Most people go through their lives based on a system of personal values and beliefs that, while those may vary from person to person, help them set goals and objectives, or bring them satisfaction and meaning. At the deepest level of a human being, a spiritual dimension influences an individual’s decision and defines a course of life. It gives them the strength to choose a worthy goal and start the journey of their lives with clear principles. Spirituality is the central sense of life that guides people’s lives.

In health care, nursing is a profession aimed at promoting the health of individuals and communities. One of the most fundamental concepts in nursing theoryis spiritual nursing, which helps people achieve spiritual well-being and wholeness. Through the individual’s inherent spiritual strength, unsolved life issues and vicissitudes of life could be overcome [1].

Although spirituality has been recognized as having a link to health and healing, spiritual care has not been easily performed. Considering the holistic care perspective in which nurses are supposed to care for the physical, psychological, and even spiritual aspects of patients, most of the staff lack adequate spiritual care [2]. Insufficiency in education and training in spiritual care exacerbates this problem, making nurses unready to direct spiritualperspectives in spiritual care [2]. Lack of time, expanded workloads, and the vagueness of spiritual nursing are the challenges that make it difficult for the nurses to provide spiritual nursing.

Thus, it is crucial to have a clearer understanding of what spirituality means for nurses who provide spiritual care as this fosters professional confidence in their practice [3]. Having intellectual knowledge of spirituality derived from nursing science and biblical studies provides nurses with advanced knowledge of spiritual care. This knowledge helps to provide more detailed and accurate care which in turn has an impact on the patient’s care. By examining the diverse aspects of spirituality, nurses are aware of the fact that the concepts of spirituality not only enhance the nursing practice but also encourage the holistic view of patients.

Biblical Foundations of Spiritual Nursing

To have a more comprehensive understanding of the theoretical development in spiritual nursing, it is crucial to discuss the biblical origins of spirituality. Spirituality is a term that is generally unfamiliar to many ordinary people. In ordinary people, spirituality is considered subjective, abstract, and separated from reality [4]. From a biblical point of view, humans were created in the image and likeness of God. So, humans are said to be spiritual beings like God. In the words of Genesis (2:7), God made man out of the dust of the earth and breathed life into his nose, so that humans became the breath of life. The breath, in other words, the inspiration has given into human life. The bible says that God is the spirit and that human spiritual needs can be met only by communion with God.

To know more about the holy spirit spoken of in the bible, it is important to understand the concept of trinity in the bible. God is the holy trinity: the father, the son, and the holy spirit who cooperate. God’s work is accomplished according to the father’s plan through the revelation of the son, with the help of spirit. The body of the three in trinity is an integrated one. The bible says that when christians are filled with the holy spirit through their religious lives, due to the presence of the holy spirit in christians, Christians walk by the spirit, are led by the spirit, live by the spirit, and keep in step with the spirit (Galatians 5:16,18,25). Thus, the bible says that the mind governed by spirit obtains life and peace. When people live the day by the day given to them, the holy spirit is with them, and the strength obtained from God makes them overcome their illnesses. When christians experience God’s presence, God who is spirit works in christians. Christians are strengthened by spirits. Even if the human body is not healed, it is the holy spirit who gives the human the strength to rise again. It can be seen as an expression of spirituality from a christian perspective. From a biblical perspective, the spirit is invisible and formless. Going a little further, spirituality is a dynamic process of gaining strength by communing with God who is the spirit. According to Warren (2012), the strength of the holy spirit is not seen as a miracle or intensely emotional. The power of the holy spirit appears in human life in a peaceful way that most humans do not recognize.

It could be difficult for those in pain to realize and express their spiritual needs. Nurses should be prepared to identify and assist those in need of spiritual care in season and out of season. Let’s learn about the prayer. Prayer is asking and communicating to God in language. Prayer may take some forms, but it does not require a special form due to personal inner matters being more important than outer shapes [5]. In the bible “If you abide in me, and my words abide in you” (John 15:7), When the word of God dwells in the nurse, the nurse thinks and judges based on the word of God. In Nightingale’s note, praying nurses might set high standards and strictly monitor themselves in their nursing duties and lives. By praying in communion and cooperation with God, a nurse’s life and work become a prayer. Busy nurses can pray while walking down the hallway and providing care. Trained nurses can pray without closing their eyes and raising their hands [5]. Performing spiritual care does not mean praying or preaching next to the patient’s bedside. Nurses should not pray apart during work hours and this can lead to ethical concerns [5].

In addition, it is also important to understand the role of the clergy. In spiritual care performed by clergy, the priest had a brief conversation with the patient and then performed the religious worship service by reading the bible, praying, and having a formal communion. Religious patients seemed to be participating in a meaningful time. Through spiritual intervention with the priest, they were feeling spiritual inspiration within them. They might discover themselves as spiritual beings and have the strength to overcome disease by spending time contemplating the absolute, which leads to deep introspection and determination about life [6]. If intensive spiritual care is required, referring clients to the clergy would be recommended because the priest is a professional of theological knowledge and experience of religious practice compared to the nurses.

Nursing as a vocation & Nightingale’s environmental theory

Moreover, when nursing is viewed as both an art and a science, the nursing profession signifies an extraordinary mission with an adherence to the use of empirical evidence.

Nursing is a science-based profession that requires theoretical knowledge and practical skills. Shelly [7] regards spiritual nursing from the perspective of vocation as God’s work to the sick through a nurse who practices God’s love. From a calling point of view, according to Sawatzky (2005) [8], nursing is an expression of devotion to God by caring for the sick. Florence Nightingale describes herself as being called to caring as a coworker of God.

To briefly introduce Florence Nightingale, she established the philosophy of nursing education and emphasized nursing education to maintain the level of nursing. After realizing God’s principles surrounding the human body and nature, Florence Nightingale defines nursing as providing accurate (scientific) care for the spontaneous healing of human beings in the midst of pain [5].

Based on Nightingale’s environmental theory, Nursing is providing the right conditions (accurate care interventions according to nursing diagnosis/ medical diagnosis andcare plans) to the sick to heal [5]. To explain the reason, Sawatzky [8] says that Florence Nightingale puts the root of the scientific principles of nursing in spirituality. Trafford [9] who wrote an essay about Nightingale’s Environmental Theory says that Nightingale defined healing as bringing the body, mind, and spirit together to maintain a balanced health within humans. So, having healing conditions, which means providing appropriate nursing practice, is an imperative element of nursing care to maintain and/ or improve the health of patients [9]. So, sustainable fresh air, clean water, light, warmth, cleanliness, and a quiet atmosphere were crucial to healing. In turn, Nightingale’s environmental theory has good effects on the current nursing practice, personal hygiene, keeping patients clean, dryness to prevent infection, administration of balanced nutrition to enhance wound healing, and observation of the sick are today’s fundamental aspects of nursing [9]. According to Lee [5], nursing is not only an art but also a science. Nurses can participate in the healing process of a patient’s health by performing the nursing art of caring and standardized accurate nursing practice [9]. Nurses must do their best to ensure that nursing practice is provided scientifically [5]. Once nurses grasp the basic point of spiritual care, understanding the concept of spiritual care sets nurses performing spiritual care without being restricted by thought and behavior that makes nurses hesitate to do spiritual care due to uncertainty and ambiguity. Grasping the basicpoint of spiritual care allows nurses to act with confidence [5].

Understanding and Knowing Agonists, Atheists, and Believers

Nevertheless, balancing spirituality and religion in nursing care means that nurses know the basic principles and approaches for respecting the patient’s religious beliefs and personal views, like atheism, agnosticism, and faith in God. Each person has different physical, psychological, and spiritual needs. Thus, knowing the difference between those who know God and those who don’t know God is helpful for nurses performing spiritual care to make a distinction and a comprehension of that concept [4].

It seems complicated to see what is spirituality and religion differently. The difference between spirituality and religion could require a slightly different angle of analysis, let’s think about it together [10].

Some people may have a religion, but they may not be spiritual. Conversely, some people may use spirituality, but they do not have a religion [11]. From a holistic point of view that humans are made up of body, mind, and spirit, it is said that spiritual needs are not absolutely religious. Spiritual needs are more than religious worship and are personal to each person [11]. Going back to the beginning, the differences between agonists, atheists, and believers explained in biblical studies will be explained. It would be helpful to nurses if nurses recognize that concept properly.

The first ones are the agonists also known as the unbelievers. These are the ones who do not know God. Those who claim that there is no God. Those who have no desire to become a christian or who deny it. From a christian point of view, unbelievers do not belong to the spirit. Those who are not interested in the spiritual side.They satisfy their needs for survival with the satisfaction from the bodyand the world.

The next are the atheists who in contrast to the agonists, know God. Atheists who may know God but have not changed their personality. Atheists are those who believe incorrectly or who lack faith. Having a religion doesn’t mean they have faith. Their hopes are no different from those of unbelievers. So, when difficulties come, they cannot overcome them with the power of faith in God.

The last are the believers. Believers, unlike the atheists and the agonists, know God and have transformed in character. These are very religious people. Unlike those who do not believe, the inner person is transformed and mature. Because they need a lot of spiritual demands, they need peace and strength from God. They are those who keep their faith despite difficulties, find meaning in life, and mature in faith and character.

Koeing [4] explains that agonists and atheists have a conviction that values meaning, purpose, and personal belief in their lives, and that they have intimate fellowship with others while denying that they are spiritual and religious. According to Funning [12], spiritual nursing can be provided by nurses who are agonists or atheists.

According to Narayanasamy [13], spirituality is a broader concept than religion. Some people are very spiritual, but they may not have religions. Conversely, some people may be non-spiritual but they may have religions. Spirituality can be expressed through religion and it is said that spirituality can be a means of dealing with God [14].

Spiritual care is easy to be omitted due to it belonging to a very small part of fundamental nursing. Spiritual care is not limited to christian nurses. Incidentally, spiritual care is not limited to caring for the end of life. Spiritual care is applied to people of all ages, not onlyto the elderly and to those who die [11].

How to practice spiritual nursing

Understanding how to practice spiritual nursing is crucial for nurses as they play a pivotal role in helping patients facing illness or disability finds strength and peace in the midst of life crises. The main purpose of spiritual care is to help a person suffering from illness or disability gain strength and maintain peace.

Each person has different ways of dealing with life crises.

Lifetime crises such as illness, trauma, or loss are expressed as fear, anger, anxiety, and low self-esteem due to loss of meaning in life. According to Shelly [7], hospitalized patients may have destructive ideas that they may be harmed and even die. In the midst of illnesses, patients want to know the meaning and reason of their pains. The nurse is often the closest person to whom patients can reach. Spiritually trained nurses engage in spiritual care for patients to obtain strength and maintain peace by understanding the spiritual aspects of humans with the approach of the whole person based on the holistic view. Nurses should encourage their patients to adapt well to unexpected changes.

Spiritual nursing is not something to say about how it should be done [7]. Spiritual nursing is not performed in a special form and is no different from general nursing [5]. The way to identify a patient’s spiritual needs is to assess the patient’s spiritual state through listening and observation with therapeutic communication and interpersonal relationship skills. Once the conversation starts with the patients, the approach of spiritual care hasalready begun while communication comes and goes. While making conversation in the nurse-patient therapeutic relationship, the patient becomes aware of their condition, the patient realizes there is something inexplicable in human ability. The nurse continuously responds to the patient’s questions. When the patient confronts human limitations, the patient may begin to think of the existence of a divine being, and the patient may desire the way to divine being for their absolute necessity no matter whether they have religion or not [5].

Spiritual care is being within a compassionate presence. Spiritual care is to listen to those who are in pain while sharing their pain and providing an appropriate response to their pain [11]. Providing spiritual nursing is an approach that supports the spiritual needs of the patient and provides the necessary assistance such as showing concern and kindness, having empathy with them, taking the time to listen, and respecting their point of view [11] are required. The Science of Nursing is the act of helping patients achieve their health. In the midst of diseases, patients strive to find the meaning and purpose of life and the nature of the problem. In spiritual nursing, the nurse can help the patient express the personal meaning of the disease. Human disease can lead to many changes in normal thinking and stability [15]. In case patients are in unhealthy conditions, as the patients may understand their problems, they may try to solve their problems, and they may find appropriate solutions, nurses must support clients in illness to solve their problems [5]. As the illness progresses, when the possibility to heal is likely less, the patients are depressed [7]. Nurses can show them they are still loved and treated respectfully as human beings, not just diseases in spiritual nursing [15]. Supporting to discover the meaning of life through illness, to maintaining peace even in illness or death are the roles of nurses performing spiritual nursing [5].

During physical difficulties precipitated by illness, the patients may have questions and be keen to get answers about who they are, why illnesses happen to them, what life is, and what death is [7]. Therefore, if nurses do not have a deep understanding of life, nurses cannot help the patients. Nurses performing spiritual nursing should be careful not to be satisfied with what they have done. Nurses should not obsess over their desires to perform spiritual nursing. Nurses should not make their patients dependent on nurses [5]. Spiritual care must be provided scientifically [5]. The nurse can provide an appropriate standard of nursing interventions and support for patients suffering from physical illness and psychological anxiety while patients express spiritual needs during their illness process [5].

Nurses who provide spiritual care are required to assess the mental, spiritual, religious, and existential needs of patients as a whole person and their families within the scope of practice. Nurses who have prepared for spiritual nursing could be sensitive to and cope with certain spiritual issues [15]. In providing spiritual nursing care, nurses who are prepared for spiritual care can handle stress well, can accept themselves with confidence, enjoy life in harmony with others, and use the intentional and/ or unconscious therapeutic self [15].

Reviewing the concept of spirituality analyzed in the Science of Nursing

In addition, from the view point of nurses, many nurses reveal a lack of familiarity with the concepts of spirituality within the realm of nursing. According to Narayanasamy [13], many nurses are embarrassed that the outward appearance of spirituality is not scientific.

Some nurses may think that spirituality is only religious, which may be misunderstood as it may be considered abstract due to a lack of scientific explanation of spirituality [13]. According to Narayanasamy [13], there is a growing demand for a holistic approach in nursing that focuses on the whole person and takes care of the body, mind, and spirit. Spirituality is an essential dimension of human well-being. When looking at a person as a spiritual being, spirituality is a profound and central aspect of a person. Nurses who intend to practice spiritual nursing must study to understand the concepts of spirituality in terms of religious, existential, and biological aspects. By knowing the concepts of spirituality, the author intends to help nurses who practice spiritual care gain a sense of spiritual care due to a clear understanding of spirituality in education can lead to confidence in practice [10].

When thinking of spirituality, it is easy to think of it as a religion, something related to religion and something only limited to those who believe in God. According to Murray and Zentner (1989, p259), spirituality is beyond religion and is viewed as inspiration, awe, and meaning and purpose for those who do not believe in God due to spirituality being personal and universal. From the point of view of christian theory, humans are made up of body, mind, and spirit. Humans became a life because God breathed life into humans’ noses. God made human beings in the image of God. According to Narayanasamy (1999) [2], the importance of the christian faith is to emphasize the fruit of the holy spirit. It is the fruit of the inner attributes. “the fruit of the spirit is love, joy, peace, long-suffering, mercy, goodness, faithfulness, gentleness, and self-control” (Galatians 5:22-23). When christians bear the fruit of the holy spirit, it means that they are transformed through the holy spirit and restored to the image of God, and it means that they resemble the character of God. A nurse who has been transformed by the holy spirit can use the fruits of inner attributes to care for those in pain.

From an existential point of view, spirituality is universal to everyone beyond religion and is seen as an important aspect of life and daily life. Ruth Stoll studied two aspects of spirituality, which are vertical and horizontal, to define spirituality. The vertical dimension refers to the transcendence of life. The word transcendence means that humans go beyond the limits of their daily experience and reach a new perspective. For example, uplifting, inspiration, awe, wonder, and faith in a deity are related to spirituality in the vertical aspect. According to Sawatzky [8], transcendence refers to the ability of humans to understand a given situation in a way that reaches beyond the limits of their thoughts and reaches spiritual freedom and perfection. The perception of transcendence is through the relationship with the divine being, and the ultimate reality, understanding the nature of the ultimate problem, and then solving the problem beyond the limits of a given situation. Spiritual care can be provided without transcendental behavioral interventions that are contrary to ethics and can lead to concerns [8]. The horizontal dimension refers to experiences and individual values. Examples include relationships with a divine being, relationships with others, each individual’s lifestyle, quality of life, and nature (RCN, 2010). This horizontal dimension describes that spirituality is connected and interrelated with each individual, a divine being, others, and the world. From an existentialist point of view, it is universally claimed that humans have unique and potential spirituality [2]. The existential view states that humans have the ability and free will to realize each individual’s potential. Bernard, says that both agonists and atheists could be spiritual and have spiritual needs, along with an existential view. Agonists and atheists are alsomoral humans who judge right and wrong and act with responsibility. Spirituality (inner potential) motivates humans to find meaning and purpose in life. According to Stoll, human beings consciously or unconsciously choose the values that become the supreme focus of life and make life. These supreme values motivate human life to achieve their goals and desires. It says that this existential point of view of spirituality can be applied equallyto those with and/ or without religious beliefs.

Spirituality is biologically one of the elements of essence of hu- mans. According to Hay, humans recognize the existence of spirit in the way they find their identity within society regardless of re- ligion and feel unity in nature. Humans recognize the existence of the spirit with a feeling that is not separated from reality. Accord- ing to Hay, humans experience spiritual awareness when experi- encing a psychological, physical illness or other form of stress. Howden [16] analyzed four types of the concept of spirituality by studying the attributes of spirituality. As attributes of spirituality,’ the meaning and purpose of life’, ‘inner driving force’, ‘harmoni- ous relationship’, and ‘transcendence’ were presented. Therefore, spirituality is an element that reveals the meaning and purpose of life, inner strength, and transcendence through interconnection. Human spirituality can be revealed by spiritual demands expressed through thoughts and actions. According to Narayanasamy [13], spirituality imparts character and individuality to humans, and is the power and energy as an inner resource, and the guiding force that leads to life. Spirituality is an intangible dimension within humans that motivates humans to engage with others including a divine being. Human spirituality has a mystical nature. Peace and tranquillity are obtained according to what humans valuemost.

Human spirituality allows humans to grow and develop. Spirituality provides humans with wholeness, stability, wellness, security, hope, and peace. It also gives wisdom and inspiration [14]. So, when humans face emotional stress, physical illness, and death, spirituality forces humans to focus on life.

Conclusion

As the study has demonstrated, many individuals are unfamiliar with the concepts of spirituality. Spirituality perceived by the general public is considered subjective, abstract, and apart from reality. Humans are spiritual beings who consist of body, mind, and spirit. When humans are viewed as a whole, the human body, mind, and spirit form a mutual organic interaction. As per Narayanasamy [13], there is a growing demand for nurses to provide spiritual care. However, due to confusion over the concept of spirituality, spiritual care is not being delivered appropriately. Providing spiritual nursing can be challenging due to various factors such as insufficient time, overwhelming workload, ambiguity of spirituality, uncertainty about an individual’s religious views, and insufficient education on spiritual nursing. The author hopes to support nurses who are interested in knowing about spiritual care by presenting the ideas of spiritual care and spirituality from both the science of nursing and the biblical perspective.

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