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The meaning of spirituality: a literature review

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Journal of Advanced Nursing, 1997, 26, 1183–1188

The meaning of spirituality: a literature review

Jane Dyson MEd BA(Hons) RGN DipN RNT
Head of Nursing, University of Derby

Mark Cobb BSc

Palliative Care and Health Care Chaplain, Derbyshire Royal Infirmary NHS Trust

and Dawn Forman MBA PGDip(Research) TDCR MDCR

Dean of School of Health and Community Studies, University of Derby, Derby, England

Accepted for publication 27 November 1996

DYSON J., COBB M. & FORMAN D. (1997) Journal of Advanced Nursing 26,
1183–1188
The meaning of spirituality: a literature review
This paper presents a literature review in relation to the meaning of spirituality.
It is proposed that meeting the spiritual needs of patients is a fundamental part
of providing holistic nursing care, but that the assessment and meeting of those
needs is impeded by inadequate definitions and conceptual frameworks. It
should not be assumed that spirituality is either synonymous, or coterminous,
with religion, and it is suggested that to adopt this restrictive view is unhelpful
in the provision of individualized care. Reflection on the literature reveals that
the self, others and ‘God’ provide the key elements within a definition of
spirituality, and that other emerging themes namely meaning, hope,
relatedness/connectedness, beliefs/belief systems and expressions of
spirituality, can be articulated in the context of those three key elements. In
particular, it is proposed that the nature of ‘God’ may take many forms and,
essentially, is whatever an individual takes to be of highest value in his/her life.
It is suggested that the themes emerging from the literature can be utilized as a
framework to give practitioners and researchers a direction for future
exploration of the concept of spirituality.

Keywords: spirituality, meaning, religion, hope

Ross (1994) clearly identifies that spiritual care is a nurs-

INTRODUCTION
Nursing, in its claim to provide holistic care for clients, is
recognizing the need to address spirituality, one of the
dimensions upon which holism must be based. However,
cultural changes in the Western world have resulted in a
situation where, according to Ellis (1980) and Sims (1987),
‘religion’ and ‘sexuality’ have reversed their positions. In
Victorian times sexuality was hardly recognized, but spiri-
tual matters, albeit in a prescribed form, were freely dis-
cussed. Now, sexuality is recognized as an important area
of concern for nursing whereas spirituality is approached
with embarrassment and hesitation.
ing responsibility and not an optional ‘extra’ but suggests
that provision of such care is hindered by the lack of an
agreed definition of spirituality and the absence of a con-
ceptual or theoretical framework in which to deliver such
care. The concept that the provision for patients’ spiritual
needs is encompassed within the nurse’s role is also sup-
ported by Carson (1989) who emphasizes the centrality of
spirituality in making a person unique. Some nurse theor-
ists have also incorporated spirituality into their concep-
tual frameworks. This is particularly evident in the work
of Watson (1985, 1988), who specifically acknowledges
that spiritual awareness is one of the nurse’s responsibilities,

© 1997 Blackwell Science Ltd 1183

J. Dyson et al.
and Roy (1984) who makes a clear assumption that nurses
should have a role in meeting patients’ spiritual needs.
Reed (1992 p. 349) lends support to the centrality of spiri-
tuality in nursing and states that ‘spirituality in its broad-
est sense is a part of the ontologic foundation of nursing;
it is regarded as a basic characteristic of humanness,
important in human health and well being’.
If spirituality is recognized as such a key element in the
delivery of holistic nursing care, why does its definition
continue to elude the nursing profession?
Sims (1987) suggests that it may be partly related to the
adoption of the scientific paradigm by the nursing com-
munity and the increasing use of technology in care. She
claims that within such a context, the significance of spiri-
tuality is lost. Clark et al. (1991) also propose that science
and spirituality have become dichotomous concepts,
whilst Burkhardt and Nagai-Jacobson (1985) identify the
challenge that this affords the profession in integrating
spirituality into clinical practice.
Whilst the dominance of the scientific paradigm within
health care may be acceptable as a potential, and partial,
reason for inadequate spiritual care in nursing over the
past decades, the lack of agreed definition of the meaning
of spirituality continues to impede progress in this area.
This paper, therefore, seeks to review and elucidate some
of the available literature, and to identify themes and
relationships which can then be further explored in order
to identify appropriate assessment frameworks and
methods of providing for spiritual needs. This will enable
the practice of spiritual care in a real and meaningful
way and thus enhance the quality of care that patients
receive.
RELIGION AND SPIRITUALITY
One could contend that one of the major hindrances in
defining spirituality is its relationship with religion.
Narajanasamy (1993) found that most nurses appear to
understand that spirituality is about being ‘religious’ and
Moberg (1984) identified that most Americans, when asked
to define spiritual well-being, had no automatic answer
but the majority of responses were given in terms of
religious faith. This confusion is further compounded by
the fact that although there is a limited number of studies
which focus on spirituality per se, the majority of those
that do use subjects who hold Christian beliefs (Bown &
Williams 1993). Even those researchers who claim to take
a wider view (e.g. Reed 1987) still include questions about
prayer and religion. Clearly, the Judeo-Christian tradition
of western society cannot be avoided, and it is therefore
probably unrealistic to separate religion and spirituality
entirely.
However, the emerging paradigm in the study of spiritu-
ality is one which takes a broader view. Bown and
Williams (1993) suggest that seeing spirituality in terms of
1184 © 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 26, 1183–1188
religion alone, as much of the literature does, portrays a
very narrow conception of ‘holism’ and Moberg (1984)
clearly states that spiritual well-being is neither synony-
mous, or coterminous, with religiosity. Religion, according
to Steiger and Lipson (1985 p. 212) is ‘a social institution
in which a group of people participate rather than an indi-
vidual search for meaning’. As such, religion is more about
systems of practices and beliefs within which a social
group engage. This is not to say that religion has no part
to play in spirituality for some people. Indeed, Burkhardt
(1989) suggests that religion can provide a platform for the
expression of spirituality. However, she also proposes that
religious beliefs and practices can be dispiriting for a
person, inhibiting their own individual spirituality. This
relates to the concept of ‘nocebo phenomenon’ identified
by Helman (1990), whereby religious belief systems can
have negative effects on the health of an individual’s
beliefs and expectations.
Thus, in exploring the meaning of spirituality, there
needs to be a consideration of the concept outside of the
commonly held view that it is in some way exclusively
related to religion. For some individuals it may be, for
others it may not. If the profession is to establish a defi-
nition and conceptual framework of spirituality that
encompasses the needs of all its clients, this narrow and
restrictive view of relating the concept to religion must be
challenged and expanded.
SELF, OTHERS AND ‘GOD’
A strong emerging theme from the literature is the cen-
trality of the relationships between self, others and ‘God’.
Fish and Shelly (1988), Conrad (1985) and Morrison (1989,
1990) identify the importance to spiritual well-being of
‘right’ relationships between these three key elements.
Oldnall (1996) also supports the centrality of these
elements, suggesting that the focus of spirituality is on the
relationships between them.
Hay (1989) proposes that spiritual well-being results in
enhancement of one’s inner resources, supported by
Moberg (1984) who also suggests that the health of a per-
son’s inner resources is largely related to spirituality. Inner
strength is also identified as a result of spiritual well-being
(Burkhardt 1989) and Howden (1992) claims ‘innerness’,
or inner resources, and the discovering of wholeness to be
critical attributes of spirituality. This emerging theme,
then, suggests that one’s inner self and inner resources are
fundamental in the exploration of spirituality.
One’s relationships with others are also seen as pivotal
to spirituality. Hay (1989) suggests that spirituality occurs
in the context of the communities in which one is a part.
This gives a broader social view and alerts the reader to
the notion that spirituality can acquire different perspec-
tives according to the context of the individual. Many
authors also give credence to the notion that the state of

the self is largely reliant upon one’s relationships with
others. Renetsky (1979) identified an increased will to live
in those who believed in themselves and others, and links
between hope and one’s relationships with others have
been proposed by Hinds (1988) and Miller and Powers
(1988).
In the study performed by Ross (1994), nurses identified
a spiritual need as being one of giving and receiving love
and forgiveness from others and Stoll (1979) identified
relationships of trust and mutuality as being one of the
principal sources of hope and strength. Liehr (1989) also
claims that spirituality may be dependent on an individ-
ual’s ability to give and receive human elements, such as
touch, listening and committed presence in relationships
with others, whilst Mayeroff (1971) clearly stresses an
individual’s need for love and trust. This is further sup-
ported by Clark et al. (1991) who propose that trust is
accepted as the most fundamental ingredient of any
relationship. Other critical factors within relationships,
identified by Mayeroff (1971) and supported by Bevis
(1989), are honesty and genuineness.
Sodestrom and Martinson (1987) also suggest that
having a common bond with others is a major part of the
spiritual dimension and that this is achieved through
one’s relationships with others, whilst Oldnall (1996)
perceives that the focus of one’s spirituality can be seen
to be dependent on another person or on one’s
relationships.
The need for affiliation and interdependence has long
been recognized as part of human experience (e.g. Roy
1984) and has been explored within such disciplines as
psychology and social science. There are distinctive
humanistic and religious views of human relating but it is
clear that further exploration needs to take place concern-
ing the broader spiritual dimension in the context of
nursing.
The concept of having some sort of relationship with
‘God’ has traditionally been understood within a religious
framework. However, a more liberated and less restrictive
view of ‘God’ is emerging within the literature. Stoll (1979
p. 1574) provides a useful definition when she states that
‘whatever a person takes to be the highest value in life can
be regarded as his ‘‘ ‘God’ ’’. This definition does not reject
the notion of some form of God associated with deity and
religious systems, but it may include the less sacred and
more realistic concept that ‘the God around whom his life
revolves may be his work, physical activity or even him-
self ’ (Stoll 1979 p. 1574). Oldnall (1996) also identified
this concept of ‘God’ within the literature, suggesting that
spirituality may be dependent on some ‘thing’, for
example, work, money, personal gain. The key element in
this broader definition is that whatever the ‘God’ may be,
it provides a force which activates the individual or is an
essential principle influencing him/her (Vaillot 1977).
Clark (1987) also supports this broad view by suggesting
© 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 26, 1183–1188
The meaning of spirituality
that spirituality is essentially based upon the ‘life
principle’ of a person.
The notion of ‘God’ having a central role in the individ-
ual’s life is further argued by Jourard (1971 p. 307) who
contends that an individual’s ‘God’ will provide ‘the focus
and purpose of his time and life’.
The centrality of self, others and ‘God’ (however that is
defined by the individual), and the relationships between
those elements clearly emerges from within the literature.
These three elements provide a framework within which
other key themes can be articulated.
MEANING
The quest to find a meaning in life emerges as focal theme,
with self, others and ‘God’ and their relationships,
contributing to the finding of such meaning.
Howden (1992) identifies ‘purpose and meaning in life’
as being critical attributes in spirituality and includes in
this a search for relationships and situations that give a
sense of worth and a reason for living. Autton (1980) sug-
gests that this need for meaning is a universal trait, essen-
tial to life itself, and that a lack of meaning can lead to
spiritual distress and feelings of emptiness and despair.
This is also the much cited view given by Frankl (1959
p. 115), perceiving that man’s primary concern is ‘not to
gain pleasure and avoid pain but rather to see a meaning
in life’, and Bown and Williams (1993) contend that this
search for meaning is at the core of the individual’s being
and is the driving force behind intellect and emotion. The
discovering and struggling with meaning and purpose in
life is described in different ways. For example, Burkhardt
(1989) describes it as ‘unfolding mystery’ whilst Mische
(1982) perceives it as a sacred and existential journey.
Many other authors also perceive this search for mean-
ing as being a major component of spirituality (e.g.
Highfield & Cason 1983, Burkhardt & Nagai-Jacobson 1985,
Fish & Shelly 1988). However, meaning in life is also recog-
nized as a personally perceived phenomenon (Ellis 1980)
providing a person with uniqueness and individuality.
Frankl (1959) also claimed this view by proposing that the
meaning of life must be specific and personal, and can
only be realized by the individual.
Illness, suffering and death are perceived to challenge
the personal meaning systems that people hold (Sims
1987, Burnard 1988), but if meaning can be found, an indi-
vidual can find peace no matter how severe their illness
(Dickinson 1975). Antonovsky (1979) and Kobassa (1979)
also identified the ability to find meaning as an influencing
factor in a person’s ability to cope with stress, and
Renetsky (1979) found healthy self-love to be a predictor
of increased levels of being. However, if an individual is
unable to find meaning, all domains of life may be
affected (Burnard 1986) and spiritual distress will be
experienced.
1185
J. Dyson et al.
HOPE
According to Nowotny (1989) and Herth (1989, 1990),
hope is a spiritual need common to everyone. Examples
of ‘miraculous’ healings identify hope as being a central
feature (e.g. Gardner 1983). Indeed, Dominian (1983) sug-
gests that prognoses cannot be established on a scientific
basis alone, but must also account for the level of hope
within the individual. Ross (1994) also identified the
relationship between hope and a will to live, lending sup-
port to these findings. Hope can be identified in a number
of ways. Owen (1989) described it as a sense of energy
exchanged between people and their environment,
whereas Miller and Powers (1988) and Hinds (1988) per-
ceived hope as emanating from mutual affiliation and a
sense of concern for others as well as oneself. Francis
(1986) suggested that hope encompasses a sense of
relatedness to possibilities and powers beyond oneself and
the present. The source of hope has also been found to rest
with relationships with others, as identified by Clark et al.
(1991), when patients said that knowing that others cared
gave them hope, and hope was closely related to trust and
presence.
However it is defined, the majority of studies relating to
spirituality identify hope as a key component.
RELATEDNESS/CONNECTEDNESS
This emerging theme focuses on the relationship between
the three key elements previously identified — self, others
and ‘God’. Hungelmann et al. (1985) identified the inter-
connectedness of these three core elements as being at the
heart of spirituality. Ley and Corless (1988 p. 101) further
state that spirituality is ‘a state of connectedness to God,
to one’s neighbour and to one’s inner self ’. Fish and Shelly
(1988) continue to focus on the relationship that one has
with others by identifying sources of love and relatedness
as being key components of spirituality, and describe these
sources as coming from close relationships where there is
unconditional acceptance. This sense of relatedness and
connectedness is also described in terms of harmony —
harmony with the self, others and a sense of relatedness
to ‘God’ (Burkhardt 1989).
Lane (1987) suggest three forms of connectedness.
Firstly, the ability to engage in generative activities; sec-
ondly, the ability to belong to another; and thirdly, the
ability to achieve an inner sense of ultimate purpose.
When an individual utilizes these abilities they will
experience a sense of wholeness.
BELIEFS
This theme is one which can potentially cause confusion
between spirituality and religious faith, with many per-
ceiving beliefs to be connected with religious practices and
1186 © 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 26, 1183–1188
belief systems. However, if one defines ‘God’ as the con-
struct which represents the principal value in a person’s
life, and which patterns and shapes their beliefs, values
and choices, then, as Hay (1989) suggests, both religious
and non-religious belief systems should be considered in
the exploration of spirituality.
Clark et al. (1991) perceive the uniqueness of each indi-
vidual’s belief system in enabling them to have meaning
and hope, a view supported by Jourard (1971) who claims
that an individual holds a set of beliefs that help to explain
the meaning of life. This set of beliefs will emanate from
the driving force that gives meaning to the life of the indi-
vidual, whether that be, for example, their work, relation-
ships with others, and whatever that individual’s ‘God’
may be.
EXPRESSIONS OF SPIRITUALITY
Incorporating spirituality into the caring dimension
requires a sensitivity to the many ways in which
spirituality may be experienced, and thus expressed.
Whilst many accept the role of religious practices in the
expression of spirituality, given the emerging paradigm
and the incorporation of a broader perspective,
expressions of spirituality cannot be restricted to this
narrow view. If spirituality is concerned with the self,
others and ‘God’, the spiritual expression will take a
variety of forms.
Whilst experience would suggest that many hold a view
that art forms may provide an expression of spirituality
there is a paucity of literature in support of this view. Only
Cohen (1990) appears to support this, suggesting that
appreciation of music, food, wine, sex, literature and
humour can all reflect spirituality.
However, the literature does go beyond purely religious
practices as a means of expression. Burkhardt and Nagai-
Jacobson (1985) recognize the key elements within the
spiritual dimension suggesting that spirituality is
expressed and experienced in the context of caring connec-
tions with oneself, others, nature and ‘God’. These caring
connections may be expressed through happiness or crying
(Lindholm & Eriksson 1993), through relationships with
other people (Mayeroff 1971) and through the expression
of caring within those relationships exemplified through
hugging and holding (Oliver 1990).
CONCLUSIONS
Reflection on this literature review has identified a
working framework for the exploration of spirituality. This
framework primarily consists of the self, others and ‘God’
and the relationship between them. Within this overall
framework the emerging themes of meaning, hope,
relatedness/connectedness, beliefs/belief systems and the
expression of spirituality can be articulated. Whilst this

may not provide a definitive explanation of spirituality, it
does give a direction for health care practitioners and
researchers.
Sims (1987) suggests that although nursing as a pro-
fession strives to care for the whole person, in reality the
physical, social and psychological aspects are stressed
whilst spiritual care is often ignored or left to chaplains
or other spiritual leaders. The nursing profession needs to
realize its responsibilities, work closely with the multidis-
ciplinary team, and identify appropriate assessment frame-
works for spiritual needs, so that interventions to meet
those needs can be planned and implemented. Burkhardt
and Nagai-Jacobson (1985) suggest that spirituality is the
cornerstone of holistic nursing practice and Carson (1989)
proposes that spirituality should become the fourth recog-
nized domain of nursing. In order to explore this domain
and enhance client care, nurses need to reject an exclus-
ively scientific paradigm, which many claim has caused
the neglect of spiritual care, and utilize the art and
intuition of nursing.
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