of their total care.
This raises the question of the nurse’s role in spiritual care.
The nurse’s role in spiritual care
Florence Nightingale, a pioneer in the emergence of nursing, considered that:
“the sick body is something more than a reservoir for storing medicines.” (Kramer, 1957, p.36)
In addition to caring for patients’ physical needs she described nursing as a “fine art”
“the living body--the temple of God’s spirit”. (Colliton, 1981, p. 492)
Nursing has its origins in religious orders where the body and spirit were cared for
together. About a century ago, however, the importance attributed to the spiritual dimen-
sion was to change, the philosophy of care moving away from a holistic to a dualistic
approach. Care of the individual’s spirit and body gradually separated, the latter increasing
in importance while the former declined (Penrose and Barret, 1982).
Despite evidence of attempts to rediscover holism, e.g. complementary therapies, nursing
remains dominated by the medical model which concentrates on the disease process with
medical and surgical treatments. In a climate where the medical model is prevalent, two
(1) Are patients’ spiritual needs given due attention?
(2) Should spiritual care be part of the nurse’s role?
In an attempt to answer question (I), some of the literature on spiritual care is explored.
Question (2) can only be answered by recourse to definitions of nursing, codes of conduct,
models of nursing and guidelines for nurse education.
Are patients’ spiritual needs given due attention?
Nursing texts devoted to or incorporating spiritual care of the patient tend to agree that
nurses should be giving spiritual care; however, in many of the texts, operational definitions
of “spiritual” and “spiritual need” are lacking as are guidelines for the practice of spiritual
care (Beland and Passos, 1975; Carson, 1989; Fish and Shelly, 1978; Henderson and Nite,
1978; McGilloway and Myco, 1985; Murray and Zentner, 1975; Narayanasamy, 1991;
Shelly and John, 1983).
Nursing research on spiritual care is very much in its infancy. The ability to generalise
findings to Britain is limited by the fact that the majority of studies are American in origin.
Only two British studies were identified (Chomicz, 1984; Simsen, 1985). In addition to the
fact that many of these studies are now rather outdated, most researchers used small
samples of convenience and tools which had not been tested for reliability or validity.
Moreover, comparison between studies is made difficult by the fact that operational defi-
nitions of terms are frequently lacking or are not cited in summarised versions of the
original studies. There is no guarantee, therefore, that the terminology used is consistent
462 L. ROSS
Bearing these limitations in mind, an overview is presented below of this small, but
growing, body of research by looking first at studies which address the patient’s perspective
of spiritual need and spiritual care, followed by those concerning nurses’ opinions and
Research relating to the patient’s perspective on spiritual need and spiritual care
Five studies were identified which looked at the patient’s perspective on spiritual need
and spiritual care (Chomicz, 1984; Kealey, 1974; Martin et al., 1976; Simsen, 1985;
Stallwood-Hess, 1969). With the exception of one study (Kealey, 1974), it was found that
for many patients illness and hospitalisation can become spiritual encounters. During
these experiences a considerable proportion of patients reported spiritual needs such as for:
meaning; belief in God, often expressed through formal religious practices; relief from fear,
doubt, loneliness; relatedness to others/God (Chomicz, 1984; Martin et al., 1976; Stallwood-
Hess, 1969), and furthermore considered these needs of importance to them (Simsen, 1985).
Some patients would have liked nurses to help them with their spiritual needs by listening,
“being there” and referring to the clergy where appropriate (Chomicz, 1984; Kealey, 1974;
Martin et al., 1976; Stallwood-Hess, 1969). However, many felt that the nurse was too busy
to help in these ways.
Although patients tended to express satisfaction with the assistance they had received,
Stallwood-Hess (1969) found that the majority felt their needs had not been met to the full.
Furthermore, chaplains reported that, despite being given excellent physical care, patients
were often struggling to grasp the meaning of their suffering (Bowlby, 1980; Patey, 1977).
Given that hospitalised patients considered their spiritual needs of importance it would
seem appropriate that nurses should endeavour to help patients meet these needs. How
nurses perceive their role in spiritual care is addressed by looking at the appropriate
Research relating to the nurses’s perspectizje on spiritual need and spiritual care
Six American studies, dating from as early as 1957, sought to obtain nurses’ opinions of
spiritual care and their role in this. As no British studies were identified which sought to
ascertain British nurses’ perceptions and giving of spiritual care, this formed the basis of
the author’s doctoral study (Ross, 1994a; Ross, 1994b; Waugh, 1992) the results of which
are briefly reported.
In general, the studies reviewed indicate that nurses within the samples were aware
patients had spiritual needs, the majority regarding it their duty to make provision for at
least some of these needs. According to Waugh (1992) and Piles (1986) 94.4% and 87.6%
of nurses, respectively, disagreed that spiritual care was the remit of the clergy only. Despite
this, however, it would appear that nurses had a limited ability to attend to the spiritual
needs of patients.
Chance (1967) found that the majority of student nurses identified spiritual needs,
although these results may be somewhat biased given that the nurses were enrolled at a
Seventh Day Adventist College. Although the majority of nurses (76.8%) in Waugh’s (1992)
study said they had identified patients’ spiritual needs, they were only asked if they had
done so at some point in their practice, therefore, there is no indication of the frequency
with which they identified these needs. In addition, the basis on which over half the nurses
THE SPIRITUAL DIMENSION 463
in Chadwick’s (1973) study concluded that patients’ spiritual needs had been adequately
met was unclear.
It is the general consensus of other studies, however, that despite the fact that nurses
usually displayed some knowledge of and ability to identify the more obvious, direct
religious needs e.g. for communion (Chadwick, 1973) they were less aware of spiritual
needs than those pertaining to the psychosocial dimension (Highfield and Cason, 1983).
Moreover. they demonstrated limited knowledge of spiritual needs and limited ability to
help patients meet these needs (Highfield and Cason, 1983; Kramer, 1957; Waugh, 1992).
Kramer (1957) Kealey (1974) and Piles (1986) found that whilst 93.6, 91 and 87.6%,
respectively, of nurses agreed that spiritual care was a nursing responsibility, only 56.4, 50
and 34.1%, respectively, felt able to provide for this adequately. Waugh (1992) and Chad-
wick (1973) similarly found that, despite the fact that 93.7 and 75% of nurses, respectively,
felt spiritual care was part of their role, only 47.8 and 50%, respectively, said that they
personally responded to patients’ spiritual needs. In Kealey’s study, patients with spiritual
needs received no help from nurses.
The inadequacy felt by nurses in providing spiritual care was further borne out by the
fact that, with the exception of Highfield and Cason’s (1983) study, many expressed the
need for further education in the meeting of such needs (Chadwick, 1973; Piles, 1986).
It would appear from the research reviewed that practising nurses expressed the desire
to be involved in giving spiritual care but felt inadequate in providing this. Patients’ spiritual
needs may, therefore, not be as fully met as they could be, the implications of which could
be serious as shown in Fig. 2.
Research relating to nurse education and spiritual cure
From the guidelines for nurse education, it appears that the teaching of spiritual care is
a necessary pre-requisite to its practice by nurses. No research, however. could be identified
which tested this assumption.
Few research studies, and certainly no British ones, were identified which looked at
whether or not spiritual care was taught to nurses. From responses received from persons
in charge of basic nurse education establishments in Scotland, it appeared that spiritual
care does not form substantial identifiable component in any education programme, e.g. it
may take the form of a one hour session from the hospital chaplain and be touched upon
in religious practices in care of the dying (Waugh, 1992).
In the U.S.A., however, moves have been made in the area of curriculum development.
As early as 1957, Lewis (Lewis, 1957) set about developing a resource unit for the inclusion
of spiritual care in the basic nursing curriculum at the University of Washington School of
Nursing. Hitchens (1988) found that students tended to project themes from their own
faith, values and life experiences into patient care situations. Life experience/crisis was a
major factor in determining the level of the student’s faith development which in turn
appeared to influence the way in which students planned spiritual care. These personal
attributes of the nurse were similarly noted by Waugh (1992) as factors apparently influ-
encing whether or not and how nurses in her sample gave spiritual care.
Although moves have been made in the U.S.A. to incorporate the teaching of spiritual
care into basic nurse education programmes, this seems not to have happened in Scotland.
Further British research is, however, required to clarify the current position.
Tmted with 8V8ihbk
knowledge within the
M8y bC tatally May be in8duluate
inappropriatein in sufficiently meeting
(IQtdWd md Cnoa 1983)
May 8ffcct the
ability to cope
Generally heighted stress level.
H8rmtill effects on functioning of foUowing aspects.
& of which arc inter-r&ted:-
hi al Fhysiokagic8l
tBlyIk 1975; cox. 1978)
I- + _I
Failure of nursing to
prevent uness, promote
he&b and wclMcing
According to Madow (1970. p. 407)
Btxaune gmwth needs ere less obvious
than deficit d, e.g. for food,
the consquences of not satisfying
them may be less obvious.
Failure to satisfy needs.
“M~logy” which blow
(1970. p. 407) &kc5 88:
“illnes.s rcalthlg from frueation
or depliv8tion of higher necd.T.
This may display itself in
e.g. lack of meaning,
alienation, lack of direction
The final sod ultimate consequence of
such need deprivation
1 actualisation” hasbeendisruptcd 1
3. Spiritual need identified. E
Approprkte action taken
Spiritual need met
4 I t
of spiritual facilitated
:iti Rernr of +ss effej Iyc2,0ticd
of barrier ta recovery
Fig. 2. The implications of meeting and failing to meet patients’ spiritual needs
THE SPIRITUAL DIMENSION 465
Should spiritual care be part of the nurse’s role?
nursing. Definitions of nursing state that it is the responsibility of the nurse
“..promote health, to prevent illness, to restore health and to alleviate suffering” (ICN, 1973).
“..assist the individual, sick or well, in the performance of those activities contributing to health or
its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength,
will or knowledge” (Henderson, 1977, p. 4).
Central to these definitions is the nurse’s role in assisting patients to achieve their
maximum health potential (Rogers, 1970). If, as discussed above, the level of health achieved
by an individual will depend in part on the extent to which their spiritual needs are met,
then in order for nurses to fulfill their function of promoting health, spiritual care is clearly
part of their role.
Codes of conduct. Both British and international codes of conduct support spiritual care
as a nursing responsibility.
The United Kingdom Central Council for Nursing, Midwifery and Health Visiting
(UKCC) states that it is the duty of the nurse to:
“Take account of the customs, values and spiritual beliefs of patients/clients” (UKCC, 1984a, p. 2).
Furthermore, it considers this to be:
“...a statement to the profession of the primacy of the interests of the patient or client” (UKCC,
1984b. p. 4).
The International Council of Nurses (ICN) (1973) considers its Code for Nurses to be:
“a guide for action based on values and needs of society...” and states that “The nurse, in providing
care, promotes an environment in which the values, customs and spiritual beliefs of the individual
Thus the spiritual beliefs of the individual are recognised and valued by the UKCC and
the ICN, so much so that this is reflected in their guidelines for nursing practice. However,
it is unclear what is actually meant by “taking account off’ and “respecting” patients’
“spiritual beliefs” or “promoting an environment” in which this can be achieved. It is not
clear if the nurse is expected to be actively or passively involved in helping patients meet
their spiritual needs. Also the definition of “spiritual beliefs” is open to interpretation; it
could be viewed in terms of religious needs only or in a broader context. The fact that the
ICN (1977, p. 14) considers the nurse:
“...best able to assess the operating... beliefs and incorporate her knowledge of them in directing
the nursing care...”
which suggests an active rather than a passive role for the nurse in respecting patients’
Although some issues require clarification, codes of conduct acknowledge spiritual care
as a necessary and valued part of the nurse’s role.
Models of nursing. Models of nursing include consideration of the spiritual dimension
either in religious terms (Henderson, 1977) or by concentrating on the needs for: meaning
(Fitzpatrick, 1989; Watson, 1989); transcendence (Fitzpatrick, 1989); wholeness, of which
the spiritual is part (Cerilli and Burd, 1989; Raleigh, 1989). Most authors contend that if
466 L. ROSS
spiritual needs are essential to the healthy individual’s sense of well-being, they will be all
the more necessary during illness.
Guidelines,for nurse education
Both British and international guidelines for nurse education indicate that spiritual care
should be taught to nurses.
In preparation for Project 2000 it was recommended that nurse education should:
“provide opportunities to enable the student to... acquire the competencies required to: xiv)
identify... spiritual needs of the patient or client. devise a plan of care, contribute to its implemen-
tation and evaluation by demonstrating an appreciation and practice of principles of a problem
solving approach.” (UKCC. 1986, pp. 40-41).
This is further reflected in the National Board for Scotland’s (NBS) consideration of the
reforms for basic nurse education. Amongst its aims and objectives is that the nurse will be
“assess, plan, implement and evaluate care to meet the...spiritual...needs of the individual and
family/friends.” (NBS., 1990, p. 16)
In short, in the U.K., nursing students are to be taught how to give spiritual care using
the nursing process.
On the international scene the ICN (1973) which, as stated above, includes spiritual care
in its Code for Nurses, considers that:
“ln order to achieve its purpose the Code must be... put before and be continuously available to
students... throughout their study and work lives.”
Furthermore, the American Association of Colleges of Nursing (AACN) (1986) (p. 5)
recommends that the education of professional nurses should ensure their ability to:
“Comprehend the meaning of human spirituality in order to recognise the relationship of beliefs to
culture, behaviour, health and healing”
and to plan and implement this care.
Having looked at definitions of nursing, codes of conduct, models of nursing and guide-
lines for nurse education, it would seem that spiritual care is a nursing responsibility and
not an optional extra.
Spiritual well-being is important for the individual’s health potential and the experience
of illness/hospitalisation can threaten optimum achievement of this potential. There are
many indications that spiritual care is considered to be a nursing responsibility but there is
a lack of clarity. There is no agreed definition of what is meant by “spiritual.“, “spiritual
need” and “spiritual care” and there are few guidelines for nursing practice. There is a
distinct lack of research, particularly of British origin, on spiritual care. Bearing in mind
the limitations of available studies, it would appear that patients experience spiritual needs
but often these needs are not fully met, the implications of which could be serious. Patients
consider that the nurse could have a significant role in giving spiritual care and nurses
appear to be willing to do so but feel inadequate in this regard. It would seem that, despite
the fact that guidelines for nurse education advocate the teaching of spiritual care, this does
not happen to any great extent.
Although moves have been made to contribute to the knowledge base for spiritual care,
THE SPIRITUAL DIMENSION 461
this is very much in its infancy and nurses currently lack guidelines for practice. Clearly
there is need for further research to ascertain how patients feel they can best be helped to
meet their spiritual needs, to clarify the nurse’s role in spiritual care and to identify ways
in which spiritual care can best be taught.
ilc,kno~~k~dyrmenfs~The author wishes to acknowledge her director of studies, Dr L. Hockey, and her supervisors,
Miss E. Dove and Rev. Dr D. Lyall, for their advice and support throughout the study, and Queen Margaret
College for providing the research studentship. Special thanks also to Dr L. Hockey and Dr B. Alder for their
helpful comments on the manuscript.
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(Received 28 February 1994; accepted in revisedform 9 January 1995)