Frontiers of Nursing • 7(2) • 2020

DOI: 10.2478/FON-2020-0014

Frontiers of Nursing

Research progress in the definition,

assessment tools, and practice of
spiritual care

Review

Lan Deng, Hua-Xia Liu*

School of Nursing, Shandong First Medical University, Tai’an, Shandong 271016, China

Received: 13 June 2019; Accepted: 14 September 2019; Published: 20 June 2020

Abstract:   To promote the development of nursing spiritual care and humanistic care, this article introduces the current status of the definition,
assessment tools, and practice of spiritual care at home and abroad.

Keywords:   spirituality • spiritual care • humanistic care • assessment

© Shanxi Medical Periodical Press.

1. Introduction proposed by the National Health and Family Planning

Commission (2017) that provide physical, psychologi-
With the development of a modern medical model, the cal, spiritual, and social support for patients with care
connotation of nursing has extended to provide holistic and humanistic care services.8 However, spiritual care,
care for patients at four dimensions: physical, psycho- as a key element of humanistic care, has not received
logical, social, and spiritual.1 Spirituality has attracted enough attention in China. Therefore, this article reviews
the attention of nursing science since the 1960s, and the definition, assessment tools, and clinical practice of
research about spirituality has gradually become a spiritual care to provide a reference for clinical nursing
hotspot in the past 20  years. In 1995, WHO added and research.
spirituality to the concept of health. Spiritual care is the
core element of physical-psychological-social-spiritual 1.1. The definition of spirituality
pattern and the integrating energy of the other three
aspects.2,3 The Joint Commission on Accreditation of Spirituality is an abstract, subjective, and complex.
Healthcare Organizations (JCAHO), The Association of Scholars have not yet reached a consensus on the con-
American Medical Colleges (AAMC),4 ICN ethics,5 and cept: Villagomeza9 believed that spirituality is an inher-
Malta Nurses’ ethics6 pointed out that spiritual care is ent trait of an individual, which could promote optimal
an important part of high-quality nursing service, and health and stability. Weathers et al.10 pointed out that
nurses are the main providers of spiritual care.7 It is also spirituality is a way of being that enables individuals

How to cite this article: Deng L, Liu HX. Research progress on definition, assessment tools, and practice of
spiritual care. Front Nurs. 2020; 2: 81-86.

* Corresponding author.
E-mail: huaxia66@163.com (H. -X. Liu). 81

Open Access. © 2020 Deng and Liu, published by Sciendo.   This work is licensed under the Creative Commons
Attribution NonCommercial-NoDerivatives 4.0 License.
 Research progress in the definition, assessment tools, and spiritual care

to experience the connection with themselves, others, patients to achieve the best health outcomes. It can be
nature, or super-energy and to discover the meaning of concluded that spiritual care is an activity for nurses
life and transcend suffering in difficulties. Fawcett and to evaluate and alleviate patients’ spiritual distress with
Noble11 held that spirituality is much broader than reli- the guidance of their spiritual values, which could help
gion, and it focuses on inspiration, meaning, and pur- patients to find out the meaning of life, self-realization,
pose of life. When individuals face emotional stress, hope and creation, faith and trust, calm and comfort,
physical illness, or death, spirituality becomes the focus. prayer, love and forgiveness, spiritual tranquility, and
Although the definition of spirituality has not yet been comfort.3,20
unified, it is agreed that spirituality is a process of seek-
ing meaning, pursuing integrity, uniqueness, and inner 1.3. Nursing theory related to spiritual care
harmony.12 Spirituality is multidimensional and individu-
alized. Shan13 indicated that spirituality is the feeling of Nightingale, the pioneer of nursing science, pointed out
peace in the process of integration, which also refers to that21 spiritual care is essential to meet human health
the pursuit of harmony between individuals and heaven, needs and promote rehabilitation. Henderson22 classi-
others, environment and the individual, the exploration fied the human basic needs into 14 items at the three
of eternal meaning and value of life, the maintenance of levels of body, mind, and spirit. Nurses should help
harmonious relations, and the transcendence of current patients to achieve the highest level of spiritual com-
difficulties. Above all, the spirituality can be described fort. In 1969, Maslow revised the theory of human basic
as attaining the purpose and meaning of life, guiding needs (XYZ theory),23 which involves spiritual needs,
the value orientation, and helping individuals to achieve and he also agreed that spirituality is a part of an indi-
self-transcendence.14 vidual’s self-identity, inner core value, and satisfactory
life. In Neuman’s system model,24 “holism” includes
1.2. The definition of spiritual care five interrelated items: physiology, psychology, social
culture, growth and development, and spirituality. All
Because of the complexity and abstraction of spiritual- of these are coping mechanisms of stress stimulation.
ity, the definition of spiritual care is also controversial. Spirituality can help individuals to find the meaning of
Sawatzky and Pesut15 pointed out that spiritual care is life, experience happiness and hope, and develop inter-
an instinctive, interpersonal, and altruistic integrated personal relationships. Watson’s theory25 of human
care based on the transcendental dimension of nurses’ caring also indicates that spiritual care is a force that
life. This concept reflects the essence of spiritual promotes individuals to discover self-worth and achieve
care; nurses seek available spiritual resources to help the harmony of body-mind-spirit.
patients discover the purpose and significance of life
within a better nurse–patient relationship. Mok et al.16 1.4. The significance of spiritual care
believed that spiritual care is a highly dynamic process
of interpersonal communication between nurses and Spiritual care is of great significance for both nurses and
patients, and during the caring process, nurses should patients. As for patients, spiritual care can help them
treat patients without any distinction, respecting their to explore the source of internal strength, increase the
unique values, satisfying their spiritual needs, and ability to cope with diseases, rebuild and maintain the
promoting their spiritual health. Edwards et al.17 held integrity of body-mind-society-spirit,26 promote the inte-
that spiritual care is not a simple nursing mission, but gration of patients with heaven, others, environments,
a way of caring to help patients to discover the mean- and self so that to promote the level of hope,16 allevi-
ing, hope, and strength of life. The Royal College of ate negative emotions such as anxiety and depression,
Nursing18 pointed out that spiritual care is nurses’ and increase resilience, cherish the meaning and value
duty to identify and satisfy patients’ spiritual needs for of life, gain inner peace and comfort, and improve the
meaning, self-worth, and belief support when he/she is quality of life.4
faced with trauma, illness, and grief. Govier19 used 5R On the other hand, providing spiritual care for
to define the concept: Reason and Reflection: helping patients can inspire nurses to reflect on their spiritual
patients to think and explore the meaning of life; Reli- belief system, think about the significance and value
gion: guiding patients with religion to depend on their of nursing work, cultivate their spirituality, and improve
belief system, values, and etiquette practice as a way the ability of humanistic care. In addition, dealing with
of spiritual expression; Relationship: establishing a patients’ spiritual issues can also increase nurses’
constant connection with self, others, and supernatural sense of achievement to stabilize the nursing team and
power; Restoration: providing spiritual care to enable reduce the loss of nursing staff.27–30

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2. Assessment tools for spiritual aspects of spiritual care, spirituality perspectives, attri-
butes of spiritual care). The scale was compiled in a
care multicultural context with good internal consistency
(Cronbach’s a  = 0.86). The shortcoming lies in that
Identifying patients’ spiritual needs and providing indi- some of the items evaluating the subject’s spiritual view
vidualized spiritual care depend on nurses’ awareness does not truly reflect their willingness to provide spiritual
and skills of spiritual care. Therefore, it is necessary care, which needs further improvement.
to evaluate the spiritual care status of nurses. A rel-
atively well-designed evaluation system has been 2.4. Spiritual care attitude scale (SCAS)
established.
Chiang et al.38 developed this tool in 2014, which contains
2.1. Spirituality and spiritual care rating scale 15 items and 3 dimensions (spiritual growth, core con-
cepts, and practices of spiritual care). The Cronbach’s a
(SSCRS) was 0.96, the correlation coefficient was between 0.55
McSherry et al.31 developed the scale in 2002 to explore and 0.82, and the content validity was also within the
nurses’ attitudes toward spirituality and spiritual care. normal range. During the process of scale psychologi-
The scale includes 17 items and 4 dimensions (spiri- cal testing, the author took full account of the diversity
tuality, religion, spiritual care, and individualized care). between Eastern and Western and deleted the items
In 2011, McSherry and Jamieson32 conducted a survey related to religion so that the applicability is much better
that involved 4,054 nurses, which showed that the Cron- in China.
bach’s a = 0.80. It has been widely used in more than
10 countries. Wu and Lin33 introduced the scale. The 2.5. Nurse spiritual care therapeutics scale
content validity index (CVI) of SSCRS in the Chinese
version was 0.98, Cronbach’s a was 0.83, and the reli-
(NSCTS)
ability and validity were good. The development of the In 2015, Mamier and Taylor39 developed the scale to
spirituality pre-test/post-test tool (SPPT)34 is also based assess the frequency of nurses providing spiritual care,
on the SSCRS, which has excellent psychometric prop- including 17 items, the internal consistency, and the
erties and can be used to evaluate the status of nurses’ aggregation efficiency of the scale was ideal, the CVI
spiritual awareness in China. was 0.88, the Cronbach’s a was 0.93, and the total cor-
relation coefficient of the item was between 0.40 and
2.2. Spiritual care competence scale (SCCS) 0.80. However, there was no dimension in the scale, and
the item did not specify the time and effect that the nurse
van Leeuwen et al.35 developed the scale to assess should spend in providing spiritual care either. Never-
nurse’s spiritual care ability. The scale includes 27 items theless, compared with other scales, NSCTS involves
and 6 dimensions (evaluation and practice of spiritual the least religious content and the best structural valid-
care, spiritual care quality improvement, patient support ity, which is an ideal spiritual care assessment tool.
and counseling, professional referrals, spiritual care
attitudes, and communication), the Cronbach’s a was 2.6. Nurses’ spirituality and delivery of
0.56–0.82, the homogeneity of each item was higher,
the correlation coefficient between the items was >0.25,
spiritual care (NSDSC)
and the test-retest reliability was better. It has been The development of the scale is based on the Eastern
translated into multiple languages. Research36 with clini- cultural background,26 which is used to assess nurses’
cal registered nurses in China supports the high degree perceptions of self and transcendence dimensions and
of internal consistency, split-half reliability, and valid- their perspectives and practice about spiritual care,
ity, all of these demonstrate its great value for further which contains 27 items and 4 dimensions (understand-
research. ing of transcendence, self, spiritual care, and spiritual
care practice), the CVI was 0.80, test-retest reliability
2.3. Spiritual care-giving scale (SCGS) was 0.89, Cronbach’s a was 0.80, all of these shows
that the scale is characterized by good psychometric
In 2012, Tiew and Creedy37 developed the scale to eval- properties.
uate the attitude of nurses/nursing students in providing Other similar spiritual care assessment tools that
spiritual care. The scale includes 35 items and 5 dimen- have not been widely used include spiritual care inven-
sions (spiritual care value, spiritual care attitudes, key tory (SCI)27 and spiritual care perception and practical

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 Research progress in the definition, assessment tools, and spiritual care

scale (SCPPS).2 The aforementioned scales mostly large-sample, and high-quality research and verify its
aim at evaluating nurses’ spiritual care knowledge, atti- long-term effects.
tude, and ability. The individualization of spiritual care
leads to great differences in different assessment tools.
Most of the scales are based on Western Christian cul-
4. Conclusions
tural background, which is not compatible with Chinese Foreign research on spiritual care has tended to be
national conditions. Moreover, the items of these scales mature, including concept analysis, theory research,
are indistinct from the contents of psychological care. development of assessment tools, and empirical
Based on the research objective and national condi- application, but little qualitative research has been
tions, we should choose or revise appropriate spiritual done. Domestic research on spiritual care is still in its
care assessment tools to explore the level of nurses’ infancy, which limited to introducing spiritual-related
spiritual care properly. concepts, assessment tools, and intervention methods.
The literature reviews are mostly described. Due to
the deficiency of localized spiritual assessment tools,
3. Clinical application of qualitative interviews are often used to explore patients’
spiritual care spiritual feelings. Chinese culture is deeply influenced
by Confucianism, Buddhism, and Taoism. Accord-
Based on the nursing process, spiritual care is a ingly, the spiritual care conditions are greatly different
procedure that the nursing staff adopts the human- from the development of Western religious culture.
istic communication skills to develop a harmonious Therefore, the growth of spiritual care in China should
nurse–patient relationship, giving more attention to adhere to the principle of localization. Here are some
patients, making patients’ physical, psychological, suggestions:
social and spiritual needs satisfied, no matter, so that
the patient is comforted and cherish the meaning and (1) Defining the localized connotation of spiritual
value of life. care.
Most of the research on spiritual care is to guide (2) Establishing distinctive spiritual care courses
patients to review their life and reconstruct cognition, (elective/compulsory) in universities to cultivate
explore and understand the meaning of life to achieve the spiritual care ability of nursing students,
inner peace finally. In 2010, Ando et al.40 conducted a promote the formation of correct spiritual cogni-
1-week life review interview with 38 patients diagnosed tion, increase their spiritual sensitivity, and lay
with terminal cancer, recalling, and recording their life. the foundation for providing holistic physical,
As a result, the life review was effective in improving the psychological, social, and spiritual care in the
spiritual well-being, alleviating psychosocial distress, future.
and promoting a good health outcome of terminally (3) Conducting continuing education and training for
ill cancer patients. In 2011, Chochinov et al.41 treated medical staff, granting professional certification
165 dying patients with dignity therapy to assist them of spiritual care qualification for them to ensure
in recalling the most meaningful events and express- the development of clinical spiritual care;
ing wishes in their lives. When the intervention finished, (4) Developing or revising assessment tools for
most of the patients expressed spiritual comfort and the indigenous spiritual care.
depression and sadness were also relieved. In 2012, (5) Performing spiritual care research activities to
Breibart et al.42 carried out a seven-stage meaningful accumulate localized experience.
therapy for 64 patients with advanced cancer, guid-
ing them to explore the meaning of life and illness. In
the short term, the spiritual health and quality of life of Ethical approval
patients were improved significantly. In 2017, Kuru43
found that laughter therapy can also improve patients’ Ethical issues are not involved in this article.
overall health, which refers to the physical, psychologi-
cal, social, and spiritual well-being. At present, there
is no principle standard for spiritual care. The diversi-
Conflicts of interest
fication of spiritual care prompts us to explore the opti- All authors declare that there is no conflicts of interest
mal mode of spiritual care and conduct multicenter, exist.

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