35.1: Dimensions of Spirituality

Learning Objectives

By the end of this section, you will be able to:

• Recognize key concepts of spirituality
• Identify the different practices of spirituality
• Explain how spirituality affects health and well-being

Many people believe in and feel connected to a power greater than themselves. This sense of connection helps give their lives meaning and purpose and provides solace and peace as they navigate life’s challenges. One’s spirituality encompasses not only this connectedness but also the diverse practices that people follow in seeking transcendence, or experiences that move them beyond the physical or literal world. For some people, spiritual practices include belief in a particular deity or deities and worship in a religious institution such as a church, temple, mosque, or synagogue. Others may develop their spirituality through nature or art. An individual’s sense of spirituality may evolve throughout their life as they have new experiences and cultivate new relationships.

Nurses play a pivotal role in helping people cope, and spirituality is often central to these efforts. Integrating a patient’s spirituality with their care has been shown to lead to improvements in health and quality of life, as these beliefs influence how patients experience pain, respond to stress, and approach the challenges associated with serious illness and death (Balboni et al., 2022; Harvard T. H. Chan, 2022). To do this effectively, nurses must understand the key concepts and practices of spirituality.

Concepts of Spirituality

One’s sense of purpose or meaning in life, or one’s spiritual well-being, depends on positive connections between one’s self and the rest of the world, including other people, nature, art, and, for some, awareness of a higher power (American Nurses Association [ANA], 2015). When patients are confronted with an initial diagnosis of illness or a severe injury, they often struggle with the fundamental question, “Why is this happening to me?” This question is a manifestation of spiritual distress, or disruption to their core beliefs and values (Harrad et al., 2019). Nurses play a crucial role in alleviating patients’ distress by responsively addressing their discomfort and advocating for their spiritual needs throughout the health care journey.

In its first provision, the American Nurses Association (ANA) Code of Ethics emphasizes nursing practice with compassion, respect for each person’s inherent dignity, and the recognition of their unique attributes. According to this code, optimal nursing care seeks to enable patients to live with maximum well-being across physical, emotional, social, and religious or spiritual dimensions, reflecting their individual values. In the context of nursing, spirituality and spiritual values are closely intertwined with caring, as are key concepts such as faith, hope, and love.

Link to Learning

The ANA Code of Ethics for Nurses with Interpretive Statements is a useful guide for how to deliver quality, ethical care.

Faith

An acceptance of certain religious doctrines is called faith and is often associated with specific religions such as Buddhism, Christianity, Hinduism, Islam, and Judaism. Although it may be viewed in monotheistic (belief in a single deity or god) tradition as adherence to specific doctrines, faith takes the form of an attitude of devotion facilitating a gateway to spiritual practice in some cultures and religions. In a broader sense, faith can refer to a relationship with a divine force—whatever an individual believes that to be.

Engaging in a faith-based and spiritual practice can be a valuable coping strategy for patients, addressing fundamental human needs such as identity, self-care, community, belonging, and connection. As nurses, advocating to meet patients’ spiritual needs is one of the tasks of providing comprehensive, culturally aware care. Initiating conversations and creating a supportive space for discussions on faith and spirituality can play a pivotal role in promoting physical and psychological healing.

Religion

People commonly associate faith with religion; however, they are distinct concepts. Religion is a unified system of beliefs, values, and practices that a person holds sacred or considers to be spiritually significant (Figure 35.2). It is possible to be spiritual without belonging to any religion, just as it is possible to belong to a religious community and perform all the required practices without deriving any spiritual meaning from them.

Figure 35.2 These religious symbols represent some of the world’s most populous religions: (top row, from left) the word Om (Hinduism), the wheel of dharma (Buddhism), the Jain emblem (Jainism), the khanda (Sikhism); (bottom row, from left) the star of David (Judaism), the cross (Christianity), the crescent and star (Islam), and the taijitu (Taoism). (credit: modification of “Religious symbols collage” by “Howardcorn33”/Wikimedia Commons, CC BY 4.0)

Nurses should be familiar with the beliefs and practices of the religions present in their communities, particularly beliefs regarding health and well-being. For example, some religions prohibit the eating of certain foods or the utilization of specific medical interventions such as blood transfusions. Some religions celebrate holidays with different rules and expectations for behavior, such as fasting, prayer, or purification rituals. As much as possible, a nurse should tailor care to incorporate the religious needs of the patient and their family. Nurses should get clarification from patients and their families about their lived experiences of religion and spirituality—just because a patient identifies as a specific religion does not mean they follow it devotedly.

Hope

The desire for a positive outcome is known as hope. Hope is a vital and influential aspect of spiritual practice in nursing and can guide patients through challenging moments. It is central to the healing process and emphasizes the efforts of the patient’s journey through recovery.

Cultivating hope is a skill that can be developed through practice and holding specific attitudes. Patience, the ability to endure delays and allow events to unfold naturally, is one such attitude. Courage, or confidence in the face of uncertainty, is another crucial element. Persistence, persevering regardless of obstacles, forms the third pillar. True hope is realized when we sincerely declare that all will be well and genuinely believe in that affirmation.

Hope is also a desire or goal for a particular event or outcome. For example, some people may view dying as “hopeless,” but a spiritual view can define hope as a “good death,” which is when a patient dies peacefully and according to their end-of-life preferences.

People in despair may try to find witnesses who can answer their questions and replace fearful voices with hopeful ones. At times, nurses may ask patients about their fears—in these moments, simply being a compassionate listener can be a powerful healing tool beyond practical nursing care. Quality connections shape the level of hope in a patient’s life, opening up a horizon of possibilities beyond the current situation.

Love

The notion of love, a strong feeling of affection, may seem simple—after all, most of us use the word every day in a variety of contexts. But we clearly mean something different in each context: romantic love differs from parental love, which differs from the love someone has for a piece of music, a treasured possession, or delicious food. Nurses are not required to love their patients; a sense of professionalism or responsibility may be all the motivation they need to provide effective, quality care. However, contemplating the role of love in nursing can enhance nursing practice in two significant ways. First, it prompts nurses to reflect on their values and beliefs. Second, it guides them in establishing meaningful interactions with patients. Love in nursing manifests through accountability, benevolence (being kind and well-intentioned), attentive concern, respect, and the recognition of others as human beings. These behaviors contribute to patients and nurses feeling valued, fostering self-esteem, and alleviating suffering.

Practices of Spirituality

There are many ways that people can experience and express their spiritual beliefs, both as individuals and as part of a community. Practices such as praying or going to church are associated with particular religions. Others, such as communing with nature or practicing mindfulness, are more about feeling connected to oneself and the rest of the world.

Spiritual practices may involve ritual, a defined activity to commemorate or cope with something significant. Spirituality could also be a ceremony (a public, formal celebration or gathering to honor an important event). It is important for the nurse to be aware of the different spiritual practices that may matter to their patients so they can facilitate these activities as part of the healing process.

Individual Practices

Although individual practices may be performed in a group setting (such as a yoga class or a prayer group), the focus is on the individual experience of spirituality. Many of these practices involve private contemplation or similar activities to increase compassion and empathy and quiet the mind (Delagran, n.d.). This section explains some common individual practices and their associated health benefits.

Mindfulness

The practice of being present in the moment and aware of one’s thoughts, feelings, and environment is called mindfulness. This awareness is nonjudgmental: in a mindful state, we acknowledge negative experiences but do not fault ourselves for experiencing them. When practiced regularly, mindfulness helps us develop some control of our reactions, see the habitual patterns that lead to negative reactions and stress, and learn healthier patterns. Practicing mindfulness reminds us to pause, get a clearer picture of a situation, and respond more skillfully.

Consider your default state when studying for an exam in a difficult course or preparing for a clinical experience. What do you do? Do you tell yourself, “I am not good at this” or “I am going to look stupid”? Does this distract you from paying attention to studying or preparing? How might the experience be different if you had an open attitude with no concern or judgment about your performance? What if you directly experienced the process as it unfolded, including the challenges, anxieties, insights, and accomplishments, while acknowledging each thought or feeling and accepting it without needing to figure it out or explore it further? By simply observing thoughts and emotions instead of reacting to them, a person can develop a broader perspective and learn more effective responses (Schuman-Olivier et al., 2020).

Meditation

A mindfulness technique that involves focused attention—often on a particular word, phrase, or image—and deep breathing is known as meditation. Research suggests that regular meditation can contribute to reduced symptoms of depression, improved sleep quality, and enhanced mental clarity, making it a valuable tool for patients to manage stress, alleviate anxiety, and foster emotional resilience (American Psychological Association [APA], 2019). Some studies have also shown that meditation may help decrease the perception of pain and support pain management (Hilton et al., 2017).

In a healthcare setting, introducing meditation as part of patient care can be a simple yet powerful strategy. Nurses can educate patients about the practice, its positive effects on physical and mental health, and its potential to complement medical treatments. Offering guided meditation sessions or providing resources such as meditation apps can empower patients to incorporate this practice into their daily routines, promoting self-care and a sense of control over their well-being.

Real RN Stories

Focusing on the Moment

Nurse: Hillary, BSN
Clinical setting: Oncology unit
Years in practice: 16
Facility location: A hospital in rural New England

Even though I’ve been a nurse for well over a decade, I only transitioned into cancer care a few years ago. The career shift was actually for a personal reason—after my mom was diagnosed with breast cancer, I learned that our local healthcare system was really struggling to provide quality care to cancer patients and their families. I was determined to do my part to make things better, but I had no idea what I was in for. And I’ll be honest, that first year, I wasn’t sure I’d make it. But I had an amazing charge nurse, Kathy, who taught me so much about how to not just take care of my patients and their loved ones, but myself as well. One of the first “tricks” she taught me was meditation. And at first, I thought it was a little weird. Like one of those “new-age” things you go to a retreat to do. And besides that, I didn’t see how I could possibly justify taking the time out of my shift to do it when I had patients who needed me. But Kathy was adamant about the self-care work that nurses have to do. Meditating was hard at first, because I couldn’t get my brain to just shut up. But over time, it did start to get easier.

I’ll never forget the first time I felt it really working for me. I had a patient with the same cancer my mom had, but a far worse prognosis. This patient, we’ll call her Shanna, also didn’t have any family support. The situation was stressful, not just because Shanna was in so much pain and so sad, but because watching her go through what my mom had gone through just brought up a lot of my own feelings again. I was getting distracted and making mistakes, which immediately alerted me that I needed to stop, reach out for help, and find strategies for coping—and in that order.

At first, it was just a few minutes when I was restocking supplies or waiting for the fountain to fill up my water bottle—just focusing on what I could hear, see, smell, and touch. I would focus so hard on being in the moment that it would force me out of the past, where my mom was the patient, and when I walked back into Shanna’s room, I was present and there for her. Pretty soon, those little meditations just became a normal part of my shifts. Whenever I feel myself getting too caught up in my head, or someone else’s, meditating brings me back to the present moment and the patient in front of me.

Prayer

The practice of communicating with a higher power or divine entity is prayer. Unlike mindfulness and meditation, prayer is mainly used in the context of religion, though it is a deeply personal and culturally diverse practice. Encouraging prayer as part of the healing process for patients who are open to it can provide a source of comfort, solace, and connection during challenging times. Prayer can foster emotional resilience by offering patients a means to express their fears, hopes, and gratitude and helping them to navigate the complex emotions associated with illness. It is also a reminder of their faith and connection to a higher power, which can give patients a sense of hope and purpose.

For the nurse, supporting patients who want to incorporate prayer into their care plan demonstrates a commitment to holistic, patient-centered care (PCC). It honors the individuality of each patient and promotes an environment that respects and supports their diverse cultural and spiritual backgrounds. Prayer has been shown to have concrete benefits for patient health, linked to stress reduction and relaxation (Andrade & Radhakrishnan, 2009).

Breathwork

Both healthcare providers and patients often face significant stress that affects their physical, mental, and spiritual well-being. One practical approach to interrupting the stress cycle and promoting relaxation is breathwork, a technique involving intentional, controlled breathing. Breathwork is a safe and easily accessible practice that can be utilized in any healthcare setting as well in one’s daily routine. It has been proven to reduce anxiety and depression while improving sleep, making it a valuable tool for individuals seeking to enhance their well-being (Shaw-Metz, 2023). Both nurses and patients can prepare for moments of heightened stress by identifying their specific triggers and stressors and incorporating breathwork into their self-care tool kit as a coping strategy.

Nature

In many spiritual traditions, nature is a powerful source of symbolism and metaphor. The changing seasons, cycles of life, and relationships observed in nature can mirror spiritual concepts such as growth, transformation, and the interconnectedness of all living things. But the connection between the natural world and the self goes beyond metaphor. Sensory experiences in nature, such as the feel of the wind, the scent of flowers, or the sound of flowing water, can serve as conduits for spiritual experiences, promoting holistic well-being and reducing stress and anxiety (APA, 2020). As individuals relax in natural surroundings, they may find it easier to connect with their inner selves and explore spiritual aspects of their identity (Ryff, 2021).

Spending time in nature can also enhance spiritual healing by fostering a deep connection between individuals and something larger than themselves. In essence, nature provides a serene and nurturing backdrop for individuals to explore and deepen their spiritual connection. Whether providing awe-inspiring beauty or the comfort of everyday sensations, nature encourages a state of mindfulness and presence that is conducive to spiritual reflection, meditation, and inner peace (Yamada et al., 2020).

Yoga

A practice rooted in ancient spiritual traditions, yoga combines physical postures, controlled breathing, and mindfulness techniques to harmonize the mind, body, and spirit (Figure 35.3). The physical aspects of yoga, including gentle stretches and postures, contribute to flexibility, balance, and improved circulation. Systematic yoga practice has been found to reduce inflammation and stress, decrease depression and anxiety, lower blood pressure, and increase feelings of well-being (Padmavathi et al., 2023; Yatham et al., 2023). Yoga can be a valuable tool for pain management and rehabilitation both for patients dealing with chronic conditions as well as those recovering from surgeries. Yoga has also been shown to improve sleep quality by promoting relaxation and reducing anxiety, which can help with physical healing (Woodyard, 2011). The practice also encourages emotional and spiritual healing by cultivating self-awareness and mindfulness and helping individuals be fully present in the moment.

Figure 35.3 A yoga practice does not have to be advanced to offer mental and physical benefits. (credit: “Yoga” by Dave Rosenblum/Flickr, CC BY 2.0)

By incorporating yoga into patient care, nurses contribute to a patient-centered approach to healing. Yoga’s holistic nature addresses physical ailments and the spiritual dimensions of well-being. The practice’s diverse origins provide an inclusive approach to spiritual healing that respects various cultural backgrounds. Nurses can educate patients on the accessibility and benefits of yoga, encouraging them to continue the practice independently as a valuable tool for self-care beyond the healthcare setting.

Journaling

Writing one’s thoughts and documenting one’s feelings in a journal or diary is called journaling. The practice can help people become more aware of their inner lives and feel more connected to experiences. Studies show that writing during difficult times may help a person find meaning in life’s challenges and become more resilient in the face of obstacles (Sohal et al., 2022; Smyth et al., 2018). When journaling, it can be helpful to focus on three basic questions: What experiences give me energy? What experiences drain my energy? Did I experience anything today that made me feel alive and positively connected to my surroundings? Allow yourself to write freely without stopping to edit or worry about spelling and grammar.

Social Support

Social support plays a crucial role in individual spirituality, offering avenues for connection, support, and growth within a community context. One essential practice of spirituality through social support is active participation in religious or spiritual communities. Some people find a spiritual community among their family and friends. Others join a spiritual group in the community, such as a church, synagogue, temple, mosque, meditation center, nature center, or yoga class. These communities provide a space for individuals to come together, share beliefs, engage in worship, and find support from others. Within these communities, individuals often form deep bonds, offering each other companionship, encouragement, and a sense of belonging.

Within social support systems, people may also seek guidance from spiritual mentors or leaders who can offer wisdom, advice, and spiritual insight, guiding individuals through challenges and helping them deepen their understanding of their faith or beliefs. Through mentorship relationships, individuals receive personalized support and encouragement tailored to their unique spiritual needs and aspirations.

Volunteering and serving others within the community are individual practices of spirituality. Serving alongside others fosters a sense of unity, purpose, and interconnectedness, deepening individuals’ spiritual growth and fulfillment. Through acts of service, individuals express their spiritual values of compassion, kindness, and generosity while connecting with others and positively impacting the lives of those in need.

As a nurse, you may be called upon to help a patient connect with social support. There will also be times when you, as a human being, will need to lean on your social network for support. If you have a well-established support network, it will also help you help patients navigate the valuable connections with others that can bolster them spiritually in difficult times.

Organizational Practices

Organized spiritual practices typically involve religion. Although the overall percentage has been trending downward, most Americans identify as belonging to a specific religion. However, the Census of American Religion, conducted annually by the Public Religion Research Institute (PRRI), underscores the complexity of these affiliations (Public Religion Research Institute, 2023). According to the 2022 survey:

• 26.8 percent of Americans identify as religiously unaffiliated, the largest individual category, which includes:
  • atheist, those who do not believe in the existence of any divine being, and
  • agnostic, those who believe that ultimate reality is unknowable, as well as,
  • people who are very spiritual but resist identifying with a specific religion.
• Of Christians in the United States, 27.6 percent identify as nonevangelical Protestant and 23.1 percent identify as Catholic. The survey further divides these totals into subcategories by race and ethnicity: 13.6 percent identify as evangelical Protestant, 1.5 percent identify as Mormon, and 1.1 percent identify as Jehovah’s Witness.
• 1.9 percent of Americans identify as Jewish.
• Less than 1 percent of Americans identify as a member of any other specific religion, including Islam, Buddhism, and Hinduism.

Research by PRRI also reveals varying levels of certainty and nuance in the nature of belief in a god, illustrating that individuals hold distinct perspectives even within shared religious frameworks (Pew Research Center, 2023). PRRI findings emphasize the diversity within religious groups, as some unaffiliated individuals embrace specific religious beliefs, whereas some affiliated members report minimal importance of religion in their lives. Furthermore, the survey indicates that the belief in absolute standards of right and wrong is influenced not only by religious beliefs but also by practical experiences, highlighting a nuanced and pragmatic approach to morality in the United States.

Link to Learning

Learn more about the 2022 PRRI Census of American Religion: Religious Affiliation Updates and Trends that provides county-level religious affiliation data.

Every culture has atheists who do not believe in a divine being or entity and agnostics who hold that ultimate reality (such as a god) is unknowable. However, being a nonbeliever in a divine being does not mean the individual has no morality. A person who does not believe in a god can still be guided by a set of morals, ethics, and values, contribute to the world in positive ways, and have deeply meaningful relationships with others. At the same time, a person may believe in a god but do immoral, unethical, and harmful things. One’s religious beliefs may influence their sense of moral judgment, but it is not synonymous with it.

To provide effective, patient-centered care, nurses must be knowledgeable about the various cultures in the communities they serve, and religion is a key component of culture. The following subsections provide a high-level overview of the religions that nurses in the United States are the most likely to encounter. However, it is essential to recognize that the categorization of religion is not without its limitations and complexities. Most religions have formal sects, informal movements or practices (sometimes at the local level), and intersect with cultural aspects related to the ethnicity, race, and national origin of members. These labels can be oversimplified and may not fully capture the diversity and complexity of religious beliefs and practices within specific cultural contexts, and can sometimes perpetuate stereotypes or essentialize cultural identities. Finally, media depictions and literature -- even when authentically written from the perspective of a member of the religion -- can lead to assumptions or stereotypes, because religions are not monolithic.

When a nurse encounters a patient whose belief system is unfamiliar, the situation presents an opportunity for cultural humility and respectful engagement. In such instances, it is imperative for the nurse to approach the situation with an open mind and a willingness to learn about the patient's unique traditions and practices. This begins with actively listening to the patient’s perspective, asking questions to gain a deeper understanding, and demonstrating genuine curiosity and respect for their beliefs.

Judaism

Judaism is the oldest monotheistic religion, with a history spanning nearly 4,000 years. Jewish law emphasizes righteous, just behavior in all aspects of life. The Jews were the first people to declare belief in a single, all-powerful deity, and for a time, they ruled two kingdoms in the Middle East, Israel and Judah. (The word Jewish is derived from the Kingdom of Judah.) They recorded their ideas, laws, stories, and poems in a collection of scriptures called the Tanakh. The first five books of the Tanakh are called the Torah, and they contain the most important rules and rituals that Jews are expected to follow, including the Ten Commandments (Figure 35.4). The three main branches of Judaism today—Orthodox, Conservative, and Reform—are characterized partly by how strictly they interpret the Torah (Vajda, 2024).

Figure 35.4 The Torah is a sacred text that articulates the laws and rituals God expects Jews to follow. (credit: “Torah” by Lawrie Cate/Flickr, CC BY 2.0)

Christianity

The history of Christianity begins approximately 2,000 years ago, with the birth of a Jewish man named Jesus. Jesus was a charismatic leader whose interpretations of scripture led some Jews to believe he was the Messiah, a legendary warrior-king prophesied to restore the Jewish kingdoms (The Editors of Encyclopedia Britannica, 2024). These beliefs threatened the Romans, who at the time ruled over much of the Middle East, and they killed Jesus through crucifixion (Figure 35.5). After Jesus’s death, some of his followers came to believe he was the son of God and eventually formed a new religion around this belief.

Figure 35.5 The Romans crucified Jesus because they feared he would lead a revolt against their rule. Today, the crucifixion is one of the best-known symbols of Christianity. (credit: “Saint-Malo Stone Crucifix” by Nicolas Raymond/Flickr, CC BY 2.0)

The sacred text for Christians is the Bible, which includes the Old and New Testaments. The Old Testament contains many of the same books as the Jewish Tanakh, including the five that make up the Torah. The New Testament describes the life and teachings of Jesus and his early followers. Christians believe that through Jesus’s death, their sins are forgiven. When they die, their spirits will live on with God.

Contemporary Christianity consists of several main branches. The two largest branches worldwide, Catholicism and Eastern Orthodox, developed out of the churches that took root in the western and eastern halves of the Roman Empire, respectively. Another branch, Protestantism, developed from criticisms of Catholicism and consists of many distinct denominations, including Anglican, Baptist, Lutheran, and Pentecostal. Each branch or denomination emphasizes different aspects of the Bible and may use slightly different versions of the text. The Church of Jesus Christ of Latter-Day Saints follows another sacred text, the Book of Mormon, in addition to the Bible. Members of the Church of Jesus Christ of Latter Day Saints typically abstain from alcohol, tobacco, and substances.

Jehovah’s Witnesses are members of a Christian denomination that emphasizes the teachings of the Bible and the imminent establishment of God’s Kingdom. They are known for their active evangelism (the practice of spreading or preaching the Christian gospel with the intent of converting individuals to the Christian faith), often going door-to-door to share their faith, and for their refusal to participate in activities that they believe are incompatible with their interpretation of Christianity, such as military service, voting in political elections, and celebrating holidays and birthdays. They adhere strictly to their interpretation of biblical teachings and maintain a strong sense of community and discipline within their congregations.

The Amish religion is another Christian denomination known for its simple living, plain dress, and reluctance to adopt many conveniences of modern technology. Originating from an Anabaptist movement in the sixteenth century, the Amish emphasize community, humility, and separation from the non-Amish world to maintain their religious values and way of life. They believe in adult baptism, pacifism (the belief that all forms of violence, including war, are unjustifiable and that disputes should be settled through peaceful means), and a literal interpretation of the Bible. The Amish are also known for their strong work ethic (which is often seen in their farming and craftsmanship) and their commitment to mutual aid within their communities. Worship services are typically held in homes and the church is governed by a set of rules called the Ordnung, which guides everyday behavior and ensures adherence to their religious principles.

Islam

Islam is the third major monotheistic religion to originate in the Middle East. It is based on the teachings of Muhammad, an Arabian man who lived in the sixth and seventh centuries CE (Sinai & Watt, 2024). Muhammad had visions of an angel who declared there is only one God, Allah, and that a righteous life requires complete submission to Allah’s will. Followers of Islam, called Muslims, believe that Jesus, Moses, and the other major figures from the Jewish and Christian Bibles were prophets whose visions and teachings are incomplete. Muhammad is the final prophet, and Islam represents the completion of Allah’s will.

Muslims worship in buildings called mosques (Figure 35.6). Their sacred text, the Qur’an, is believed to be the literal word of Allah, which the angel recited to Muhammad during his visions. The two main branches of Islam, Sunni and Shia, originated in a disagreement over who should lead the faith following the death of Muhammad. In practical life, Muslims are guided by five “pillars” of their faith: the belief that Allah is the only God and Muhammad is his prophet; the participation in daily prayer; the obligation to give alms to those in need; the obligation for healthy adults to fast during the holy month of Ramadan; and, if possible, the making of at least one pilgrimage to the holy city of Mecca.

Figure 35.6 Mosques are sacred spaces where Muslims worship. (credit: “Azadi Mosque (5730562789)” by David Stanley/Wikipedia, CC BY 2.0)

Hinduism

Hinduism may be the oldest surviving religion on Earth, developing out of ancient traditions and ideas that originated in what is now India (Soniger & Narayanan, 2024). Hinduism encompasses an unusually diverse set of beliefs and practices, with different people in different times and places representing the nature of the divine and its relationship to human life in a variety of ways. Generally, Hindus believe in a universal, essential reality called Brahman, which may manifest in numerous specific entities, including the major deities Vishnu, Shiva, and Brahma (Figure 35.7).

Figure 35.7 Hindu gods such as Shiva may appear in a wide variety of forms, which represent different aspects of their nature. (credit: “Shiva Statue Murdeshwara Temple” by “Nkodikal”/Wikipedia, CC BY 3.0)

Although there are Hindu temples, most Hindus observe religious rituals at home, and the rituals vary greatly among regions, villages, and individuals. The main sacred texts, collectively called the Vedas, were written in Sanskrit more than 3,000 years ago. They include poems and stories about various gods and heroes and articulate key principles such as dharma, a complex idea that includes a person’s moral duties in the world. Hindus also generally believe in karma, the notion that one’s future happiness is caused by present actions: actions performed with good intent lead to future happiness, whereas actions performed with bad intent lead to future unhappiness. Karma is often connected to reincarnation, the idea that a person’s soul or spirit is reborn into a new body.

Buddhism

Another major religion that originated in the Indian subcontinent is Buddhism. According to legend, it was founded by Siddhartha Gautama, a Hindu prince who renounced his wealth and power and chose an itinerant, ascetic life after observing the poverty and suffering outside the palace (National Geographic, n.d.). However, he remained spiritually unfulfilled. At last, after meditating under a sacred fig, or bodhi, tree, he achieved a state of enlightenment called nirvana; the name Buddha means “enlightened one” (Figure 35.8).

Figure 35.8 Through deep meditation, the Buddha escaped earthly suffering and achieved enlightenment. (credit: “Four Scenes from the Life of the Buddha - Enlightenment - Kushan dynasty, late 2nd to early 3rd century AD, Gandhara, schist - Freer Gallery of Art - DSC05124” by “Daderot”/Wikipedia, CC0)

Following the Buddha’s teachings, Buddhists strive to lead a moral life by accepting the four Noble Truths: life is suffering, suffering arises from attachment to desires, suffering ceases when attachment to desires ceases, and freedom from suffering is possible by following the Middle Way. The concept of the Middle Way is central to Buddhist thinking; it encourages people to live in the present, practice acceptance of others, and avoid both extreme self-indulgence and extreme self-denial. Reflecting their common origin, Buddhists also share some beliefs with Hindus, such as karma and reincarnation.

Sikhism

Sikhism is a monotheistic religion that began in the Punjab region of India in the fifteenth century (Fenech, 2014). The religion developed from the teachings of ten human gurus, each of whom is believed to have possessed the same soul, and their sacred text, the Guru Granth Sahib (Figure 35.9). These teachings proclaim the existence of one god, Waheguru, and emphasize equality for all and the importance of living a life of truth, honesty, and compassion.

Sikhism also strongly emphasizes community service; a fundamental concept of the religion is selfless service, or Seva (Sikh Missionary Society, n.d.). Another integral component is the Five Ks, which are symbols of devotion to the faith: Kesh (uncut hair), Kangha (a comb), Kara (a steel bracelet), Kachera (a cotton undergarment), and Kirpan (a sword) (The Sikh Coalition, 2018).

Figure 35.9 This illustration from a nineteenth-century text depicts the founder of Sikhism, Guru Nanak, debating Hindu holy men. (credit: “Detail of 'Guru Nanak, the founder of the Sikh religion, in dispute with Hindu holymen' from Rani Jindan's book” by Unknown author/Wikimedia Commons, Public Domain)

African Religions

African religions encompass a diverse array of spiritual traditions, beliefs, and practices that are indigenous to the African continent. These traditions vary widely across different ethnic groups and regions but share common themes such as reverence for ancestors, connection to the natural world, and rituals for healing and community cohesion. The grouping of African religions as a category acknowledges the continent’s rich religious diversity while recognizing commonalities and shared cultural elements among various traditions. This approach allows for a broader exploration of spiritual practices within the African context, highlighting themes and dynamics unique to the continent’s religious landscape.

Some common themes in African spirituality include belief in a specific god or supreme being and the existence of a spiritual world that is closely connected to the physical world (Chakale & Marumo, 2018). Many African religions also incorporate aspects of monotheistic Abrahamic religions, primarily Christianity and Islam, both of which are prominent throughout the country (Pew Research Center, 2010; Pew Charitable Trusts 2016; U.S. Department of State, 2022). African spirituality also emphasizes community, harmony with nature, and divine healing and medicine, which is reflected by the traditions and practices—many of which are passed down orally (such as through song) instead of in writing.

In some African religions, communal worship is often characterized by vibrant ceremonies that bring together members of the community to honor deities, ancestors, and spiritual forces. These ceremonies can vary widely depending on the specific religious tradition but often involve rituals such as drumming, dancing, chanting, and offerings. The importance of ancestors is also central to many African spiritual practices and is featured in many celebrations and festivals (van Beek, 2020). For example, in the Yoruba tribe's religion, ceremonies such as the “Egungun” festival are held to honor ancestors, whereas in Vodou, rituals such as the “lave tèt” involve purification and communion with spirits (Daniels, 2016). Some African religions worship different gods depending on region and culture:

• In some religions of the Yoruba culture, Olorun is considered the supreme deity, the creator of the universe, and the source of all life. Orishas, on the other hand, are deities that serve as intermediaries between Olorun and humanity and represent different aspects of nature, such as Oshun (goddess of rivers and love), Shango (god of thunder and lightning), and Ogun (god of iron and war) (Indiana University, 2024).
• Some religions in the Igbo culture, Amadioha is a deity associated with thunder and lightning. He is considered a powerful and fearsome god who punishes wrongdoers and protects the innocent. Amadioha is often invoked for justice, protection, and guidance in times of trouble (Kanu, 2021).
• Anansi is a trickster god in Akan mythology, primarily worshiped by the Ashanti people of Ghana. Anansi, depicted as a spider and known for his cunning and cleverness, is a symbol of wisdom, creativity, and resourcefulness (Britannica, n.d.).
• Nyame is the supreme god in Akan mythology, worshiped by some of the Akan people of Ghana and the Ivory Coast. Nyame, associated with the sun and considered the creator of the universe, is often invoked for blessings, protection, and guidance in daily life (Oxford Reference, 2024).
• In Vodun or Voodoo traditions, Osun is a deity associated with fertility, love, and healing. She is often depicted as a river goddess and worshiped by devotees seeking blessings in matters of love, childbirth, and prosperity (Britannica, n.d.).

Indigenous American Spiritual Practices

Oral tradition through song and storytelling, honoring ancestors, and celebration of community are often key themes within Indigenous spirituality and central to the healing practices that are also part of the culture. The following are a few spiritual practices that nurses can familiarize themselves with related to American Indigenous communities (Smithsonian Institute, 2024; U.S. Forest Service, 2024; Centennial College, 2015):

• Connection to the land: Central to Indigenous American spiritual practices is a deep reverence for the land and the natural world. Many Indigenous traditions view Earth as a sacred and living entity, with spiritual beings inhabiting the land, waters, and skies. Spiritual practices often involve rituals and ceremonies conducted in natural settings, such as mountains, rivers, and forests, to honor and connect with the land and its spirits.
• Ceremonial rituals: Integral to some Indigenous American spiritual practices, ceremonial rituals serve as occasions for prayer, communion, and cultural expression. These rituals vary widely among Indigenous communities and may include sweat lodge ceremonies, vision quests, pipe ceremonies, sun dances, and powwows. Many traditions have rituals and ceremonies to mark important milestones and transitions in life, such as birth, puberty, marriage, and death. Seasonal ceremonies, such as harvest festivals and solstice celebrations, are common and serve to honor the changing seasons and give thanks for Earth’s bounty.
• Ancestral veneration: Ancestor veneration includes traditions honoring and communing with the spirits of ancestors. Ancestors are guardians, guides, and sources of wisdom for the living, and rituals are performed to honor their memory and seek their blessings and guidance.
• Visionary and shamanic practices: Many Indigenous American spiritual traditions incorporate visionary and shamanic practices that involve altered states of consciousness, trance, and spiritual journeying. Medicine people, shamans, or healers play a central role in these practices, using rituals, chants, and herbal medicines to facilitate healing, divination, and communication with the spirit world.

East Asian Spiritual Practices

East Asian religions also contribute to the religious diversity in the United States, especially for nurses working in areas with significant East Asian immigrant populations. The following are a few of the East Asian religions, philosophies, and traditions that a nurse may encounter in the course of their practice:

• Confucianism: Founded in China, Confucianism emphasizes social harmony, respect for elders and authority, and ethical conduct. Confucianism is not a religion in the traditional sense but a system of philosophical and moral teachings founded by Confucius. (Britannica, n.d.) The principles of Confucianism are an important part of many East Asian cultures and can influence how people view life, illness, and death. Confucianism emphasizes family, especially respecting elders.
• Taoism (Daoism): Another Chinese philosophical and religious tradition, Taoism (Daoism) focuses on striving for balance in life and living in harmony with nature (BBC, n.d.). Holistic healing practices paired with traditional medicine may be the preference of Taoist patients. In Taoism, there is an emphasis on health, longevity, and healing, which often includes the use of herbal medicine, acupuncture, and qigong (a traditional Chinese practice that integrates physical postures, breathing techniques, and focused intention).
• Shinto: Shinto, the indigenous religion of Japan, holds deep reverence for nature spirits and ancestors (kami) and balancing the physical and spiritual worlds. Shintoism emphasizes cleanliness and purification (Britannica, n.d.).
• Folk religions: Many folk religions throughout East Asia feature ancestor worship, animism, and deities specific to a region.

The Impact of Spiritual Beliefs on Health and Well-Being

Spiritual care is associated with better health and well-being for everyone. Spirituality significantly contributes to a person’s overall sense of wellness and quality of life. These impacts include the following:

• Meaning and purpose: Spirituality provides a framework through which individuals interpret their experiences and find a sense of direction in life.
• Connection and relationships: Spirituality nurtures connection with others. Positive relationships and a sense of community contribute to well-being.
• Inner peace and resilience: Spiritual beliefs and practices can provide individuals with inner peace, comfort, and resilience in the face of challenges, including illness.
• Quality of life: Studies suggest that individuals who report a strong sense of spirituality often experience a higher quality of life (Borges et al., 2021).
• Coping mechanism: Spirituality can serve as a coping mechanism during times of stress, illness, or loss. It provides individuals with a source of strength and support.

Spiritual resources can help nurses overcome the emotional toll of caring for seriously ill and dying patients and prevent compassion fatigue and burnout. Provision 5 of the ANA Code of Ethics states, “The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth” (ANA, 2015). A desire to help others in need is an important part of spirituality.

Link to Learning

Michaela, a nursing student, is also a patient undergoing chemotherapy. In this video, she discusses how her spiritual journey has helped in her recovery.

Patient-Centered Care

Integrating a patient's spirituality into care aligns closely with the principles of patient-centered care (PCC), which prioritizes the individual's preferences, values, and unique needs. By recognizing and incorporating a patient's spiritual beliefs and practices into their care plan, nurses demonstrate a commitment to honoring the patient’s holistic well-being and promoting a sense of connection and engagement (see Chapter 6 Promoting Individualized Care for more about patient-centered care).

Moreover, integrating spiritual participation into the care plan reflects a proactive approach to addressing the patient’s holistic health needs beyond just the physical aspects of their condition. People who hold spiritual beliefs and participate in a community, such as religious service attendance, are associated with positive health outcomes, including greater longevity and reduced depression, suicide, and substance use (Chen et al., 2020). By recognizing the value of spiritual participation in promoting overall well-being, nurses demonstrate a commitment to providing comprehensive, patient-centered care that addresses the patient's spiritual, emotional, and social needs.

Spiritual Healing

Nursing care has progressed significantly toward adopting a holistic care model, which views humans as biological, social, psychological, and spiritual beings and emphasizes the importance of considering all these dimensions in the care process. It is important to recognize how the spiritual dimension is integral to a patient’s overall well-being and health (Forough Rafii, 2020). In times of crisis and illness, one’s spirituality often becomes prominent and spiritual needs more evident. Patients frequently turn to spiritual coping strategies during the illness process, with spiritual healing and prayer being among the most widely utilized spiritual sources of comfort.

Spiritual healing is considered a form of alternative and complementary medicine and involves purposeful interventions by individuals to improve the conditions of others. Evidence suggests a rising global trend in the use of spiritual healing, with more than 64.1 percent of Americans incorporating prayer and spiritual healing (Forough Rafii, 2020). This process generally entails two components: the recipient, someone with a physical or mental illness, and the healer, an individual using faith and prayer to facilitate healing. Healers, performing nonmedical treatment either hands-on or from a distance, are involved in spiritual healing through prayer. For some patients with refractory diseases who have not found relief from conventional medical interventions, healing prayer has been explored as a possible therapeutic tool (Forough Rafii et al., 2020).

Clinical Safety and Procedures (QSEN)

Balancing Spiritual Needs and Safety

The nurse is an advocate for patient safety, and there may be times when a patient’s spiritual beliefs could bring them harm. In these complex situations, the nurse will need the skills to navigate a compassionate conversation with the patient and their family and address the challenge that the balance of spiritual needs and safety presents.

Although some patients with refractory diseases (diseases or conditions that do not respond to standard treatments or therapies) may explore spiritual healing as an option when conventional medical interventions have failed to provide relief (Forough Rafii, 2020), it is important to be aware of risks and limitations—including for exploitation.

Patients who are afraid, ill, and in pain are often targeted by people who are touting “spiritual healing,” “miracles,” and “cures” only with the intention of monetary gain. Such scams are exploitative and harmful to patients and their families. Although the presentations of these scams may have similarities to the legitimate spiritual practices previously described, they are usually designed to appeal to patients with the ultimate goal of exploiting their need, desperation, fear, or hopelessness.

Healthcare providers, including nurses, must be aware of the potential risk and help patients access reputable resources and encourage them to be wary of any person, product, or service that makes promises or claims related to health and wellness—particularly when money is involved (National Consumers League, 2017).

There may also be less overt situations where spiritual healing offers a patient some relief or comfort, even if it’s more of a “placebo effect” than clinically measurable improvement. Although these situations may not harm a patient directly, they may become risky if patients are drawn away from the traditional medical care prescribed or recommended for them or if the practices interfere with evidence-based treatments (Cundiff-O’Sullivan et al., 2023).

Nurses should be prepared to discuss a patient’s spiritual healing preferences, and determine whether a patient is being placed at risk, and intervene, if necessary, to prevent harm.

Developing knowledge and skills related to patients’ spiritual care is essential for effective communication, trust, and empathy in nursing practice. Nurses not only address the varied spiritual needs of their patients but also meet those needs while also balancing their own beliefs—which may, at times, be at odds with those held by the patients they treat.

Spiritual Practices

Just as the beliefs and values that define an individual’s spirituality vary, so will the activities that help them feel connected to their spiritual life. Spiritual practices that are commonly acknowledged and respected in the nursing profession include the following:

• Prayer and meditation: Many individuals find solace and connection through prayer or meditation. Nurses can support patients in their spiritual practice by providing a quiet and peaceful environment, respecting designated prayer times, and allowing patients the privacy to engage in their spiritual rituals.
• Mindfulness and presence: It can be spiritually enriching to practice mindfulness by being present in the moment and aware of one’s thoughts, feelings, and environment. Nurses can guide patients in simple mindfulness exercises, such as focused breathing or mindful walking, to promote a sense of calm and centeredness.
• Sacred rituals and ceremonies: A ritual is a defined practice that individuals or groups use to commemorate or cope with something, such as birth, death, healing, or another life transition. A ceremony is a public and formal celebration or gathering that honors or commemorates something. Nurses can support patients by respecting and facilitating their rituals and ceremonies, when possible, to ensure cultural sensitivity and inclusivity.
• Connection with nature: For some individuals, connecting with nature is a profound spiritual practice. Nurses can facilitate this by arranging access to natural settings, such as gardens or outdoor spaces for patients.
• Pastoral care and spiritual counseling: Many healthcare settings have pastoral care services, or spiritual counselors, (individuals who support patients in exploring and expressing their spiritual needs). Nurses can collaborate with these professionals to ensure patients receive spiritual guidance and counseling tailored to their beliefs.

Incorporating these practices into patient care demonstrates a commitment to addressing the spiritual dimension of health and well-being, and nurses should approach these discussions with sensitivity, respect, and a nonjudgmental attitude.

Self Care Behaviors

Nurses are regularly exposed to human pain and suffering, which has physiological, psychological, and spiritual dimensions. Despite dedication to patient care, nurses often neglect their own physical, spiritual, and social needs, subconsciously overlooking their own needs as being a necessary aspect of professionalism. As nurses provide care involving death and dying, maintaining spiritual health is crucial for emotional and physical well-being. Studies indicate that some nurses may use religious beliefs to cope with patient deaths, emphasizing the importance of spirituality in healthcare settings (Greene, 2020). Nurses can also face moral distress and secondary traumatic stress, putting them at risk of burnout. Awareness of spiritual health is necessary for processing moral distress and preventing burnout (Table 35.1).

Pillar of Self-Care	What It Means	Examples
Physical	Take care of your body.	Moving your body (walk, dance, stretch), eating nutritious foods, getting enough quality sleep
Emotional	Manage your feelings.	Journaling, deep breathing, meditation, therapy
Mental	Keep your mind active.	Reading, learning, doing puzzles
Spiritual	Find meaning and connection.	Praying, meditating, spending time in nature
Environmental	Take care of your space.	Going outside, keeping your home clean
Social	Stay connected with others.	Spending time with loved ones, joining a club, volunteering
Recreational	Do things you enjoy.	Listening to music, playing a sport, doing something creative

Table 35.1 Pillars of Self-Care

Spiritual health enhances self-awareness and self-care, acting as a shield against compassion fatigue, secondary trauma, and burnout (Ibrahim et al., 2020). Nurses can tend to spiritual health needs through conscious self-care planning, incorporating practices such as remembrance and renewal (R & R)—a practice that involves reflecting on the past while simultaneously revitalizing or rejuvenating oneself for the future—to process loss and grief through reflection and strategies that promote growth.

Cultural Context

Cultural Perspectives on Self-Care

Cultural factors significantly influence self-care behaviors, shaping individuals’ approaches to health and well-being. Cultural norms, beliefs, and practices play a pivotal role in determining the choices people make in caring for themselves. For instance, dietary habits can be deeply rooted in cultural traditions, influencing what individuals eat and how they view nutrition. Similarly, attitudes toward mental health, physical activity, and preventive healthcare measures are often shaped by cultural perspectives. The importance placed on communal and family support also varies across cultures, impacting the reliance on social networks for well-being. Additionally, cultural perceptions of health encompass physical and mental, emotional, and spiritual dimensions. Rituals and traditions further contribute to self-care, as practices related to food, exercise, spirituality, and holistic health are often intertwined with cultural identity. Recognizing and respecting these cultural nuances is essential for designing effective and inclusive self-care strategies that resonate with diverse populations.

Source of Comfort

Meeting the spiritual needs of individuals involves recognizing the diverse ways they seek fulfillment, a dynamic process influenced by personal values and changing priorities. These methods often include spending meaningful time with loved ones, immersing oneself in nature, pursuing enjoyable hobbies, and engaging in religious practices such as prayer or attending services.

For patients with terminal illness, palliative care extends beyond the physical realm to encompass spiritual well-being. A diagnosis of a terminal illness often triggers shifts in spiritual needs, prompting individuals to address broken relationships, grapple with unresolved issues, and contemplate the deeper meanings of life and death. The holistic approach of palliative care acknowledges the interconnectedness of spiritual, physical, social, and emotional needs, ensuring comprehensive support for individuals and their families. Understanding the evolving nature of spiritual needs is crucial in promoting overall well-being for those navigating the complexities of terminal illnesses.

Source of Conflict

When assessing sources of spiritual conflict or distress, nurses often are entrusted with information that may otherwise go undetected or recognized. Whether patients have acute, chronic, or terminal illnesses, they are often in situations that can cause spiritual distress. Asking questions about relationships, loss, fears, and conflict is important. Such information can reveal information including the following:

• Relationships: Feeling like they no longer have a role in their family, losing the ability to be a supportive person in the lives of loved ones, and experiencing loneliness.
• Loss of independence: Losing sense of personal identity, concerns about becoming a “burden” on loved ones.
• Fear of dying: Worry about what dying will be like, questioning what will happen after death.
• Loss of control: Struggling with a lack of control over physical and mental health, feeling like they no longer have agency in life, feeling like the future is out of their hands.
• Loss of purpose: Struggling to see the point of life, unable to find meaning in life.

It is important for nurses to include the patient’s family and caregivers in the assessment, as they may also be experiencing spiritual distress as well. A patient’s family needs to be included in the care plan to ensure a holistic approach to spiritual health and overall healing.

Patient Conversations

Searching for Meaning

Nurse: Good morning, Mrs. Spiegel. How are you feeling today?

Patient: Oh, I’m still alive.

Nurse: You sure are! How is your pain?

Patient: Well, not much better than last night but . . . [tearfully] I feel such an ache in my chest and my throat. And I don’t think it’s from the treatment. Or the cancer. At least, not physically.

Nurse: It sounds like you’re feeling a different kind of hurt—the emotional kind?

Patient: [nods, then starts to cry] Why did this happen to me?

Nurse: You aren’t alone in asking that question. Is there any particular reason you’re thinking about it this morning?

Patient: Oh, I don’t know. I just lay awake all last night listening to these beeping machines and wishing I was home in my own bed, with my husband and my dog. I was trying to figure out where I went wrong—or what I did wrong.

Nurse: About the cancer, you mean?

Patient: Maybe it’s silly but . . . [trails off and reaches for a tissue]

Nurse: It’s not silly, it’s how you feel. And it matters.

Patient: I never smoked or drank; I never did drugs. I ate right and exercised . . . sometimes. I always tried to be a good neighbor, a good wife, and a good mother. I volunteer, I donate money, I try to never say a bad word about anyone . . . now I wasn’t perfect or a saint, not by a long shot. But I did all the things I thought I was supposed to do and I just don’t understand why I’m getting punished.

Nurse: You feel like the cancer is a punishment?

Patient: Well, it sure feels like it.

Nurse: What you’re feeling and thinking right now is very painful, but I want you to know that you’re not alone. I have talked with patients, even in the same bed you’re in, who have asked themselves the same question. And I don’t have any answers, but I can listen and help you figure out what kind of support you’d like to have as you process this experience. It’s a very personal journey, so what’s helped someone else might not be what you need. But I’m here, and I’m ready and willing to help you figure it out.

Patient: Do people usually blame God?

Nurse: Not always. Do you blame God?

Patient: No, no. I guess I blame myself. I don’t want to believe that God is anything but merciful.

Nurse: Is your spirituality an important part of your life?

Patient: I believe in God, yes. I haven’t been to church since I got diagnosed though . . . just have felt so tired. I stopped praying because . . . well, I guess I don’t know what to say.

Nurse: Well, let’s talk more about what we can do to make sure you’re feeling that connection and comfort.

Scenario follow-up: The nurse has opened the door for a compassionate, supportive conversation with the patient about their spiritual needs. The nurse actively listens and uses thoughtful, open-ended questions to guide the patient through their thoughts and help them better understand their needs. From this conversation, the nurse gathered the information needed to make a plan for incorporating spiritual needs into the patient’s care.