service of spiritual assistance by nurses is receiving wide spread
acceptance at the international level.1,2
Spirituality is included in nursing theories and is integrated into
the nursing documentation system.3,4
In Spain, spiritual attention in the context of holistic assistance
is beginning to be taken into account.5,6
understand spirituality as "the aspect of the human condition
that refers to the way individuals seek and express meaning and
purpose, as well as the way they express a state of connection with
the moment, with oneself, with others, with nature and with the
meaningful or sacred".7
Religion is a personal experience that gives rise to an organized
system of beliefs, practices, rituals and symbols that characterize
a community in the collective sphere.8,9
Religion is believed to be composed of three dimensions:7
a cognitive one, in relation to religious beliefs; another behavioral
that includes religious and ritual, institutionalized or conventional
behaviors; and the affective, which corresponds to the links between
man and transcendency.10
conceptually possesses an area shared with religion as it includes
a search for and discovery of the transcendent, as with religiosity,
although in the case of spirituality it may imply religious beliefs
Besides, the words spirituality and religiosity when referring to
the transcendent experience are usually interchanged in our environment.10,12
spiritual care is an integral part of nursing care, its provision
is very diverse and may be influenced by the personal, cultural
and educational needs of each nurse.13
However, all professionals should be alert, sensitive and prepared
to recognize spiritual anxiety, evaluate it and attend or refer
Therefore, it is necessary to promote training and nurse performance
in this care setting. In Western Andalusia, it has been argued that
this dimension is weakly integrated into the nurses' imaginary about
care in the dying process.15
aim of this study is to describe the degree of knowledge about the
internationally accepted construct in our medium by the nursing
profession on spirituality and religiosity as well as the attitudes
towards the nursing practice of spiritual and religious care.
is a descriptive and cross-sectional study. The study sample was
for convenience and has been collected through a survey among the
nurses of the Hospital San Juan de Dios del Aljarafe, which serves
a region of 250,000 people in the province of Seville (Spain). The
total population, constituted by the nurses on the staff of the
afore mentioned Hospital was 184. Of these, 128 agreed to participate
in the study. The surveys were answered voluntarily and anonymously.
The study period was from December 2015 to May 2016.
knowledge and attitudes regarding the concept of spirituality and
religiosity were examined using a self-designed questionnaire consisting
of 30 items scored on a Likert scale. The items were selected from
among those which an internationally accepted construct of spirituality
and religiosity gathered and consists of three groups, a first group
of 15 items (of which 6 are proposed in the opposite direction),
based on the Spirituality and Spiritual Care Rating Scale modified
by us and examines knowledge, another group of five items (of which
2 are proposed on the opposite way) based on the work of Puchalski
et al., examines attitudes about the role of the nurse, and the
third group of 10 items selected among the Nursing Interventions
Classification (NIC), that explores the attitudes of nurses to the
practice of spiritual and religious care.7,16
Their theoretical construct has been validated through a board of
experts in order to verify their adequacy to our Spanish context.
Cronbach's alpha was 0.764 for the 30 items.
Of the 128 nursing
professionals who participated, 30 (23.40%) were men and 98 (76.60%)
were women. The mean age was 34.61 years (SD 7.436), with an age
range between 22 and 60 years. The mean number of years of professional
practice was 11.34 (SD 6,786) with a range between 1 and 34 years.
Regarding their experience in palliative care, 54 (42.20%) reported
having no experience in this area of care and 74 (57.80%) declared
as having experience.
78.23% was obtained
in the correct knowledge score [Table 1] and 69.84% in a
positive attitude towards spiritual and religious care [Tables
2 and 3]. Among these, 68.91% of the positive attitude
regarding the role of the nurse in regard to spiritual and religious
care was obtained [Table 2] and 70.31% regarding the attitude
about the nursing interventions for spiritual and religious care
In regard to knowledge
of the spirituality and religiosity construct [Table 1],
the traits accepted by most of the nursing professionals surveyed
included a personalized understanding of spirituality (98.44%) and
intensely lived individually (47.66%). The word religiosity was
linked to the beliefs in a God or Supreme Being as well as to the
practices and standards of approaching Him (77,35%). It was understood
that spirituality and religion are not the same issue (67.19%).
In fact, spirituality was not necessarily related to belief in God
or a Supreme Being (76.56%), nor mainly to places of worship (88.28%),
so that spirituality care was considered applicable to atheists
and agnostics and was related with life transcendence(88.28%), with
art, creativity, free expression (75.00%) as well as with ethics
and morality (85.16%). Spirituality and religiosity are related
to the growth of personal friendships and other interpersonal or
social relationships (49.22%), and the need to forgive and be forgiven,
to feel at peace with ourselves and others (71.09%). It was considered
that "in practice, spirituality and religiosity impel individuals
to face difficult life situations, seeking answers about the meaning
and purpose in life" (96.09%) and that "spirituality is
a force that allows each person to be in harmony within, in peace
with oneself, with others and with the world, cosmos and eternity"
(93.75%). It was also considered that spiritual and religious well-being
is important for the emotional well-being of a patient (90.63%).
the understanding of the Nurse's Role in Spiritual and Religious
Care [Table 2], most of the respondents expressed the conviction
that excellent care provides spiritual well-beingto the patient
(92.18%), that this care must be provided by a multi-professional
team approach (85.94%), and that the nursing professional should
explore spiritual and religious needs and plan their care adequately
(64, 06%). Disagreement was expressed with the role of nurses in
providing religious care that consists solely in facilitating the
intervention of the patient's chaplain, pastor or religious adviser
if requested (57.03%). Neither is it understood, although not mainly,
that it should be nurses who are more aware of their own spirituality
or religiosity who should provide spiritual and religious care rather
than nurses who do not have that awareness of their own spirituality
or religiosity (45.31%).
to attitudes about the practices of the Nursing Competences for
Spiritual and Religious Care [Table 3], the professionals
surveyed showed favorable attitudes towards identifying spiritual
and religious needs and use this knowledge to evaluate and provide
spiritual and religious care (48.44%), to provide adaptation of
the environmental setting for self-reflection (85.16%), to be available
to actively listen to expressions of spiritual suffering (97.66%),
to use communication techniques to help them clarify their values,
beliefs and reasons for hope (53.13%), to encourage interpersonal
relationships (89.85%), to teach methods of relaxation, meditation
and guided imagery (39.84%) to provide the patient with music, literature
or radio or TV programs to their liking (74.22%), to refer to the
spiritual/ religious adviser according to demand (83.60%), to help
the patient pray, if needed (63.28%), to facilitate the practice
of religious and/or spiritual traditions and rituals (67.97%).
A. Knowledge of the Spirituality and Religiosity Construct
based on the modified Spirituality and Spiritual Care Rating Scale16.
Note: Items 2, 3, 4, 9,11 and 12 are written the opposite
to what is desired to be measured
B. The role of the nurse regarding spiritual and religious care
based on modified Puchalski C et al.7,. Note: Items 2 and 4 are
written in the opposite direction to what is to be measured
C. Nursing interventions for spiritual and religious care
based on the modified Nursing Interventions Classification (NIC)
Nurses have been
criticized for underestimating the spiritual dimension in care and
several factors have been proposed that explain this limitation,
such as lack of awareness of their importance and lack of preparation;
a misinterpretation of the term spirituality; the lack of willingness
to offer spiritual attention.17
These difficulties partly contrast with the results of this study.
Concept of spirituality
and religiosity. 90.63% of the participants considered that
spiritual and religious well-being is important for the emotional
well-being of a patient and 88.28% of them stated that spirituality
care is applicable to atheists or agnostics, in addition to believers
in a religion. This data supports the inclusion of 27.5% of the
Spanish population who are considered agnostic or atheist.18
In addition, it supports the integration of spirituality and religiosity
into the concept of holistic health care advocated by the World
and the International Council of Nursing.20
the absence of comparable Spanish studies to ours, we do so with
a European study.16
Thus, some conceptual differences between Spanish and British nurses
have been identified. Of these, 76.56% of the professionals surveyed
state that "spirituality does not necessarily have to do with
belief and faith in a God or Supreme Being," while McSherry
only found it in 31.60%. 96.09% state that "in practice spirituality
and religiosity drive individuals to face difficult life situations
by seeking answers about the meaning and purpose in life" while
McSherry found 69.30%.
71.09% stated that
"spirituality and religiosity have to do with the need to forgive
and the need to be forgiven, to feel at peace with ourselves and
with others while McSherry found this to be 41.80%. These conceptual
differences can be explained by cultural differences between groups
from different countries, as well as by the different nuances that
have been theoretically described in the understanding of the spirituality
and religiosity construct.7
To better understand the influence of culture in the understanding
of this construct, it should be explored more thoroughly in different
territories and professional groups in our country.
the other hand, beyond the above-mentioned differences, the results
show that some aspects conceptually related to spirituality are
similarly understood in this Spanish study and the one carried out
by McSherry in Great Britain.16
Thus, only 3.13% points out that "Spirituality does not include
areas such as art, creativity and free expression" while McSherry
found 9.90%; only 3.13% affirm that "The care of spirituality
is not applicable to atheists or agnostics", while McSherry
found that 9.20% did not believe that either; only 8.59% stated
that "Spirituality and religiosity do not include the ethics
and morals of people," while McSherry found this to be 15.70%.
Role of the Nurse
in Spiritual and Religious Care. Participants in the study accept
that excellence in nursing care provides spiritual well-being to
the patient (92.18%) and that this care must be provided by a multi-professional
team (85.94%). However, despite this fact together with that spiritual
suffering can be detrimental to patients' health,22,23
and consequently, the nursing professional must play an active role
in satisfying their spiritual needs,24-26
in this study, the commitment to assume this active role reaches
a moderate support, of 64.06%, by the participants. In other studies,
the involvement of nurses has also proved to be insufficient, even
to a greater degree.27
On the other hand, the results show
a high acceptance to refer to the chaplain or religious adviser,
which, in itself, may be adequate and related to the fact that the
majority of the Spanish population declares themselves to be of
the Catholic religion (67,80%),18
and that the immediate availability of Catholic chaplains in public
hospitals is guaranteed by Church-State agreements.28
Such a referral to the Catholic chaplain or another spiritual or
religious counselor should be performed with the patient's consent
or explicit request but it should not mean the inhibition or withdrawal
of the nurse, so coordination is required in the provision of such
care as this must be multi-disciplinary.7
Moreover, it is of some relevance for
the group surveyed to prioritize the performance of this care by
especially vocational nurses, as in other studies, which have shown
that the nurse's own spirituality and attitudes in care are predictors
of spiritual attention.29
Possibly, when applying spiritual and religious care, it may be
especially relevant to distinguish between the degree of personal
involvement, by virtue of one's own values or beliefs, and the professional
obligation to respond to a universal right of the patient.30
Both issues, the active involvement
in this care and its implementation independently of personal beliefs
or values, require a certain adjustment in our environment, which
could be achieved by encouraging greater awareness and practical
training of all professionals towards this care.
Practices of Nursing
Competencies for Spiritual and Religious Care. The attitude
towards interventions in spiritual and religious care was favorably
considered in the generality of the items, although some actions
more clearly assumed and scored with more than 80% of the possible
total, such as the predisposition to listen actively to expressions
of spiritual suffering, promoting interpersonal relationships, adopting
a peaceful environment, and referral to the chaplain or spiritual/religious
adviser on demand. These attitudes are essential for spiritual and
religious care, and systematically integrated into the general care
plans of patients.
However, other non-punctual
interventions are precisely those that are more specific, such as
teaching methods of relaxation and meditation, identifying needs
and designing care plans in this area, using communication techniques
that generate hope, helping the patient to pray, facilitate the
practice of religious or spiritual traditions and rituals or provide
the patient with music, literature or audiovisual programs to their
liking. This lower acceptance may be motivated by lack of time,
professional skills to perform them or lack of motivation, and coincides
with other studies in which it is considered as a training objective
for nurses to increase their competencies in the detection and management
of these needs and their incorporation into professional practice.27
To ensure in the future that each nurse
has an adequate competence in spiritual care, nursing educators
should be encouraged and helped to teach and choose methods that
promote the integration of the necessary knowledge and skills, including
the capacity for self-reflection in both theory and practice.31
Specific education that includes reflection on one's own life experiences
leads the nurse to be able to be more responsive to the patient.32
study has some conditioning factors. The hospital where it has been
performed is of a public nature and is managed by the Hospital Order
of San Juan de Dios, which expressly promotes a model of holistic
which probably influences the care system and the mentalization
of nursing professionals on the importance of Spiritual and Religious
Care. It may be conceivable that in most hospitals in the public
network, if they were managed differently, they would yield different
In conclusion, we can point
out that in our country, nurses demonstrate an understanding of
spiritual and religious care in harmony with the construct that
nowadays is mainly advocated both in our Spanish environment and
in Europe and the United States. The nurses' attitudes towards this
care are favorable, although the need to be aware of the specific
responsibility in this respect has been detected. It is necessary
to complete the training, in some aspects,of the intervention such
as the identification of spiritual and religious needs, the use
of techniques to help the individual to clarify their beliefs and
values, their areas and reasons for hope in life as well as the
value for the patient and family to practice methods of relaxation,
meditation and guided imagery.
1. Rothman J. Spirituality: what we can teach
and how we can teach it. J. Relig. Spiritual. Soc. Work. 2009; 28 (1-2): 161-84.
2. International Council of Nursing. The ICN
Code of Ethics for Nurses. 2012. Disponible en https://www.icn.ch/images/stories/documents/about/icncode_english.pdf [acceso: 17/11/2014].
3. Harding RH, Bishop SM. Logical reasoning.
In Nursing Theorists and Their Work. 7th ed. En Alligood MR, Tomey AM (eds).
Maryland Heights MO: Mosby Elsevier. 2010; p. 26-49.
4. Herdman TH, editora. NANDA International.
Diagnósticos enfermeros: definiciones y clasificación 2012-2014.
Madrid: Elsevier, 2013.
5. Grupo de Trabajo de la Guía de Práctica
Clínica sobre Cuidados Paliativos. Guía de Práctica Clínica
sobre Cuidados Paliativos. Madrid: Plan Nacional para el SNS del MSC. Agencia
de Evaluación de Tecnologías Sanitarias del País Vasco;
2008. Guías de Práctica Clínica en el SNS: OSTEBA Nº
6. Payás Puigarnau A, Barbero Gutiérrez
J, Bayés R. ¿Cómo perciben los profesionales de paliativos
las necesidades espirituales del paciente al final de la vida? Med Paliat. 2008;
15 (4): 225-37.
7. Puchalski C, Ferrellb B, Viranib R, OtisGreenb
S, Bairdb P, Bull J et al. La mejora de la calidad de los cuidados espirituales
como una dimensión de los cuidados paliativos: el informe de la Conferencia
de Consenso. Med Paliat. 2011; 18 (1): 55-78.
8. Quinceno MJ, Vinaccia S. La salud en el marco
de la psicología de la religión y la espiritualidad. Divers Perspect
Psicol. 2009; 5:321-36.
9. Rivera-Ledesma A, Montero-López Lena
M, Ejercicio clínico y espiritualidad; An Psicol. 2007; 23: 125-36.
10. Sandoval Guzmán PE, Rangel Domínguez
NE, Allende Pérez SR, Ascencio Huertas L. Concepto de Espiritualidad
del Equipo Multidisciplinario de una Unidad de Cuidados Paliativos: un Estudio
Descriptivo. Psicooncología 2014; 11 (2-3): 333-44.
11. Koenig HG, D. E. King DE, Carson VB. Handbook
of Religion and Health 2nd edition. New York, NY, USA: Oxford University Press,
12. McSherry W, Cash K, Ross L. Meaning of spirituality:
implications for nursing practice. J Clin Nurs. 2004 Nov; 13(8): 934-41.
13. Van Leeuwen R, Tiesinga LJ, Post D, Jochemsen
H. Spiritual care: implications for nurses' professional responsibility. J.
Clin. Nurs. 2006; 15: 875-84.
14. Muñoz Devesa A, Morales Moreno I,
Bermejo Higuera JC, Galán González-Serna JM. La Enfermería
y los cuidados del sufrimiento espiritual. Index de Enfermería 2014;
15. Ortega Galán AM, González de
Haro MD. El valor de la dimensión espiritual en el final de la vida desde
la perspectiva de los profesionales de enfermería. Med Paliat. 2016;
16. McSherry W, Draper P, Kendrick D. Construct
validity of a rating scale designed to assess spirituality and spiritual care.
Int J Nurs Stud. 2002; 39: 723-34.
17. Cadge W, Ecklund EH, Short N. Religion and
Spirituality: A barrier and a bridge in everyday professional work of Paediatric
Physicians. Social Problems 2009; 56: 702-21.
18. Centro Investigaciones Sociológicas
de España. Estudio 3146 Barómetro de julio de 2016. Disponible
en https://www.cis.es/cis/opencms/ES/NoticiasNovedades/InfoCIS/2016/Documentacion_3146.html [acceso: 04/09/2016].
19. WHOQOL SRPB group's. A cross-cultural study
of spirituality, religion, and personal beliefs as components of quality of
life. Social Science & Medicine 2005, 62(6):1486-1497.
20. Consejo Internacional de Enfermeras. Código
Deontológico del CIE para la profesión de Enfermería [Monografía
en Internet]. Ginebra. CIE; 2012. Disponible en https://www.icn.ch/images/stories/documents/publications/free_publications/C%C3%B3digo%20del%20CIE%202012%20web.pdf
21. Albarran J, Rosser E, Bach S, Uhrenfeldt
L, Lundberg P, Law K. Exploring the development of a cultural care framework
for European caring science. Int J Qual Stud Health Well-being 2011; 6(4). doi:
22. Koeing HG, Larson DB, Larson SS. Religion
and coping with Serious Medical Illness. Ann Pharmacother. 2001; 35: 352-59.
23. Baldacchino D. Spirituality in Illness and
Care. Veritas Press: Malta, 2003.
24. Taylor B. Nursing as healing work. Contemp
Nurse. 1995; 4: 100-6.
25. Wright KB Professional, ethical, and legal
implications for spiritual care in nursing. Image. J Nurs Scholarship, First
Quarter. 1998; 30: 81-3.
26. Speck P. The evidence base for spiritual
care. Nursing Management. 2005; 12: 28-31.
27. Mesquita AC, Costa Valcanti Avelino C, Neves
Barreto M, Alves Nogueira D, Souza Terra F, Cássia Lopes Chaves E. El
bienestar espiritual y la prestación del cuidado espiritual en un equipo
de enfermería. Index de Enfermería 2014; 23(4), 219-23.
28. Convenio entre la Consejería de Salud
de la Junta de Andalucía y la representación de los Obispos de
Andalucía para la asistencia religiosa católica en los Centros
Hospitalarios de la Red pública integrada de Andalucía. Boletín
Oficial de la Junta de Andalucía, 17.03.1987;22: 845-846.
29. Rafii F, Oskouie F, Nikravesh M. Factors
involved in nurses' responses to burnout: a grounded theory study. BMC Nurs.
2004; 3: 6.
30. Royal College of Nursing. RCN spirituality
survey 2010. London: RCN; 2011.
31. Giske T. How undergraduate nursing students
learn to care for patients spiritually in clinical studies: A review of literature.
J Nurs Manag. 2012; 20(8): 1049-57.
32. Cockell N, McSherry W. Spiritual care in
nursing: an overview of published international research. J Nurs Manag. 2012;
33. Fernandes de Freitas G, Siles González
J. Antropología y cuidados en el enfoque de San Juan de Dios. Index de
Enfermería 2008; 17(2): 144-148.