Differentiating the diagnoses through a review of the nursing literature

Spirituality and religiousness: Differentiating the diagnoses through a review of the nursing literature

Burkhart, Lisa

PURPOSE. To differentiate the definitions of spirituality and religiousness as used in nursing literature.

DATA SOURCES. Journal articles, books, book chapters.

DATA SYNTHESIS. The nursing literature has been inconsistent in defining spirituality and religiousness. The spirituality literature defines spirituality as the broader concept, with religiousness as a subconcept, while the religiousness literature defines religiousness as the broader concept, with spirituality as a subconcept.

CONCLUSIONS. Spirituality and religiousness are two separate nursing diagnoses with some common elements to both.

PRACTICE IMPLICATIONS. The growth of parish nursing as an ANA-recognized specialty practice has heightened the awareness of caring for the human spirit. Clarity is needed in the terms used to define this specialty.

Search terms: Nursing diagnosis, religion, religiousness, spirituality

Spiritualite et religion: Differencier les diagnostics par le recensement des ecrits professionnels infirmiers

BUT. Differencier les definitions de Spiritualite et de Religion dans les publications infirmieres. SOURCES. Articles, ouvrages, chapitres d’ouvrages.

SYNTHESE DES DONNEES. Les definitions de la spiritualite et du caractere religieux retrouves dans la litterature professionnelle, presentent quelques incoherences. Les articles sur la spiritualite definissent la spiritualite comme un concept plus large que la religion, alors que les articles sur la religion presentent celle-ci comme un concept plus large et la spiritualite comme un sous-concept.

CONCLUSION. La spiritualite et la religion sont deux diagnostics infirmiers distincts ayant des elements communs.

IMPLICATIONS POUR LA PRATIQUE. Le developpement des soins infirmiers paroissiaux en tant que specialite reconnue par l’Association des Infirmieres Americaines a augmente la prise de conscience des soins centres sur l’aspect spirituel de la personne. Il est donc important de clarifier les themes utilises pour definir cette specialite.

Mots-cles: Caractere religieux, diagnostic infirmier, religion, spiritualite

Espiritualidade e religiosidade: Diferenciando os diagnosticos atraves de uma revisao da literatura de enfermagem FINALIDADE. Diferenciar as definicoes de espiritualidade e religiosidade conforme a sua utilizacao na literatura de enfermagem.

FONTES DE DADOS. Artigos de periddicos, livros, capitulos de livros.

SINTESE DOS DADOS. A literatura de enfermagem tem sido inconsistente quanto a definir espiritualidade e religiosidade. A literatura sobre espiritualidade a define como o conceito mais amplo, sendo a religiosidade um sub-conceito, enquanto que a literatura sobre religiosidade a define como o conceito mais amplo, com a espiritualidade como um sub-conceito. CONCLUSAO. Espiritualidade e religiosidade sao dois diagnosticos de enfermagem separados, com alguns elementos comuns aos dois.

IMPLICACOES PARA A PRATICA. O crescimento da enfermagem paroquial como uma prdtica especializada reconhecida pela ANA tem aumentado a consciencia quanto ao cuidado do espirito humano. E necessdria maior clareza nos termos empregados para definir esta especialidade.

Palavras para busca: Diagnostico de enfermagem, espiritualidade, religiao, religiosidade

Espiritualidad y religiosidad: Diferenciando los diagnosticos a traves de una revision de la bibliografia enfermer

PROPOSITO. Diferenciar las definiciones de espiritualidad y religiosidad como se utilizan en la bibliografia enfermera.

FUENTES DE LOS DATOS. Articulos de revistas, libros, capitulos de libros.

SINTESIS DE LOS DATOS. La bibliografta enfermera ha sido inconsistente al definir espiritualidad y religiosidad. La bibliografia sobre espiritualidad define la espiritualidad como un concepto mas amplio con religiosidad como un sub-concepto mientras que la bibliografia sobre religiosidad define la religiosidad como un concepto mas amplio con la espiritualidad como un sub-concepto.

CONCLUSION. Espiritualidad y religiosidad son dos diagnosticos de Enfermeria separados con algunos elementos comunes a ambos.

IMPLICACIONES PARA LA PRACTICA. El crecimiento de la Enfermeria Parroquial como una especialidad prdctica reconocida por la ANA (Asociacion Norteamericana de Enfermeras), ha incrementado la conciencia de cuidar del Espiritu Humano. Se necesita clarificar los terminos utilizados para definir esta especialidad.

Terminos de busqueda: Diagnostico enfermero, espiritualidad, religion, religiosidad

Parish nursing as a specialty practice has the potential to heighten awareness of the nursing profession to care for the “spirit” of the patient or client, as well as to be inclusive of the religious beliefs of the individual. The philosophy of parish nursing holds that the spiritual dimension is central to the practice and that the focus of the practice is the faith community unit and its ministry (Solari-Twadell & McDermott, 1999). Are these two aspects-one related to spirituality and the other related to religiousness-philosophically and conceptually different? The answer lies with the individual.

For some people, involvement in their faith community, its rituals, and its ministries feeds the spirit. For others, spiritual well-being does not necessarily revolve around participation in a particular religious denomination. The purpose of this article is to explore the differences between religiousness and spirituality through a review of the nursing literature, including a discussion of the philosophical underpinnings of these concepts. Additionally, the implications for using standardized nursing language to document spiritual and religious care is addressed.

Philosophical Perspectives of Spirituality

The nursing literature provides different definitions of spirituality. One way to find structure in understanding spirituality is by exploring two philosophical perspectives of human existence-one based on realism and the other more existential in nature.

From a realist perspective, spirituality is a characteristic of being human. This view is derived from philosophers like Aristotle in Posterior Analytics (1928) and Teilhard de Chardin in The Phenomenon of Man (1955/1965). Realism is a belief that there are real entities in the world, and the basis of the truth of those entities lies within the entities themselves. Aristotle claimed that existence consists of real entities that can be named (e.g., human beings), and the characteristics of real entities that can be named and studied (e.g., temperature, shape, color, and odor). Real entities have many characteristics; however, a few characteristics are critical to the definition of the real entity. For example, what makes human beings different from animals? Aristotle refers to these characteristics as essences.

Teilhard de Chardin (1955/1965) viewed spirituality as a defining characteristic-or essence-of being human. From a Darwinian evolutionary perspective, at one point in human evolution humans became human. What characteristics did prehumans gain to become human? One is an advanced ability to think. Teilhard de Chardin holds that a defining characteristic of being human is the ability to contemplate one’s own existence. For example, humans can contemplate and discuss what is the meaning of life by asking, Why am I here? What purposes do life or my actions serve? This ability to search for meaning and purpose in life is spirituality. Therefore, from a realist perspective, humans are viewed as physical beings having a spiritual characteristic.

An existential view of spirituality has its philosophical foundations from philosophers like Rene Descartes in Meditations on First Philosophy (1911) and Soren Kierkegaard in The Sickness Unto Death (1849/1989). Descartes introduced the notion of a mind-body dualism that humans consist of two coexisting substances: a thinking substance housed within a physical body. Kierkegaard expanded on this view, but further differentiated the mind into a psyche and spirit. The psyche includes psychological manifestations that affect behavior. These include phobias, addictions, and anxieties-that is, the “conditions or diseases” treated by many psychologists and psychiatrists. Kierkegaard held that there is another dimension called the spirit that relates the mind to the body. The fact that humans can self-reflect implies there is something that is doing the reflecting (the thinking mind) and something that is being reflected on (the physical world). That “inbetweenness” is the spirit (Kierkegaard; Westley, 1995). Therefore, one characteristic of the spirit is that it is a relation between the mind and body.

Another characteristic of the spirit is freedom of choice. A common characteristic between the physical body and the mind (or psyche) is that they are both predetermined and cannot be changed by themselves. However, the spirit is different. It is the spirit that gives human beings free will (Kierkegaard, 1849/1992; Westley, 1995). The spirit is the driving force to direct an individual on how to live the physical, psychological, and social dimensions of his or her life. Each human being constantly compares who he or she is to how he or she is living his or her life. For example, humans ask themselves,”Am I living my life the way I ought to? When I go to sleep at night, am I at peace?” It is the spirit as a relationship between mind and body with the characteristic of free choice that makes each human being an individual (Kierkegaard; Westley). From an existential perspective, humans are spiritual beings existing in a physical world.

Review of Spirituality in the Nursing Literature

Whether from a realist or an existential view, humans have a spirit, and the spirit is associated with discerning meaning and purpose in life. How does one find meaning and purpose in life? As the nursing literature documents, this can happen in many ways: to connect with oneself through self-reflection; with others in relationships; with art, music, literature, and nature; and with a Higher Power through prayer or meditation. The nursing literature suggests this connectedness happens through the spirit.

A number of nursing authors discuss spirituality in terms of finding meaning and purpose in life (e.g., Dudley, Smith, & Millison, 1995; Haase, Britt, Coward, Leidy, & Penn, 1992; Hall, 1997; Labun, 1988; Martsolf & Mickley, 1998; Oldnall, 1996; Reed, 1991,1992; Smucker, 1996). Meaning and purpose are sought through self-reflection and a sense of connectedness to self (Aldridge, 1993; Bellingham, Cohen, Jones, & Spaniol, 1989; Dyson, Cobb, & Forman, 1997; Engebretson, 1996; Fahlberg & Fahlberg, 1991; Goldberg, 1998; Lane, 1987; Meraviglia, 1999; Narayanasamy, 1996; Newshan, 1998; Nolan & Crawford, 1997; O’Neill & Kenny, 1998). Spirituality is also explored through relationships with others (Aldridge; Bellingham et al.; Dyson et al.; Fahlberg & Fahlberg; Goldberg; Lane; Mayer, 1992; Meraviglia; Narayanasamy; Newshan; Nolan & Crawford; O’Neill & Kenny; Reed, 1992) and is enhanced through experience and connectedness with music, art, literature, or nature (Dyson et al.; Goldberg; Kierkegaard, 1843/1992; Meraviglia; O’Neill & Kenny; Watson, 1985). In addition, if this is part of one’s belief system, spirituality can be explored through communicating with or connecting with a Higher Power, which some people call God (Bellingham et al.; Carson, Winkelstein, Soeken, & Bruinins, 1986; Charnes & Moore, 1992; Dyson et al.; Fahlberg & Fahlberg; Goldberg; Lane; Meraviglia; Nolan & Crawford; Narayanasamy; O’Neill & Kenny; Reed, 1992; Sherman, 1996). Therefore, whether one’s point of view is realist or existential, spirituality is defined as the experience of and integration of meaning and purpose in life through connectedness with self, others, art, music, literature, nature, or a power greater than oneself.

The spirituality literature supports differentiating spirituality and religiousness in that religiousness is one way to express one’s spirituality, but not necessarily the only way (Carson et al., 1986; Engebretson, 1996; Labun, 1988; Mayer, 1992; Oldnall, 1996; O’Neill & Kenny, 1998; Reed, 1991). Pehler (1997) studied spiritual distress among children ages 3 to 18 and found that all of NANDA’s (1994) defining characteristics for spiritual distress were represented, except for religious/cultural ties. These results suggest that religiousness is not a defining characteristic of spiritual distress in the pediatric population. In addition, the Spirituality Well-Being Tool to measure spirituality includes two subscales, one for religious and one for existential well-being (Fehring, Brennan, & Keller, 1987; Mickley, Soeken, & Belcher, 1992). From this perspective, it may be appropriate to conceptualize spirituality as the broader concept and religiousness as a subset of spirituality.

Review of Religiousness in the Nursing Literature

The religiousness literature consistently differentiates spirituality and religiousness in a similar way. While spirituality is a universal, personal concept, religiousness is more closely linked to a culture and a societal subgroup (Engebretson, 1996; Meraviglia, 1999; Pehler, 1997). Religion consists of a set of beliefs, rites, and rituals adopted by a group of people (Carson et al., 1986; Engebretson; Fahlberg & Fahlberg, 1991; Meraviglia; Pehler).

Religiousness is further differentiated as having two dimensions: extrinsic and intrinsic. Extrinsic religiousness views religion as a way of obtaining social status, personal security, self-justification, and sociability (Mickley et al., 1992). From this perspective, religiousness takes on social, rather than spiritual, characteristics. Comparatively, intrinsic religiousness refers to internalizing the beliefs regardless of social pressures (Alport, 1967; Mickley et al.). This perspective is more closely linked to spiritual connectedness. Therefore, religiousness can have both spiritual and social dimensions. Although closely related to spirituality, religiousness is more closely related to a faith community or a social institution. Therefore, the definition of religiousness is an understanding of a particular faith belief system or dogma and participation in the rituals and services offered by a faith community.

This conceptualization emerges from a more cultural and social perspective. Spirituality is at the core of all religions (Johnston, 2000); however, each religion conceptualizes spirituality within a culture and a theology. Health-related issues may relate only to religious issues (i.e., rites and rituals within a faith community) but not to finding meaning and purpose in life. For example, a Jewish patient requesting a kosher diet has religious needs, but not receiving a kosher meal would probably not precipitate a spiritual crisis-that is, questioning meaning and purpose in life.

Reed (1986, 1987) also found conceptual differences between spirituality and religiousness. The Religious Beliefs Questionnaire, adapted from King and Hunt’s (1975) Dimensions of Religiosity scales, which measures religiousness, includes both spiritual and religiousness subscales. This suggests that spirituality is a component of religiousness (Reed). Reed also identified the linkage between spirituality and religiousness in her research. In an attempt to measure these concepts separately, Reed revised the Religious Perspective Scale by removing the social dimensions of religiousness and retaining the spiritual dimensions. The tool was then renamed the Spiritual Perspective Scale (Reed). In this instance, religiousness would appear to be the broader concept and spirituality a subset of religiousness.

Reconciling the Nursing Literature

The spirituality nursing literature suggests that spirituality is the broader concept and religiousness is a sub– concept, while the religiousness literature indicates religiousness is the broader concept, with spiritual and social dimensions. Both of these bodies of literature support the notion that spirituality and religiousness are two different concepts with different definitions, but at the same time they share some common characteristics.

Effect on Nursing Standardized Languages

When analyzing a concept for inclusion in a standardized vocabulary, researchers are guided in defining the concept of the structure of the vocabulary. NANDA defines a nursing diagnosis as “a clinical judgment about individual, family, or community responses to actual and potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable” (NANDA, 2001, p. 245). Spirituality and religiousness are clearly life processes, and both have personal and social implications.

Diagnosing alterations in spirituality versus alterations in religiousness, however, leads to a set of different nursing interventions. For example, a person learning of a terminal diagnosis may ask, “Why me? What did I do wrong?” Spiritual distress may be an appropriate diagnosis. Nursing interventions, as identified in the Nursing Interventions Classification (NIC) (McCloskey & Bulechek, 2000), may include Presence, Active Listening, Emotional Support, Spiritual Support, Hope Instillation, Values Clarification, and Spiritual Growth Facilitation. In the case of the hospitalized patient unable to receive communion or a kosher diet but without any expressed spiritual concern, “altered religiousness” is an appropriate diagnosis because the person only wants assistance to participate in religious rituals and does not indicate a crisis or concern about finding meaning or purpose in life. Possible NIC interventions for this diagnosis may be Religious Ritual Enhancement or Cultural Brokerage. Relating alterations in either of these concepts to different interventions also supports a separate diagnosis distinction.

Philosophical differences emphasized by a review of the nursing literature support separate diagnoses for spiritual and religiousness alterations. Historically, nursing has confused these terms because the nursing literature does not clearly define spirituality, religiousness, and how these terms relate (Dyson et al., 1997; Goldberg, 1998; Hall, 1997; Newshan, 1999; Pehler, 1997). It is quite understandable that when discussing spirituality, nurses may refer to belonging to a religion or a belief in God.

As part of a Kellogg Foundation grant (“Partners in Health and Healing”) awarded to Lutheran General Health Systems (now Advocate Health Care), Johnson, Ludwig-Beymer, and Micek (1999) assessed the ability of NANDA nursing diagnoses to capture parish nursing practice. It became apparent that there was much confusion related to spiritual care. Subsequently, the International Parish Nurse Resource Center, Advocate Health Care collaborated with the Nursing Diagnosis Extension Classification (NDEC) team from the University of Iowa to review the nursing literature and develop new diagnoses related to spirituality and religiousness. Table 1 compares the current NANDA spirituality diagnoses to a proposed set of diagnoses for spirituality and religiousness. For examples of the use of spiritual distress, both “altered religiousness” and spiritual distress, and “altered religiousness,” see inset on page 52.

Implications for Nursing Education, Practice, and Research

Establishing clarity between what is spirituality and what is religiousness has important implications for nursing education, practice, and research. If there are clear differences between religiousness and spirituality, with points of commonality, it is important that this be taught to nursing students. In order to effectively work with patients, students must be clear regarding the personal integration of spirituality and religiousness. Nursing students who have material related to both spirituality and religiousness woven throughout their nursing education will become more comfortable with the content and be better placed to address these concepts with those they are caring for, no matter the physical malady.

Nursing practice will benefit from having clarity of terms and concepts, because the clarity will improve the assessment, diagnosis, intervention, and outcomes of patient care. Clearer understanding will enhance the ability of the nurse to know more specifically whether the presenting issue is spiritual or religious in nature. Once there is enhanced understanding, a more accurate nursing diagnosis can be made. The accuracy of the diagnosis will provide direction for intervention. Spiritual distress may not be addressed adequately by a particular religious ritual; however, a religious ritual may be a particularly important intervention for someone who is struggling with alienation from a particular religious practice. Clearer knowledge can result only in better care of the patient.

Nursing research is desperately needed, but if there is no clarity regarding the nature of the phenomena, the research will be compromised from the beginning. Acceptance of spirituality and religiousness as two separate, but related, concepts will provide for more in-depth studies of each, resulting in better findings that will ultimately enrich both practice and education.

Acknowledgment. Thanks to Francis J. Catania, PhD, Professor Emeritus, Philosophy Department, Loyola University Chicago, for providing his expertise in realism when reviewing this manuscript, and to Richard J. Westley, PhD, Professor Emeritus, Philosophy Department, Loyola University, Chicago, for his expertise in existentialism when reviewing this manuscript.

Author contact: Lisa.Burkhart@advocatehealth.com, with a copy to the Editor: rose_mary@earthlink.net

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Lisa Burkhart, PhD(c), MPH, RN, and Ann Solari-Twadell, MSN, MPA, RN

Lisa Burkhart, PhD(c), MPH, RN, is Coordinator of Parish Nurse Development, and Ann Solari-Twadell, MSN, MPA, RN, is Director, International Parish Nurse Resource Center, Advocate Health Care, Park Ridge, IL.

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