JAN ORIGINAL RESEARCH

Relationship of nurses’ spirituality to their understanding and practice

of spiritual care
Loretta Yuet Foon Chung, Frances Kam Yuet Wong & Moon Fai Chan

Accepted for publication 16 October 2006

Loretta Yuet Foon Chung PhD RN RM C H U N G L . Y . F . , W O N G F . K . Y . & C H A N M . F . ( 2 0 0 7 ) Relationship of nurses’

RSCN
Assistant Professor
School of Nursing, The Hong Kong
Polytechnic University, Hung Hom,
Kowloon, Hong Kong
Frances Kam Yuet Wong BSN MA PhD RN
Professor
School of Nursing, The Hong Kong
Polytechnic University, Hung Hom,
Kowloon, Hong Kong
Moon Fai Chan BSc PhD
Assistant Professor
School of Nursing, The Hong Kong
Polytechnic University, Hung Hom,
Kowloon, Hong Kong
Correspondence to L.Y.F. Chung:
e-mail: hslchung@inet.polyu.edu.hk
spirituality to their understanding and practice of spiritual care. Journal of
Advanced Nursing 58(2), 158–170
doi: 10.1111/j.1365-2648.2007.04225.x
Abstract
Title. Relationship of nurses’ spirituality to their understanding and practice of
spiritual care
Aim. This paper reports a study to examine the relationship of nurses’ spirituality to
their understanding and practice of spiritual care.
Background. Continued debate surrounds the concept, practice and teaching of
spirituality, highlighting the complexity and importance of understanding spiritu-
ality and the delivery of spiritual care. Spirituality is defined in this study as the
relationship with the self and a dimension beyond the self.
Method. A convenience sample of 61 nurses from a part-time Bachelor of Science
degree programme in nursing in Hong Kong, more than half of whom reported their
religious affiliations, completed a newly developed, 27-item five-point Likert scale
questionnaire. The data were collected in 2002. Descriptive statistics were calcu-
lated. Correlations were used to determine relationships among self, understanding
and practices of spiritual care. The Mann–Whitney U and Kruskal–Wallis tests were
used to examine differences between demographic variables and spirituality,
understanding and practices of spiritual care. Multiple linear regression was used to
determine factors contributing to understanding and practices of spiritual care.
Findings. A positive statistically significant correlation was found between self and
the following three variables: dimension beyond self (r ¼ 0Æ35, P < 0Æ001),
understanding of spiritual care (r ¼ 0Æ57, P < 0Æ001), and practice of spiritual care
(r ¼ 0Æ26, P < 0Æ05). The relative contributions of self to understanding (beta ¼
1Æ06, |t| ¼ 10Æ74, P < 0Æ001) and practice of spiritual care (beta ¼ 0Æ68, |t| ¼ 3Æ62,
P ¼ 0Æ001) were statistically significant. There was no statistically significance dif-
ference between any of the demographic variables and understanding and practice
of spiritual care, except for a negative relationship between religious affiliations and
the dimension beyond self (P < 0Æ001).
Conclusion. Through continuously seeking self-awareness and connecting to a
dimension beyond the self for inner resource, the contented whole self will be able to
provide spiritual care.

Keywords: carers, empirical research report, instrument development, nursing, self,

spirituality

158  2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd
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Introduction
Nursing history acknowledges its commitment to spiritual
care (ICN 1973, McSherry 2000), and the spiritual dimension
is regarded as an important (Shelly & Fish 1988, Carson
1989) and ethical obligation in holistic care (Wright 1998a,
Burkhardt & Nagai-Jacobson 2005). Yet, as medical ad-
vances make the nursing care more technological, the intent to
provide spiritual care as part of holistic care is often not put
into practice (Cavendish et al. 2004). Nurses who infrequently
assess patients’ spiritual needs may neglect spiritual care
(Labun 1988, Narayanasamy 1999b) and sometimes delegate
it to chaplains, especially if it is seen as a religious ritual
(Narayanasamy 1999a). Studies suggest, however, that spir-
ituality, as a resource for well-being (Oldnall 1995, Naraya-
nasamy 2004), although intimately related to health
(Davidhizar et al. 2000, Coleman 2003), is often neglected
(Cavendish et al. 2001). It has been suggested that nurses need
a personal spiritual perspective in order to provide spiritual
care (Dossey & Keegan 2000), but the diversity of descrip-
tions of spirituality and complexities in understanding
spiritual care (McSherry & Watson 2002, Bash 2004) create
a climate where it is difficult to isolate the core elements of the
relationship between the two. Few studies have researched the
relationship between nurses’ personal spirituality and delivery
of spiritual care. Our study seeks to shed light on this subject
by exploring nurses’ spiritual profile and their practice and,
furthermore, provide nurse educators with information which
should help them design relevant programmes.
Literature review
The literature provides several definitions of spirituality, empi-
rically based on quantitative and qualitative research method-
ologies (e.g. Oldnall 1996, Ross 1997, Narayanasamy 2001,
Bash 2004, van Leeuwen & Cusveller 2004, Villagomeza 2005),
or on concept analyses (Meraviglia 1999, Tanyi 2002, Sawatzky
& Pesut 2005). The concept of spirituality is viewed as subjective
(Hall 1997), representing worldviews of people from all walks
of life (Carson 1989). It is argued that a spiritual dimension is a
universal human phenomenon inherent in everyone, but the
degree of awareness varies (Pierce & Hutton 1992).
In our review, spirituality and nursing conceptual models,
spirituality and its characteristics, and perceptions and
practice of spiritual care will be presented.
Spirituality and nursing conceptual models
Historically, it is suggested that modern nursing grew out of
spiritual roots, and that spiritual care is a component of
 2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd
Spirituality and nursing care
holistic care (Bradshaw 1996, Taylor 2002). Both these
elements are apparent in Florence Nightingale’s model of
nursing which incorporated the Christian tradition of care, it
was holistically directed at the human being in entirety
created by a loving God (Nightingale 1996). Nightingale
believed that spiritual care is integral to human needs and
essential to healing (Macrae 1995, O’Brien 1999).
Holistic care sees individuals as a combination of physical,
social, psychological and spiritual components, which are
closely inter-related, and in which the whole is greater than
the sum of its parts (Cavendish et al. 2004). Many contem-
porary nursing theories also advocate holistic care and
perceive humans in this way (Barnum 1996, Dossey &
Keegan 2000), and claim that holistic care includes body,
mind and spirit (Narayanasamy 2001).
Nurses may still, however, lose the holistic perspective and
reduce human beings to different parts by focusing on specific
aspects and not giving adequate consideration to their inter-
relationships; consequently, the totality of care may be lost
and spiritual care is not integrated. For example, Henderson
(1966) assumed humans to be a set of different systems,
regulating specific activities. Although Henderson (1966,
1969) highlights the need to be able to worship according to
one’s faith, this is done in the context of urging nurses to be
informed and enable patients to achieve this.
Roy (1976) assumed a materialist view of the human as an
adaptation organism, and considered nursing care as primar-
ily involving the manipulation of physical systems to obtain
adaptation in the client using a stimulus-response behavioural
model. Roy (1984) modified this model to include issues of
human self-perception and development. Self-concept is
categorized into physical and personal selves. Personal self
is subdivided into the moral-ethical-spiritual self, self-consis-
tency, and self-ideal. The spiritual dimension of care is tied to
religion as an aspect of clients’ cultural belief systems, while
the moral-ethical-spiritual self is what validates behaviour.
Although a spiritual dimension of care was added, this
revised model was inconsistent with Roy’s understanding of
what a human being is. She did not attempt to reconcile the
inherent rationalist notion of the human self-concept (condi-
tioned by interaction and adaptation) with her later inclusion
of a human self that is subjectively and creatively experienced
(Bradshaw 1994).
Roy’s later work (Roy 1997, Roy & Andrews 1999, Roy
2000a,b) expands her discussion to focus on awareness,
purposefulness in the universe, enlightenment and faith, and
mutual relationships with God and the world, as integral
components of a human being, while adaptation is redefined
to stress the mutuality of person and environment. Roy
(2000b) encourages nurses to engage in scholarly dialogue
159
L.Y.F. Chung et al.
and envisioned nursing administrators shaping the future of
nursing care systems. Malinski (2002), on the other hand,
suggests researching spirituality and healing from the
perspective of awareness, choice, and person–environment
integration to find a new perspective which better reflects
Roy’s (2000b) vision for nursing.
These different understandings not only show that there
are different understandings of what is meant by ‘human
being’, but also differing worldviews. Martsolf and Mickley
(1998) adopted Fawcett’s (1995) categories of worldview
(reciprocal interaction and simultaneous action) to argue that
different worldviews may account for inconsistent definitions
of spirituality.
In the reciprocal interaction worldview, people are viewed
as having interactive dimensions (e.g. Roy 1984). Interactions
between people and environment are reciprocal and changes
may occur in either. Therefore, nurses assess clients’ physio-
logical, psychological, social, cultural and spiritual dimen-
sions and view them as interactive and interrelated, yet
unique.
The simultaneous action worldview identifies humans by
patterns and considers spirituality within this context (e.g.
Parse 1995a,b). Nurses recognize overall patterns of client
interaction with their environment by being present and
providing assistance in re-patterning (Martsolf & Mickley
1998).
Parse (1981, 1987) has continued her work in this field by
developing the theory of human becoming which assumes
that humans are open, unitary beings freely choosing
personal meaning and evolving towards greater complexity
through continuous transaction with the environment. She
presents three themes: meaning, rhythmicity and co-trans-
cendence. Meaning is discovered as apart of life, or in
moments of everyday existence, while rhythmicity refers to
co-creating rhythmical patterns of relating through revealing–
concealing, enabling–limiting while connecting–separating.
Co-transcendence is the process of reaching beyond the self.
Spirituality is implicit in such a view of human beings, which
allows for recognition of both nurses’ spiritual perspectives
and clients’ participative experiences. Furthermore, the
importance of nurses’ presence in the moment as a potential
means of illuminating meaning, synchronizing rhythms, and
helping people to improve their quality of life through
transcendence is recognized (Parse 1993, Walker 1996,
Cavendish et al. 2004).
Caring to Watson (1999) is fundamentally a spiritual act
that assists clients to achieve a greater sense of self, and
harmony of body, mind and soul (Taylor 2002). Watson
(2002) suggests the concepts of ‘intentionality’ and ‘con-
sciousness’ as a means to understand what happens in
160  2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd
transpersonal caring. ‘Transpersonal’ refers to deep connec-
tedness of relationship, subjective meaning and shared
humanity. Watson argues that the body is situated in a
spiritual environment within a field of consciousness, con-
nected and integral to all consciousness (Rafael 2000). When
people care, they move beyond ego to spiritual, cosmic
concerns and connections at the transpersonal spirit-to-spirit
level. Consciousness is shared intentionally, with the result
that healing potential actualized (Rafael 2000, Walton 2002).
Watson (2001) admits that her model is abstract and is still
evolving, but is a way to understand how delivery of spiritual
care is possible only through personal experience.
In brief, nursing scholars agree that humans are bio-
psycho-social-spiritual beings. Some scholars consider spirit-
ual care as the core (e.g. Nightingale, Watson), but others
treat it as an isolated dimension without any integration (e.g.
Henderson’s).
Spirituality and its characteristics
One of the obstacles in researching and practising spirituality
in nursing has been the lack of conceptual clarity and
consensus in understanding spirituality (Martsolf & Mickley
1998, McSherry et al. 2004, Gall et al. 2005). Spirituality can
be viewed as an integrating force (Kelley et al. 2002), or a
multidimensional concept including meaning, value, tran-
scendence, connecting and becoming (Martsolf & Mickley
1998). Common characteristics: (1) search for meaning and
purpose; (2) relationships; and (3) transcendence will be
discussed below.
Search for meaning and purpose
A quest for meaning and purpose is usually regarded as the
existential aspect of spirituality (Ross 1997, Fawcett & No-
ble 2004). Finding meaning can be interpreted as having a
specific goal and experiencing it in everyday living (Land-
mark et al. 2001). Each individual is personally responsible.
The search for a specific meaning to life provides not only a
primary motivational force (Frankl 1963, 1988), but also a
framework of reference to justify behaviour.
Recognizing the meaning of life is a core component of
spirituality inherent in holistic nursing theory. It recognizes
the wholeness of individuals and their connectedness to a
supreme being (Cavendish et al. 2001). Self-care is an
important factor in discovering meaning (Burkhardt &
Nagai-Jacobson 2002). Self-care facilitates self-awareness,
hence promoting growth, healing and transformation (Lau-
terbach & Becker 1996). The role of nurses is to encourage
clients in self-care activities to find meaning (Delaney 2005)
when illness intervenes, and present worldviews cannot
JAN: ORIGINAL RESEARCH
explain the situation. Worldviews are the mental manuals,
values and standards which explain the world and our lived
experiences, drive our behaviour (Pesut 2003), and help us to
make sense of our spirituality.
Relationships
Relationships are the connections we have with ourselves,
others, God/Supreme Being, and the environment (Stoll 1989,
Hungelmann et al. 1996, Burkhardt & Nagai-Jacobson
2002). Our relationship with ourselves comes about through
the integration of all our human dimensions and is known
through thoughts and feelings. It is manifested by inter-
dependent relationships with others, which encourages mu-
tual growth. However, it requires confronting our own
personal weaknesses, and working towards change. Through
acting in ways which achieve balance in interpersonal re-
lationships, we learn to be at ease with both independence
and interdependence (Pesut 2003). Furthermore, the pursuit
of balance also requires interaction with God/Supreme Being,
which may be expressed through activities such as reflection,
meditation, prayer, art, music, and nature appreciation.
Transcendence
Connectedness integrates the entire human, developing inner
strength and peace (Benzein et al. 1998, Kelley et al. 2002,
Tanyi 2002), as well as reaching out beyond personal con-
cerns and transcending self-boundaries (Reed 1992, Harrison
& Burnard 1993, Ross 1997).
The transcendent nature of spirituality makes it difficult to
comprehend through objective analysis alone; however,
through action and the synthesis of meaning, transcendence
can be understood (Kendrick & Robinson 2000). The
experience of transcendence is dynamic as it is a continual
search to find enrichment through connectedness. In our
study, we use the term ‘spirituality’ to denote the deepest core
of personhood, which entails relationships with the self,
others and God/Supreme Being in the search for meaning,
connectedness and transcendence.
Understanding and practice of spiritual care
Although there is a growing consensus in categorizing
characteristics of spirituality, there is less when defining
what is meant by ‘spirituality’ and ‘spiritual care’. Spirituality
is, however, usually perceived as personal and subjective
(Hall 1997, Smith & McSherry 2004).
However spirituality is defined, nurses’ self-awareness and
personal spiritual perceptions are important when providing
spiritual care (Dossey & Keegan 2000, Cavendish et al.
2004). It has also been shown in a number of studies that
 2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd
Spirituality and nursing care
explore nurses’ spiritual perspectives and care that hospice,
critical care, mental health and parish nurses show a
heightened sense of personal spirituality, and value the
integration of such care into their practice (Narayanasamy
& Owens 2001, Tuck et al. 2001, Cavendish et al. 2004,
Kociszewski 2004, Belcher & Griffiths 2005). These studies
identify the most frequent forms spiritual care offered by
nurses which include: listening, touching, being present,
prayer, use of religious objects, attendance at religious
services, talking with clergy, reading the bible (Don 2004),
conveying a benevolent attitude (Taylor et al. 1995), accept-
ance and non-judgemental attitude, validation of clients’
feelings and thoughts, facilitation, instilling hope (Sellers &
Haag 1998), discussing an issue in depth, suggesting the
clients seek help, making a referral to spiritual experts and
informing clients of local resources (Kristeller et al. 1999).
Another aspect of spiritual care arises from the assumption
that humans, as part of an indivisible, universal conscious-
ness, transcend space and time. Interventions such as visual-
ization, guided imagery, dream work, therapeutic touch or
Reiki therapy, are seen as ways of helping heal clients’ souls.
This kind of energy-based raises problems of competence in
delivery (Pesut 2006) and, furthermore, not only nurses but
also clients may feel uncomfortable or unconvinced about the
efficacy of such interventions. Indeed, Taylor and Mamier
(2005) found that spiritual care that was less intimate,
commonly used and not overtly religious was most wel-
comed.
Theoretical framework
To provide a definition of spirituality for this study, we
incorporated all characteristics described in the literature. We
make the assumption that individuals are personally respon-
sible for finding and pursuing their own existential meaning
and purpose. Through interacting with themselves and others
appreciation and development of the meaning of life are
heightened (Ross 1997, Fawcett & Noble 2004). Spirituality
is defined in our study as relationship with the self (the self
dimension) and with a dimension beyond ourselves (the
beyond dimension).
Our second assumption is that nurses need a personal
spiritual perspective in order to provide spiritual care (Dossey
& Keegan 2000). With dimensions of both the self and
beyond, we both connect with and transcend the everyday
world, and this is manifest in the spiritual care provided.
Spiritual care does not, however, take place in a vacuum but
is supported by our worldviews which underpin the two
dimensions and, in particular, our understanding of spiri-
tuality and spiritual care.
161
L.Y.F. Chung et al.
In summary, spirituality, and understanding and practice
of spiritual care, constructed the framework we used to
develop the instrument and test the following propositions:
• Nurses’ spirituality correlates with their understanding of
spiritual care.
• Nurses’ spirituality correlates with their practice of spirit-
ual care.
• Nurses’ demographic variables correlate with their spiri-
tuality, understanding and practice of spiritual care.
The study
Aim
The aim of our study was to examine the relationship of
nurses’ spirituality to their understanding and practice of
spiritual care.
Design
A correlational design was adopted and the data were
collected in 2002.
Power analysis
Based on MedCalc (2004), the required sample size was 84 in
order to achieve 80% power at 5% alpha level with a two-
sided test. A two-sided test was used because we tested our
null hypothesis of non-existing relationship between variables
against the alternative that some relationships existed, in
which the direction was unclear. However, only 61 respond-
ents were recruited, and the correlation coefficients of our
findings ranged from 0Æ26 to 0Æ57; therefore the power ranged
from 66% to 92% at 5% alpha on a two-sided test (MedCalc
2004).
Participants
A convenience sample of 61 students on a Bachelor of Science
in Nursing (BSN) programme at one university in Hong Kong
was recruited.
Study instrument
We developed a 27-item five-point Likert scale questionnaire,
the Nurses’ Spirituality and Delivery of Spiritual Care
(NSDSC), specifically for the study. The 27 items measured
nurses’ relationship with the self dimension and the beyond
dimension and their understanding and practice of spiritual
care. Items measuring demographic variables were appended
162  2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd
to the questionnaire. The beyond dimension (items 7–9)
refers to the relationship with God or a Supreme Being, and
the self dimension (items 1–6 and 15–21) refers to the
relationship with oneself; understanding and practice of
spiritual care were measured by items 10–14 and 22–27
respectively. In order to prevent any response-set bias, five of
the 27 items (18Æ5%) were phrased in a converse manner.
Validity and reliability of the instrument
Conceptually, four dimensions were identified: self, beyond,
understanding and practice of spiritual care. A panel of four
experts (three nurses involved in chronic care and one
researcher from a holistic care education centre) established
content validity for the instrument. We requested them to
evaluate the format and content of the questionnaire and
comment on each question, and to return the completed
validation form within 2 weeks. The comments of the experts
were used to calculate the content validity index of the
questionnaire, which was 0Æ80.
Test–retest reliability was performed with six nurses who
were asked to fill in the questionnaire twice within 2 weeks,
resulting in an overall test–retest reliability of 0Æ89 which we
deemed acceptable (Shelley 1984). First, serial calculations
of item-total correlation coefficients were identified, and items
that contributed very little (< 0Æ25) to the internal consistency
of the four dimensions were eliminated from the instrument
(Stevens 2002). We then carried out a factor analysis based on
the principal components method with varimax rotation to
examine the factor loading of each item in the instrument
(Table 1). A factor loading of 0Æ32 was required for an item to
be retained, and all 27 items met this criterion for further
analysis (Stevens 2002). Four factors were generated, which
accounted for 45Æ1% of the variance. Factor 1 (items 1–6 and
15–21) accounted for 11Æ2% of the variance, had a factor
loading range from 0Æ37 to 0Æ67, and reflected concerns
related to relationship with oneself. Factor 2 (items 7–9)
contributed 9Æ2% of the variance, had a factor loading range
from 0Æ63 to 0Æ67, and focused on the relationship between
oneself and the beyond dimension. Factor 3 (items 10–14)
contributed 13Æ0% of the variance, with a factor loading
range of 0Æ37 and 0Æ63, and demonstrated nurses’ under-
standing of spiritual care. Factor 4 (items 22–27) contributed
11Æ7% of the variance, had a loading range of 0Æ44–0Æ76, and
related to nurses’ spiritual care practice. The Kaiser–Meyer–
Oklin value was 0Æ55, and Barlett’s test of sphericity
reached statistical significance (v2 ¼ 653Æ75, d.f. ¼ 351,
P < 0Æ001), supporting the factorability of the correlation
matrix (Stevens 2002). Cronbach’s alphas for factors 1, 2, 3, 4
and overall were 0Æ74, 0Æ76, 0Æ73, 0Æ71 and 0Æ80. All results
JAN: ORIGINAL RESEARCH Spirituality and nursing care

Table 1 Factor analysis and item analysis of the instrument

Factor Score, Item-total

Scale loading Item mean (SD ) correlation Cronbach’s a

Factor 1: The self

1 0Æ44 I’m satisfied with my life when I have achieved my set goals 4Æ0 (0Æ5) 0Æ26 0Æ74
2 0Æ54 I still feel life is positive when I’m facing uncertainties 3Æ9 (0Æ6) 0Æ37
3 0Æ40 I find real purpose for my life 3Æ8 (0Æ7) 0Æ26
4 0Æ56 I set goals for myself even in times of difficulty 3Æ7 (0Æ7) 0Æ57
5 0Æ54 I don’t feel any relationship between my values and what I do 3Æ5 (0Æ9) 0Æ33
6 0Æ57 I still feel disturbed when I think about bad experience(s) I’ve had 2Æ7 (0Æ9) 0Æ26
15 0Æ63 I welcome change and perceive it as an opportunity for growth 3Æ9 (0Æ5) 0Æ42
16 0Æ60 I review my life periodically to search for and/or confirm my pursuits 3Æ8 (0Æ6) 0Æ50
17 0Æ67 I always have inner energy to pursue my goals in life 3Æ7 (0Æ6) 0Æ62
18 0Æ37 I believe I live up to my potential 3Æ5 (0Æ7) 0Æ28
19 0Æ63 I do something to show love for myself 4Æ0 (0Æ5) 0Æ40
20 0Æ65 I feel fragmented and have no energy for finding interest in things 3Æ6 (0Æ8) 0Æ45
21 0Æ58 I regard my spiritual health as good 3Æ8 (0Æ6) 0Æ37
Sub-total 3Æ6 (0Æ3)
Factor 2: Dimension beyond the self
7 0Æ63 I believe that God (a high power) loves me and cares for me 3Æ7 (0Æ9) 0Æ69 0Æ76
8 0Æ66 Prayer (to a high power) is an important part of my life 3Æ4 (1Æ0) 0Æ69
9 0Æ67 Spiritual reading (e.g. religious material, a good story, motto, etc.) 3Æ5 (0Æ8) 0Æ43
gives me direction in life
Sub-total 3Æ6 (0Æ8)
Factor 3: Understanding of spiritual care
10 0Æ39 Spiritual strengths can be drawn on to promote the healing of the 3Æ6 (0Æ8) 0Æ35 0Æ73
physical body
11 0Æ37 I believe nurses can provide spiritual care only by arranging the 3Æ3 (0Æ9) 0Æ27
client’s own religious leader if requested
12 0Æ58 I don’t believe nurses can provide spiritual care by showing concern 3Æ8 (0Æ7) 0Æ39
when giving care
13 0Æ63 I believe nurses can provide spiritual care by listening to the clients’ 3Æ9 (0Æ6) 0Æ47
concerns, discussing and exploring their fears, anxieties and troubles
14 0Æ51 I don’t believe nurses can help a client to find meaning in his/her illness 3Æ7 (0Æ7) 0Æ39
Sub-total 3Æ7 (0Æ4)
Factor 4: Practice of spiritual care
22 0Æ66 I usually explore the client’s religious practices 3Æ2 (0Æ8) 0Æ55 0Æ71
23 0Æ76 I usually explore the client’s spiritual values 3Æ1 (0Æ8) 0Æ57
24 0Æ69 I usually explore the client’s hopes and sources of strength 3Æ6 (0Æ7) 0Æ54
25 0Æ44 I refer the client to his/her spiritual counsellor (e.g. hospital chaplain) 3Æ8 (0Æ8) 0Æ26
if needed
26 0Æ62 I usually comfort clients spiritually (e.g. reading books, prayers, music, etc.) 3Æ4 (0Æ7) 0Æ45
27 0Æ46 I will sit with the client if needed 3Æ7 (0Æ6) 0Æ31
Sub-total 3Æ5 (0Æ5)

The Kaiser–Meyer–Oklin value ¼ 0Æ55; Barlett’s test (v2 ¼ 653Æ75, d.f. ¼ 351, P < 0Æ001); overall alpha ¼ 0Æ80; overall mean total ¼ 3Æ60,
SD¼ 0Æ29.

demonstrated a satisfactory internal reliability threshold for a
new instrument (Shelley 1984).
Ethical considerations
A university human ethics committee approved the study.
Recruitment was undertaken by a research assistant during
the 2002 class recess of the BSN course. After explanation
of the nature, procedures and potential significance of the
study, as well as assurances of confidentiality and the right
to withdraw, all 61 study participants signed consent
forms. The questionnaires were then distributed with the
request to return them to a designated mail box within
2 weeks.

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L.Y.F. Chung et al.

the beyond dimension and understanding of spiritual care to

Results
be significant (rs ¼ 0Æ33, P < 0Æ05).

Participant characteristics
Relationship of demographic variables with spirituality,
The majority of nurses were single, young women with
understanding and practice of spiritual care
experience of admission to hospital either as a patient or a
patient’s relative. Thirty-four (63Æ4%) reported their religious Mann–Whitney U and Kruskal–Wallis tests were performed
affiliations as Christianity (40Æ9%), Buddhism (8Æ2%) and to detect any differences between demographic variables and
Taoism (14Æ3%). The mean length of total postregistration spirituality, and understanding and practice of spiritual care
work experience was 6Æ3 years, 3Æ0 years in their present (SPSS, version 10.0, SPSS Inc. 2001). As shown in Table 4, we
specialty (Table 2). found no statistically significant relationship between any
demographic variables and the self, beyond dimension,
understanding and practice of spiritual care except nurses’
Relationship of nurses’ spirituality to their understanding
religion. Nurses who had no religion belief had a higher
and practice of spiritual care
beyond dimension score (mean ¼ 3Æ9, SD ¼ 0Æ7) than nurses
A correlation matrix of the self and beyond dimensions, who claimed a religious belief (mean ¼ 3Æ1, SD ¼ 0Æ6,
understanding and practice of spiritual care is shown in P ¼ 0Æ001).
Table 3. A significant positive correlation was found between
the self and beyond dimensions (rs ¼ 0Æ35, P < 0Æ001), the
Factors contributing to understanding and practice of
self and understanding of spiritual care (rs ¼ 0Æ57,
spiritual care
P < 0Æ001), and the self and practice of spiritual care
(rs ¼ 0Æ26, P < 0Æ05). We also found the correlation between We used multiple linear regression analyses to determine the
contribution of the self and beyond dimensions to under-
standing and practice of spiritual care, adjusted by age and
Table 2 Participants characteristics work experience both postregistration and in present speci-
n (%) alty.
Table 5 shows that the self was statistically significant
Sex
(beta ¼ 1Æ06, |t| ¼ 10Æ74, P < 0Æ001) in relation to under-
Male 6 (9Æ8)
Female 55 (90Æ2) standing of spiritual care, but not to the dimension beyond
Marital status the self (beta ¼ 0Æ01, |t| ¼ 0Æ11, P ¼ 0Æ916), nor other
Married 25 (41Æ0) adjusted factors. With regard to practice of spiritual care,
Unmarried 36 (59Æ0) our results showed that the self was statistically significant
Age (years)
(beta ¼ 0Æ68, |t| ¼ 3Æ62, P ¼ 0Æ001) but the beyond dimen-
21–30 33 (66Æ0)
31–40 13 (26Æ0) sion (beta ¼ 0Æ19, |t| ¼ 1Æ16, P ¼ 0Æ258) and other adjusted
40þ 4 (8Æ0) factors were not.
Religious affiliation
Yes 34 (63Æ4)
Christianity (40Æ9) Discussion
Buddhism (8Æ2)
Taoism (14Æ3) Relationship of spirituality to understanding and
No 18 (34Æ6) practice of spiritual care
Work experience
Postregistration (years) Our study demonstrates correlations between nurses’ self,
Mean (SD ) 6Æ3 (6Æ4) beyond dimension, understanding and practice of spiritual
Range 0Æ5–31Æ0
care. As stated in the theoretical framework session, spiritu-
Present specialty (years)
Mean (SD ) 3Æ0 (3Æ3) ality refers to relationships with the self and with God/a
Range 0Æ0–15Æ0 Supreme Being (i.e. the beyond dimension). Only the self and
Previous hospitalization not beyond dimension was a statistically significant factor in
The self 24 (43Æ6) practice of spiritual care. A correlation between nurses’
Relatives 27 (49Æ1)
spirituality and understanding of spiritual care is logically
The self and relatives 4 (7Æ3)
implied, but not the practice of spiritual care. This finding is

164  2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd
JAN: ORIGINAL RESEARCH Spirituality and nursing care

Table 3 Correlation (rs) matrix of the self,

Dimension beyond Understanding of Practice of
beyond, understanding and practice of
the self spiritual care spiritual care
spiritual care
The self (13 items) 0Æ35** 0Æ57** 0Æ26*
Beyond (3 items) 0Æ33* 0Æ11

*P < 0Æ05; **P < 0Æ001.

Table 4 Comparison of the self, the dimension beyond the self, understanding and practice of spiritual care by demographics

Spirituality and spiritual care

The self, Dimension beyond Understanding, Practice,

Demographic n mean (SD ) the self, mean (SD ) mean (SD ) mean (SD )

Sex
Male 6 3Æ7 (0Æ1) 3Æ2 (0Æ7) 3Æ5 (0Æ4) 3Æ8 (0Æ6)
Female 55 3Æ6 (0Æ4) 3Æ6 (0Æ8) 3Æ7 (0Æ4) 3Æ4 (0Æ5)
Mann–Whitney U-test U ¼ 149Æ5, P ¼ 0Æ714 U ¼ 113Æ5, P ¼ 0Æ218 U ¼ 116, P ¼ 0Æ247 U ¼ 118, P ¼ 0Æ268
Marital status
Married 25 3Æ7 (0Æ3) 3Æ5 (0Æ8) 3Æ7 (0Æ5) 3Æ4 (0Æ5)
Unmarried 36 3Æ6 (0Æ3) 3Æ6 (0Æ7) 3Æ6 (0Æ4) 3Æ5 (0Æ4)
Mann–Whitney U-test U ¼ 377, P ¼ 0Æ678 U ¼ 422, P ¼ 0Æ678 U ¼ 433Æ5, P ¼ 0Æ806 U ¼ 384Æ5, P ¼ 0Æ333
Age (years)
21-30 33 3Æ6 (0Æ4) 3Æ6 (0Æ7) 3Æ7 (0Æ5) 3Æ4 (0Æ5)
31-40 13 3Æ6 (0Æ3) 3Æ4 (0Æ9) 3Æ6 (0Æ3) 3Æ3 (0Æ5)
40þ 4 3Æ7 (0Æ2) 3Æ3 (1Æ1) 3Æ5 (0Æ6) 3Æ7 (0Æ3)
Kruskal–Wallis test v2 ¼ 0Æ97, P ¼ 0Æ617 v2 ¼ 0Æ384, P ¼ 0Æ825 v2 ¼ 1Æ17, P ¼ 0Æ558 v2 ¼ 2Æ79, P ¼ 0Æ248
Religious affiliation
Yes 18 3Æ6 (0Æ4) 3Æ1 (0Æ6) 3Æ6 (0Æ5) 3Æ6 (0Æ5)
No 34 3Æ7 (0Æ3) 3Æ9 (0Æ7) 3Æ7 (0Æ4) 3Æ5 (0Æ4)
Mann–Whitney U-test U ¼ 270, P ¼ 0Æ487 U ¼ 129, P ¼ 0Æ001 U ¼ 238, P ¼ 0Æ185 U ¼ 282, P ¼ 0Æ641
Work experience
Postregistration (years), rs 61 0Æ203, P ¼ 0Æ116 0Æ089, P ¼ 0Æ496 0Æ124, P ¼ 0Æ340 0Æ174, P ¼ 0Æ180
Present specialty (years), rs 61 0Æ09, P ¼ 0Æ591 0Æ245, P ¼ 0Æ138 0Æ128, P ¼ 0Æ443 0Æ075, P ¼ 0Æ655
Previous hospitalization
The self 24 3Æ7 (0Æ4) 3Æ7 (0Æ9) 3Æ7 (0Æ5) 3Æ4 (0Æ5)
Relatives 27 3Æ6 (0Æ3) 3Æ5 (0Æ6) 3Æ6 (0Æ4) 3Æ4 (0Æ5)
The self þ relatives 4 3Æ8 (0Æ2) 3Æ4 (1Æ0) 3Æ7 (0Æ3) 3Æ7 (0Æ3)
Kruskal–Wallis test v2 ¼ 2Æ54, P ¼ 0Æ281 v2 ¼ 1Æ21, P ¼ 0Æ546 v2 ¼ 0Æ34, P ¼ 0Æ845 v2 ¼ 1Æ24, P ¼ 0Æ54
Life event
No 43 3Æ6 (0Æ3) 3Æ5 (0Æ7) 3Æ6 (0Æ4) 3Æ5 (0Æ5)
Yes 13 3Æ8 (0Æ4) 3Æ8 (0Æ8) 3Æ8 (0Æ5) 3Æ5 (0Æ6)
Practice 5 3Æ6 (0Æ1) 3Æ4 (0Æ8) 3Æ6 (0Æ4) 3Æ3 (0Æ4)
Kruskal–Wallis test v2 ¼ 1Æ55, P ¼ 0Æ460 v2 ¼ 1Æ81, P ¼ 0Æ404 v2 ¼ 1Æ64, P ¼ 0Æ440 v2 ¼ 1Æ40, P ¼ 0Æ498

different from those of other studies that show that nurses’
spirituality is a significant factor in supporting the under-
standing and practice of spiritual care. Cavendish et al.
(2004), for example, asserted that nurses’ spirituality was
intrinsic to their lives and was the basis of their spiritual care
practice. Belcher and Griffiths (2005) surveyed 204 hospice
nurses about their spiritual practices and their ability to apply
their spiritual values to client care, and concluded that
personal spirituality and a knowledge base of spiritual care
needs were statistically significant factors supporting spiritual
caregiving.
The 13 self items in the NSDSC questionnaire refer to
the relationship with the self in searching for and reviewing
the purpose of life, living up to personal values, satisfaction
with life, loving oneself and evaluating one’s own spiritual
health. The three beyond items refer primarily to a
personal relationship with a higher being that gives inner
resource and direction to life. The five items relating to
understanding of spiritual care concern beliefs held about
spiritual care, and the six items relating to practice of
spiritual care focus on managing relationships with clients
in giving spiritual care (e.g. exploring clients’ hopes and

 2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd 165
L.Y.F. Chung et al.
Table 5 Multiple linear regression (n ¼ 61) on factors contributing to understanding and practice of spiritual care
Spiritual care
Understanding
Factor Beta |t|-statistics
The self 1Æ06 10Æ74
Dimension beyond the self 0Æ01 0Æ11
Age 0Æ10 0Æ61
Postregistration experience 0Æ01 0Æ74
Present specialty experience 0Æ03 0Æ80
F ¼ 772Æ21, P < 0Æ001, adjusted R2 ¼ 0Æ992
*Significant at P < 0Æ05.
sources of strength, spiritual values, and being with clients
if needed).
In addition, the results of our multiple linear regression
analyses demonstrate the contribution of the self to under-
standing and practice of spiritual care adjusted by age, work
experience (postregistration and in current specialty). The
importance of the self to spiritual care is shown through the
need for continuous development within the self through
seeking greater self-awareness, wholeness and a sense of
satisfaction. The contented whole self reaches out to under-
stand others (Chilton 1998) and enables us to focuses on
others’ concerns when delivering spiritual care (Kendrick &
Robinson 2000).
Relationship of demographic variables with spirituality
and understanding and practice of spiritual care
No differences were found between the demographic vari-
ables and understanding or practice of spiritual care. These
findings are inconsistent with those of Cavendish et al.
(2004), where married people scored higher on the spiritual
perspective scale (SPS) than single people or those living with
a significant other. Both young (under 40) and older (above
40) nurses with a religious affiliation had higher SPS scores
than their counterparts with no religious affiliation.
Another finding, that the beyond dimension is negatively
related to religion, questions the claim that spirituality equals
religion (Weaver & Flannelly 2004). This finding reminds us
to differentiate religion and spirituality (Labun 1988, Reed
1991, Peri 1995).
This phenomenon may be symptomatic of different inter-
pretations of religion and spirituality. Religion has been
understood both individually and institutionally. James
(1902, cited in Hill & Pargament 2003) distinguished a
firsthand, experiential religion that is direct and immediate
from a secondhand institutional religion that is an inherited
tradition. Religion has arguably now become separated from
166
Practice
P-value Beta |t|-statistics P-value
<0Æ001* 0Æ68 3Æ62 0Æ001*
0Æ916 0Æ19 1Æ16 0Æ258
0Æ55 0Æ09 0Æ29 0Æ772
0Æ465 0Æ03 0Æ88 0Æ385
0Æ432 0Æ05 0Æ66 0Æ515
F ¼ 166Æ41, P < 0Æ001, adjusted R2 ¼ 0Æ965
spirituality (Hollins 2005). The term religion is usually used
to describe a fixed system of ideological commitments,
regulating the conduct of members, and the rites and
practices used in the system of worship (Ellis 1980).
Spirituality, however, can be defined as the quality of having
a dynamic and personal relationship with God (Ellis 1980).
This suggests that people may be so readily absorbed in the
rituals and regulations of the prescribed routine of a
particular religion (Vassallo 2001) that they lose sight of
the meaning itself and the process of its manifestation
(Matthew, Chapter 23 in the Bible).
Nurses tend to equate spirituality with religion (Oldnall
1996, Narayanasamy 1999c), possibly due to their nursing
heritage. Bown and Williams (1993), however, suggest that
nurse researchers focusing on religion but not spirituality to
study holism limit the understanding of holistic care, as
holism supports spirituality as a dimension of personhood
including those with no formal religious belief.
Spirituality is personally experienced and interpreted. Only
the individual can tell others about his/her spirituality
(Harrison & Burnard 1993, Hall 1997), which is character-
ized by personal meanings that define identity, life purpose,
wellness, illness and relationships with others (Duldt 2002).
Religion refers to specific faith traditions and unique
theological and scriptural orientations. However, there is
debate about the relationship between religion and spiri-
tuality. For example, Dyson et al. (1997) argue that a
differentiation of religion and spirituality is required to
encourage the development of a definition of spiritual care,
while Hammond (2003) states that most people who practise
a religion believe spirituality and religion to be inseparable.
Religion is a set of beliefs that attempts to answer life’s
questions and provide guidelines to which individuals adhere.
Individuals’ quest for meaning can be raised from an
individual level by participation in a religious community
(Hammond 2003). Although religion can provide a platform
for the expression of spirituality, it is contended that
 2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd
JAN: ORIGINAL RESEARCH
What is already known about this topic
• There is a widespread interest in understanding spir-
ituality and spiritual care.
• Spirituality is often considered to be elusively but posi-
tively related to religion.
• Nurses can and should assess the spiritual needs of
patients and provide spiritual care.
What this paper adds
• Nurses’ own spirituality seems to influence their deliv-
ery of spiritual care.
• The negative relationship of religion with the dimension
‘beyond the self’ implies that religion cannot be equated
to spirituality.
• In order to be able to care for the client spiritually,
nurses need to care for themselves by continuously
promoting harmonious integrity.
belonging to a religion does not automatically mean one is
spiritual (Burkhardt 1989, Helman 1990); this is empirically
supported by our study.
Implications for nursing practice
Nurses’ ability to participate in a holistic nursing relationship
is dependent upon personal, professional and, crucially,
spiritual development. If nurses ignore their spiritual health
or spiritual issues in life, it seems that they will find difficulty
in addressing clients’ spiritual needs (Barnum 1996, Wright
1998b, Cumbie 2001). Both nursing education and admin-
istration play an important role in developing strategies that
allow students and nurses to explore their own spirituality
and provide spiritual care (Shih et al. 2001, Pesut 2003,
Cavendish et al. 2004). Useful strategies include encouraging
people to live a balanced life and promoting a caring
environment (Gallia 1996, Greenstreet 1999, Catanzaro &
McMullen 2001). Other suggested strategies involve building
a curriculum that incorporates an appreciation of spirituality
in different cultures and fosters a climate of spirituality that
promotes intra- and interpersonal connectedness between
students and teachers, and nurses and clients (Pesut 2003).
With the input of the curriculum, students and teachers can
relate to each other as peers and support each other
personally and professionally in searching for and practising
spiritual care (Schaffer & Juarez 1996, Grams et al. 1997).
It is suggested that knowing a person’s religion does not
reveal all aspects of their spirituality (Dyson et al. 1997). It is
simplistic to say that nurses should assess spiritual needs and
 2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd
Spirituality and nursing care
provide spiritual care with no consideration of the uniqueness
of spiritualities and practicalities for practice (Oldnall 1996).
Therefore, promoting spirituality and spiritual care cannot be
prescriptive (Pesut & Sawatzky 2006).
Study limitations
Given the data were collected only with Hong Kong nurses at
one small university and that a self-report method was used,
caution is needed in generalizing the findings.
Conclusion
Our findings add to the emerging empirical work on
spirituality. Nurses’ spirituality correlated with their under-
standing of spiritual care. Holistic care is possible only when
the nurse is conscious about the self that is integrated and
harmonious. A disharmonious and fragmented nurse cannot
bring a sense of harmony to the client. In contrast, nurses
with a whole self can care beyond themselves and pay
attention to clients’ concerns. In order to be able to care for
the client spiritually, nurses need to care for themselves by
continuously promoting harmonious integrity. Through ser-
enity, nurses come to realize how to relate the self with a
dimension beyond, and in turn can connect with the client
spiritually. Suggestions are given for nursing education and
management to promote a climate to foster spiritual health
and care. Further research is needed to explore these findings
with larger samples of nurses and also from the clients’
perspective. In addition, qualitative studies to explore nurses’
concept of the beyond dimension and whether traditions have
an influence on their views of spirituality are needed to
enhance the evidence-base.
Acknowledgements
The authors wish to acknowledge the School of Nursing, The
Hong Kong Polytechnic University, for granting a Learning
and Teaching Project Fund to support this study, as well as
the nurses who volunteered to participate in this study.
Author contributions
LYFC and FKYW were responsible for the study conception
and design and LYFC was responsible for the drafting of
the manuscript. CLYF performed the data collection and
LYFC, FKYW and MFC performed the data analysis. LYFC
obtained funding and provided administrative support.
LYFC and FKYW made critical revisions to the paper. MFC
provided statistical expertise. FKYW supervised the study.
167
L.Y.F. Chung et al.
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