Keywords

1.1 Introduction

Since the mid-1990s, there has been an increase in the amount of literature published on the topic of spirituality across several disciplines including healthcare [1,2,3,4], psychology [5, 6], social work [7,8,9,10], counselling [11, 12] and organisational and employment literature [13,14,15,16,17]. Spirituality can affect all aspects of a person’s life highlighting the importance of the topic. It is particularly prominent during stressful life events, such as illness, suffering and bereavement and during the dying phase. Healthcare professionals such as nurses, doctors, social workers, etc. are present with people during all of these experiences illustrating the importance of spirituality to these professions [18]. Addressing spiritual needs can result in alleviation of suffering, a sense of well-being, enhanced ability to adapt and cope with adversity and a sense of peace and inner strength [19]. This chapter introduces the concept of spirituality and discusses the importance of spirituality from a clinical perspective. Furthermore, the concept of spiritual distress is introduced, and suggestions for addressing spiritual needs in clinical practice are proposed.

1.2 What Is Spirituality?

Spirituality is deemed to be that which gives life meaning, purpose and connection with others; is distinguished from religiosity but may incorporate religious beliefs for some people; and may comprise a religious system of beliefs and values or a nonreligious system of beliefs and values. It can be a metaphysical or transcendental phenomenon that relates to connectedness, transcendence and meaning and purpose in life [19].

1.2.1 Difficulties with Defining Spirituality

Conceptual and methodological inconsistencies have made it difficult to compare research findings and draw significant conclusions. Spirituality is an ambiguous concept, and few theoretical frameworks exist which aim to provide a deeper understanding of the concept. Therefore, much of the empirical research on spirituality has not been guided by a theoretical framework. There is disagreement amongst researchers in relation to both conceptual and operational definitions of spirituality with some researchers suggesting that spirituality in its essence may not be measureable. Conversely other researchers propose that spirituality is just as measureable as other subjective variables such as hope, adaptation or coping, all of which are well-established in the literature [20, 21]. Irrespective of these contrasting opinions, Breitbart [22] emphasises that spirituality and spiritual needs are of major concern for future research particularly in relation to the illness experience. According to Sessanna et al. [23], amongst the confusion and complexity, it remains that spirituality is a complex and abstract concept.

1.2.2 Useful Definitions of Spirituality

The Royal College of Nursing (RCN) [24] surveyed 4054 nurses to establish their understanding and attitudes towards spirituality and the provision of spiritual care. An online resource was created based on the findings to educate and create awareness about the concept of spirituality and spiritual care. Spirituality was stated as being difficult to define (see Fig. 1.1 and Boxes 1.1, 1.2, and 1.3).

Fig. 1.1
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What do we know about spirituality?

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Box 1.1: Spirituality is complex

Spirituality is difficult to define but very important. It is complex—however it is no more complex than other commonly used terms within healthcare. Think how difficult it is to define everyday terms such as care, community, love, attention and affection. The fact that spirituality is difficult to define and that people tend to define it in different ways is not unusual in terms of the language we use as healthcare professionals (RCN) [24].

Box 1.2: Spirituality is important in healthcare

All illnesses are first and foremost deeply meaningful human experiences. Professionals may offer diagnoses—cancer, schizophrenia, appendicitis, depression, anxiety, influenza, etc. Yet, behind the diagnostic label is a real person experiencing their illness within a specific context, accompanied by emotions and understandings. Spirituality can help people make sense of and cope better with experiences of illness and other difficult experiences (RCN) [24].

Box 1.3: Spirituality is as important as physical care

A person’s spirituality, whether religious or nonreligious, provides belief structures and ways of coping through which people begin to rebuild and make sense of their lives in times of trauma and distress. These experiences are not secondary to the ‘real’ process of clinical diagnosis and technical care (RCN) [24].

According to Swinton [25], illnesses are deeply meaningful events that can challenge people to take a different perspective on their lives. Spirituality offers ways in which people can explain and cope with their illness experiences and in so doing discover and maintain a sense of hope, inner harmony and peacefulness despite the challenges that arise when a person is ill. Swinton concludes that the experience of illness is essential to a person’s movement towards health and fullness of life even in the face of the most traumatic illness or life event [25]. Other theorists have also expressed this idea of personal growth and spiritual enlightenment in the face of illness and suffering. For example, Viktor Frankl was an Austrian psychologist and a psychiatrist who was captured during World War II and kept as a prisoner in the concentration camps. Frankl developed a theory of meaning, which he called ‘Logotheory’ derived from the word ‘logos’, which, in Greek philosophy, means purpose or meaning. According to Frankl, everyone will endure suffering at some stage of their life—it might be physical, psychological or spiritual. If a person is able to deal with this suffering in a positive way, by changing their attitude towards the situation, it can lead to a sense of inner peace and connection with others and, for some, an enhanced connection with God or a Higher Power [26].

Many authors have tried to clarify and define the concept of spirituality. Steinhauser et al. [27] stated that some clarity regarding a definition of spirituality can be established when one considers the difference between defining spirituality for the purpose of clinical practice as opposed to a definition that is used for research purposes. The focus in clinical practice is on individuality, promoting conversations and capturing the breadth of the experience of spirituality. Furthermore, in clinical practice, psychological or emotional concepts overlap with spirituality. Meanwhile, in research the focus is on measurement and generalising findings to large samples. Therefore, the concept needs to be clearly defined and differentiated from other related concepts, and specific dimensions of the concept under investigation need to be clearly delineated.

Spirituality can mean different things to different people. Figure 1.2 was developed by the authors and outlines some of the words used to describe what spirituality means to different people.

Fig. 1.2
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Words used to describe spirituality

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Given the complexity of the concept of spirituality and the difficulties with defining it, it is often useful to identify what spirituality is not. The RCN have outlined what spirituality is not [24]. Firstly, spirituality is not something that has no connection with clinical practice. Spirituality has clinical significance. In order to care for people, it is crucial to know and be able to recognise what the meaning of the illness is at the personal level. Secondly, spirituality is not just about religious beliefs and practices. It applies to people of all faiths and no faith. Spirituality is increasingly being recognised as something separate to religion but inclusive of religious beliefs and values depending on a person’s belief system. Thus, people can be spiritual but not necessarily religious. Thirdly, spirituality is not only important for chaplains. Chaplaincy is central to the delivery of spiritual care. However, chaplaincy is not the only discipline that benefits from understanding and recognising what spirituality is and how it functions in the lives of people experiencing illness and distress. Spirituality is important for all healthcare professionals. However, chaplains should be recognised as experts in the provision of spiritual care and also provide expertise and education to other healthcare professionals. Fourthly, spirituality is not only important for patients – it is important for all persons. Healthcare professionals are spiritual people, and learning to work with one’s own spirituality within a caring context is a vital tool for the delivery of holistic care; to care well, one needs to be cared for well. Finally, spirituality is not about imposing your own beliefs and values on another. Although the spirituality of carers is important and needs to be considered, this does not mean that it is in any way appropriate for carers to impose their values and beliefs on patients in situations where they are clearly vulnerable.

Personal Reflection Activity

Read the following paper: Weathers, E., McCarthy, G., & Coffey, A. (2016). Concept analysis of spirituality: an evolutionary approach. Nursing Forum 51 (2) 79–96.

After reading the paper, answer and reflect on the following questions:

  1. 1.

    What are the defining attributes of spirituality?

  2. 2.

    What are the antecedents and consequences of spirituality?

  3. 3.

    What is the conceptual definition of spirituality presented in the paper?

  4. 4.

    What are the implications of the findings for healthcare practitioners and your own practice?

  5. 5.

    Now consider your understanding of spirituality. Does this differ from the understanding offered in the paper?

1.3 Why Is Spirituality Important?

Spirituality is important for physical and psychological health as proven in prior research [4, 28,29,30,31,32]. Spirituality is becoming increasingly recognised as an important part of healthcare as reflected in global initiatives undertaken to promote the inclusion of spiritual care into healthcare [1]. A number of guidance documents and professional standards internationally have referred to the provision of spiritual care, further emphasising its importance in clinical practice (see Box 1.4). It is clear that the assessment of spirituality, and the provision of spiritual care, is being increasingly acknowledged within health policy and standards. Yet, the best way of implementing these recommendations in practice has yet to be fully discerned. Koenig [33] emphasised the importance of creating awareness amongst physicians with regard to conducting spiritual assessment and taking a spiritual history. It is equally important that nurses and other healthcare professionals are aware of spirituality and the spiritual needs of patients.

Box 1.4: Useful Resources

Example of policies and guidelines that make reference to spiritual care:

Example of practice resources for the provision of spiritual care:

Example of published government reports on spirituality:

1.4 Challenges with Terminology

There has been much societal change in recent years in relation to religion and spirituality. Gray [34] describes a ‘mood of uncertainty’ in modern society which has been marked by the decline of mainstream religion and the emergence of new forms of spiritual expression (p. 178). This societal shift has caused a loss of tradition and shared meanings, resulting in many people raising questions about the relevance of religion and its importance in people’s lives. Society appears to be moving away from institutionalised religion towards a more individualised religion, which involves a personal search for meaning [26, 35]. Also, many people now draw on Eastern philosophy or New Age thinking to emphasise the importance of values such as loyalty, respect and responsibility [34]. As a consequence of these societal changes, the terminology and meaning of the word spirituality has changed. Historically, spirituality was considered a concept that develops within a religious context and usually within established institutions designed to facilitate spirituality [27]. Nowadays, spirituality and religion are considered separate concepts that can be interrelated for some people, depending on their belief system [19, 27]. Healthcare professionals need to be aware of this diversity in meaning when caring for patients, especially given that healthcare professionals are now caring for more and more people from diverse cultural backgrounds, with different beliefs and rituals. Additionally, healthcare professionals themselves in turn hold different religious beliefs and come from different cultural backgrounds. An overview of some strategies that can be used by healthcare professionals to enhance self-awareness and create a better understanding of individual spirituality is provided in Table 1.1.

Table 1.1 Strategies for enhancing self-awareness and understanding of one’s own spirituality
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1.4.1 Differentiating Religion and Spirituality

As described in the former section, there has been a societal shift that has led to difficulties and challenges in relation to the terminology to describe spirituality. This evolution has also led to a differentiation between the concepts of spirituality and religion. The word ‘religion’ was derived from the Latin word meaning that which ‘binds together’ inferring connections to a deity or Supreme Being, to other persons and to one’s beliefs and values [27]. In light of the earlier described evolution, the word religion now increasingly refers to institutional, social, doctrinal and denominational practices or experiences [27]. Meanwhile, the word spirituality is considered to denote a broader search for meaning and purpose and connection with self, others and the transcendent [19]. From a clinical practice perspective, it is important to not assume anything in relation to a person’s spiritual or religious beliefs or practices. Implementing reflective techniques as described earlier can be useful to enhance a person’s ability to remain non-judgemental and to avoid making any assumptions.

1.5 Spirituality, Religion and Nursing

Of all the healthcare professions, nursing has the strongest spiritual and religious heritage [36,37,38]. Spirituality has been embedded within the nursing profession dating back to the pre-Christian era [38, 39]. In pre-Christian times, nursing was considered a noble act, and nursing care was concerned with nourishment of the human spirit including prayer to the Gods during illness [38, 39]. In ancient Celtic writings, a nurse was referred to as an ‘anam cara’ or a soul friend illustrating the embodiment of spirituality within nursing from a very early stage [40]. During the Christian era, nurses continued to nourish the human spirit but in accordance with a religious (Christian) framework. The mission of these Christian groups (e.g. the Béguines and the Sisters of Charity) was to care for the sick in the same manner that Jesus had cared for the sick [38, 39]. ‘Compassionate accompaniment’ was the driving force of nursing at the time [41, 42].

During the twentieth century, the rise of modern science resulted in the introduction of university-affiliated nursing programmes, which focused on the professionalisation of nursing, striving to establish a universal system of nursing education and regulation of nursing practice [37, 42,43,44]. Nursing curricula reduced the content on spirituality and spiritual care to knowledge of major religions and associated dietary practices or rituals [45, 46]. The nursing profession was said to be inadvertently led into adopting the biological, reductionist approach to healthcare [47]. However, from the 1970s onwards, the concept of holistic nursing began to re-emerge, and with it came lots of literature on the meaning of spirituality and the spiritual needs of patients [3, 43, 48,49,50,51]. The scientific biomedical model that had encapsulated nursing was no longer sufficient and left many questions unanswered [45]. Timmins and McSherry [38] (p. 951) suggest that nursing had become ‘disconnected from the spiritual dimension’ with too much focus on the technical, scientific, medical and physiological aspects.

1.6 Spiritual Needs, Assessment and Spiritual Care

The predominance of the biomedical model of care with a focus on the physical dimension has impeded the provision of spiritual care in healthcare delivery [37, 39, 43, 52, 53]. The biomedical model has been criticised for not acknowledging the spiritual dimension even though healing traditions began with care of the spirit [54,55,56]. Nonetheless, according to Watson [51], nursing models and theories have extended beyond this limited view of physical care opting for a holistic approach to health. Nursing theories and models have conceptualised health as more than merely the absence of physical disease to include the psychological and spiritual dimensions of man [57]. There is a recent spiritual re-emergence in society, and the paternalistic, biomedical model is no longer considered adequate to address the diverse health-associated needs of human beings [51, 58]. Consequently, there has been an increase in the number of published research studies exploring the concept of spirituality.

1.6.1 Spiritual Needs

Studies have investigated whether patients considered it appropriate for healthcare professionals to ask about their spiritual needs and reported that 52–63% of patients considered it appropriate [59, 60]. Additionally, addressing spiritual needs of individuals with cancer has been associated with improved satisfaction with care, better quality of life, higher existential well-being and lower costs [61,62,63,64]. Other studies have examined the spiritual needs of individuals diagnosed with cancer (see Fig. 1.3).

Fig. 1.3
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Spotlight on oncology research

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The spiritual needs of individuals with cancer are similar irrespective of cultural background. For example, Hatamipour et al. [65] identified the spiritual needs of people with cancer (n = 18) in Iran (age range 22–72 years old). Participants emphasised the need for connection (i.e. social support and to be treated normally), seeking peace (i.e. inner peace, forgiveness and hope), meaning and purpose (i.e. accepting the reality, cause of disease, reliance on self and meaning of life) and transcendence (i.e. strengthening spiritual belief, communication with God and prayer).

Personal Reflection Activity

First think about your own clinical experience in caring for spiritual needs. Then use an online search engine or database to find articles that investigate spiritual needs. Now consider both your experience and the research that you found to answer the following questions:

  • What samples were included in this prior research (e.g. people with cancer, chronic pain, people with dementia, etc.)?

  • Were other types of spiritual needs identified? If so, what were they?

  • What about individuals who are cognitively impaired—how might you address their spiritual needs?

As identified earlier in this chapter, all individuals have spiritual needs, even those who are cognitively impaired (e.g. individuals with intellectual disability or dementia). Frankl [26] identifies three dimensions to every person: the soma (body), the psyche (mind) and the noos (the soul or spirit). For individuals who are cognitively impaired, this tridimensional core of the person does not change, and they still have physical, psychological and spiritual needs. However, it is more difficult to establish their care needs, especially their spiritual needs.

In terms of assessing spiritual needs of patient who are cognitively impaired, it is best to assess the person as early as possible in the disease trajectory and develop a plan for spiritual care for both the individual and their caregiver [66]. Remarkably, some studies have found that spirituality can slow cognitive decline in people with dementia [67] and even protect against cognitive decline in middle-aged and older adults [68]. This emphasises the importance of addressing spiritual needs in all individuals.

1.6.2 Spiritual Assessment

As discussed earlier in the chapter, many governmental and professional bodies and organisations recommend the inclusion of spiritual assessment in healthcare. For example, the Joint Commission on Accreditation of Healthcare Organisations (JCAHO) mandates that all patients must be assessed for spiritual beliefs and practices. Thus, it is essential for healthcare professionals to understand how to efficiently and effectively assess cancer patients for spiritual distress. Many authors advocate a two-tiered approach (see Box 1.5) to spiritual assessment [69,70,71,72].

Box 1.5: A Two-Tiered Approach to Spiritual Assessment

  • Tier 1 is a brief, superficial initial assessment that will obtain data to determine if there is any distress that requires further focused assessment. This assessment can be limited to asking the patient about general spiritual status (e.g. how are your spirits now?), spiritual needs (e.g. what spiritual concerns are bothering you most now?) and spiritual resources (e.g. what do you think might help you with these concerns?)

  • Tier 2 is a focused assessment that engages the patient to describe the specific type(s) of spiritual distress being experienced. For example, during the initial assessment, the healthcare professional may learn that the patient is wondering ‘why?’. Tier 2 assessment questions would then reflect this specific problem of meaning. Follow-up questions could include ‘Tell me more about your “why” questions’ or ‘What answers are you finding for why?’.

Healthcare professionals can craft original questions to reflect the patient’s immediate concerns and language. Indeed, when talking with patients about their spiritual distress, it is important for healthcare professionals to be aware of the language utilised. To introduce the topic of spiritual distress, healthcare professionals can employ neutral phrases or use the language proffered by the patient. For example, if a patient remarks that it is faith and family that are getting me through this, the healthcare professional can create an assessment question using faith. Neutral phrases such as matters of the heart or spiritual interests may also be helpful. Other aspects of spiritual assessment are also important to consider. First, the quality of the data collected during a spiritual assessment will be determined by the rapport and trust the healthcare professional has established with the patient. Patients will more likely speak freely of their spiritual concerns to a healthcare professional whom they perceive as warm, kind and respectful and personally interested. Rapport can be developed rapidly by a healthcare professional who is genuinely caring. A healthcare professional presence, nonverbal messages and behaviours can convey readily the qualities a patient needs to talk openly about spirituality. Assessment data can be collected not only from the verbal interactions with patients. Healthcare professionals must also consider the nonverbal messages a patient sends. Objects such as religious jewellery or spiritually oriented books in the patient’s environment can signal information about a patient’s spirituality. This is particularly important for people with cognitive impairment.

Having read the previous sections on spiritual needs and spiritual assessment, consider the following case study activity:

1.6.3 Case Study Activity

figure a

Joan is 82 years old and attended the emergency department last night accompanied by her daughter, Shauna. Joan was complaining of difficulty passing urine for 3 days, and her daughter informed staff that she had also observed Joan to be disorientated for the previous 2 days. A short while later, Joan was admitted to the ward with a diagnosis of a urinary tract infection (UTI).

You are asked to assess Joan on admission to the unit. In your assessment, you discover that Joan is widowed for the past 4 years, and since then, she has lived with her eldest daughter, Shauna. Shauna has a family of her own, but she can manage well as Joan is usually semi-independent with mobilising, hygiene, toileting and dressing. However, with the past 3 days, Shauna has noticed that her mother has been quite disorientated and has required more assistance with some of these tasks. You continue to ask Shauna questions about Joan’s disorientation, and you discover that Joan’s memory has actually been deteriorating over the past year. Shauna reveals to you that Joan has noticed a change herself but is reluctant to discuss it with anyone. She says that the family are very worried about Joan especially over the past 2 months when they have noticed that Joan does not attend any social events anymore. Shauna tells you that ever since she can remember, Joan would go to the local church every Sunday for mass and would meet all her friends afterwards in the village coffee shop, next to the church. Shauna says that Joan really enjoyed this every week and looked forward to it. However, over the past 2 months, Joan has refused to attend mass and has had no interaction with her friends.

As part of Joan’s care plan, you need to consider spiritual needs and spiritual care. Reflect on the following questions:

  • What kind of terms would you use to discuss spirituality and spiritual needs with Joan?

  • How would you introduce the topic?

  • Who would you involve in the discussion?

  • What specific spiritual needs might arise in Joan’s case?

  • How would you ensure that Joan’s spiritual needs are prioritised along with other needs?

  • Which departments/disciplines would you consider referring Joan’s case to?

1.6.4 Spiritual Care

Spiritual care should be considered as an approach to care [73]. In other words, spiritual care is not an addition to what nurses and other healthcare professionals already do, but rather it is a natural part of compassionate care, which shouldn’t present an extra ambiguous burden to deal with [73]. The importance of communication within the healthcare professional-patient relationship is emphasised and numerous ways in which physical care or other biomedical interventions can be made spiritual [73]. Box 1.6 provides an overview of therapeutic approaches to spiritual assessment and spiritual care.

Box 1.6: Approaches to Spiritual Assessment and Spiritual Care

  • Allowing person to discuss concerns

  • Active listening

  • Using full or transcendence presence

  • Offering spiritually nurturing books, videos or other resources

  • Educating about and supporting spiritually healing nonreligious rituals

  • Facilitating the expression of the spirit through art (e.g. painting, sculpting, music, quilting)

  • Supporting religious practices

  • Introducing journal writing

  • Prayer

  • Meditation

  • Guided spiritual imagery

  • Making appropriate referrals

One way in which healthcare professionals can help people towards wholeness and finding meaning in their illness is by referral to other multidisciplinary team services or sometimes external support services. For example, referrals can be made to the following team members:

  • Chaplains (trained in clinical pastoral education, pastoral counselling and fusion of theological and psychological knowledge)

  • Clergy (depending on the religious denomination)

  • Mental health professionals (counselling experience)

  • Parish nurses (have some pastoral counselling training and understand the varieties of spiritual distress amidst illness)

  • Spiritual directors (clergy or lay persons with some training in becoming ‘holy listeners’)

  • Spiritual healers (shamans, medicine men, folk healers considered to be spiritual care experts)

Personal Reflection Activity

Think about your clinical experience and your clinical setting. Now consider the following questions:

  • What spiritual support services are available for patients?

  • What spiritual support services are available for staff?

  • Is there a need to implement further support services and education on spiritual care in your clinical setting?

1.7 Spiritual Distress

Research studies have shown that spiritual distress or spiritual pain (e.g. feeling abandoned by God) is associated with worse outcomes for patients with diverse conditions. For example, spiritual distress has been associated with increased depressive symptoms, poorer quality of life, more functional limitations, increased risk of mortality, emotional adjustment and quality of life [74,75,76]. Spiritual distress has been defined as a disturbance in the belief or value system that provides strength, hope and meaning to life [77]. Spiritual distress has been accepted as a nursing diagnosis in the NANDA International (formerly, North American Nursing Diagnosis Association) since 1978 [78]. According to Caldeira et al. [79], spiritual distress may be diagnosed if the patient is in a state of suffering associated with the meaning of his/her life, related to a connection to self, others, world or a Superior Being. A list of manifestations of spiritual distress has been identified by NANDA International (see Fig. 1.4).

Fig. 1.4
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NANDA list of manifestations of spiritual distress

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Spiritual distress is said to arise from unmet needs, and the greater the degree that a spiritual need remains unmet, the greater the level of spiritual distress experienced by the patient [79]. All humans have a spirit that deeply yearns for meaningfulness, inner peace, love and connection with a transcendent. This is magnified during the experience of illness or a traumatic life event due to feelings of loss and change, which can also initiate a search for meaning and raise existential questions [71]. Furthermore, individuals can experience a realisation of mortality; a feeling of powerlessness and vulnerability; an isolation and loneliness; and feelings of guilt or shame [71]. Thus, losses and changes to which a patient cannot assign meaning or reconcile with basic beliefs about the world will contribute to spiritual distress. Being unable to sense that one’s existence will continue in some manner after death may also exacerbate spiritual distress. Unanswered existential questions, a continued sense of vulnerability, loneliness, and guilt may have the same effect [71]. Unlike physical or psychological symptoms, spiritual distress may not always be a symptom to avoid. However, healthcare professionals need to be aware that spiritual distress can lead to negative religious coping as a result of poor adjustment to illness [79]. Examples of negative religious coping include believing that God is punishing the individual, feeling abandoned by God, viewing cancer as an act of the devil and passive deferring of decisions to the divine. Yet, spiritual distress may be a necessary and vital part of the spiritual journey, as alluded to by Debra in the YouTube clip. Although the experience will still be experienced as painful, it can produce new spiritual growth. Spiritual distress may be a natural part of a process that can lead to spiritual transformation. Although some persons may get ‘stuck’, those who embrace and learn from inwardly painful spiritual distress may experience transformation.

Online Activity: Part I

Watch this TedTalk by Debra Jarvis, who describes her experience as a healthcare chaplain and cancer survivor:

https://www.youtube.com/watch?v=4n8qT0vQbWk

No one can tell us what our experience means…we have to decide what it means.

Reflecting on your clinical practice, consider how meaning can be fostered in the patients you care for who are ill.

Online Activity: Part II

Remembering the words of Debra Jarvis:

Claim your experience…don’t let it claim you.

Consider Debra’s message about suffering and how people can interpret and deal with it in different ways. What are your experiences from your clinical practice?

1.8 Spotlight on Spirituality Research

Some researchers claim that the study of spirituality is fragmented and in the early stages [80, 81]. The progress of spirituality research has been challenged by a lack of consensus on definitions and measures [48, 57, 58, 81,82,83]. The ambiguity surrounding the conceptualisation of spirituality has been exacerbated by a lack of acceptable measurement instruments that address spirituality in a patient-centred, theoretically integrative and comprehensive manner [84, 85]. The majority of quantitative research conducted to date uses instruments measuring spiritual well-being [86, 87], spiritual experiences [88, 89] and spiritual practices [90], to operationalise spirituality. In some instances, measurement of spirituality has been simplified to religious practices [91, 92] or religiosity [93,94,95]. This may be due to poor differentiation between the concepts of spirituality and religiosity, which are often used interchangeably in the literature [3, 96, 97]. Nonetheless, the link between spirituality and health outcomes is well-established in the literature [98, 99].

1.9 Conclusion

The recent spiritual re-emergence in society has resulted in the paternalistic, biomedical model no longer being considered adequate to address the diverse health-associated needs of human beings [52, 58]. Spirituality is a highly personal and individualised concept; thus many definitions of spirituality exist. Spirituality is essential to healthcare and is increasingly recognised in healthcare policies, standards and guidelines. Spirituality can help people cope with difficult life events including a cancer diagnosis. Previous research has illustrated the prevalence and diversity of spiritual needs amongst individuals diagnosed with illness [65, 100, 101]. Spirituality can be helpful to the health and well-being of individuals; however, a person can also experience spiritual distress. Spiritual distress may manifest in many different ways depending on the person’s situation and their belief system. Yet, spiritual distress may not always be a symptom to avoid. Rather, it may be a necessary part of the spiritual journey that can lead to transformation in the individual.

With regard to spiritual assessment, a two-tiered approach is recommended. This involves an initial brief spiritual screening assessment to identify any evidence of spiritual distress. This could be performed by any healthcare professional and used to make appropriate and timely referral to spiritual support services such as the chaplaincy service. There are many different modes of assessment including surveys and interview questions. For a spiritual assessment to be successful, there must be a strong rapport developed between the nurse and the patient, and the nurse should be aware of the importance of the language utilised. Spiritual assessment also includes nonverbal and behavioural observation, e.g. looking for signals in the patient’s environment and observing their body language closely when opening a conversation with them about spirituality. Finally, spiritual care is an integral part of nursing care and should not be regarded as an ‘added extra’. Rather spiritual care is an approach to care and should be at the core of everyday nursing care provided to people with cancer [73].