The nursing and healthcare literature continue to reflect the understanding that spirituality and religion are not synonymous.³,⁴,⁵,⁶ As the essence of our being, spirituality is integral to all persons. Spirituality is a manifestation of each person’s wholeness and being that is not subject to choice, but simply is. Religion per se is not essential to existence. Religion is chosen. Spirituality is expressed and experienced in many ways, both within and beyond the context of religion.

Religion refers to an organized system of beliefs shared by a group of people and the practices related to that system. Ritual, worship, prayer, meditation, style of dress, and dietary observances are examples of such practices. Because culture influences a person’s values and beliefs, religious and other spiritual expressions often relate to personal culture. Religions reflect particular approaches to and understandings of spirituality. Religious precepts and practices often assist persons in attending to their spiritual selves; at times, however, these actions do little to nurture a person’s true spirituality. Life issues that are spiritual in nature may or may not relate to religion. Knowledge of the histories, symbols, beliefs, practices, and languages of various religious traditions increases the nurse’s ability to hear, recognize, and address religious needs of patients; however, information alone about religious affiliation and practices offers only a glimpse into a person’s spiritual self.

Because religion offers a particular structure for expressing spirituality, nurses may be more comfortable discussing spiritual concerns when they arise within an identifiable religious context than when they occur within a broader perspective of spirituality. Satisfying the rites and rituals of a particular religion may or may not meet all of a patient’s spiritual needs. Spiritual care and interventions need to be individualized and reflect the patient’s perspectives and worldview.⁷ This is of particular concern when a patient’s spirituality is not expressed through an affiliation or alignment with the practices of a particular religion, and when the patient’s culture and spiritual perspective are different from that of the nurse. Holistic nursing practice recognizes that religion and spirituality are different and
honors the unique ways in which people express, experience, and nurture their spiritual selves.

One of the barriers to incorporating spirituality into holistic nursing care is the paucity of language within Western societies for discussing and expressing matters of the spirit or soul. This difficulty with the language of spirituality is evident in the nursing literature. In Western cultures, the language used for describing and expressing spirit is generally that of science or of religion derived from the Judeo-Christian tradition. Indeed, much of the discussion of spirituality within nursing and other healthcare literature reflects Judeo-Christian values and perspectives regarding the Divine, relationships with others and the world, experience of suffering, prayer, and the like. Understandings of spirituality and language describing spiritual values and experience may be different for many people in the world who do not adhere to the Judeo-Christian tradition. Because spirituality is the essence of every person and is not limited to a particular religious perspective, nurses strive to be open to, or to create a language that allows room for, each person’s unique expression of spirituality.

A Western cultural bias can lead to misinterpretation of spiritual expression and concerns. Engebretson and Headley note that not all assumptions of Western Judeo-Christian-Islamic traditions (e.g., monotheism, transcendence, dualism) are shared with Eastern and Nature religious traditions.⁸ Monotheism is a belief in one God that is above and beyond Nature, contrasted with a belief in the existence of many gods (polytheism) or the existence of the sacred in all living things (pantheism) found in Eastern and Nature religions. Transcendence, which means to exist above material existence, is implied in the Western view of God as separate from humanity. People from such Western traditions often seek connection with the Divine by focusing outward through ritual and prayer. Eastern and Nature traditions focus on immanence, the experience of the Divine within each person. Looking inward through meditation and spiritual exercises is a way of connecting with the Divine in these traditions. Dualism (the separation of spirit and matter) is a familiar concept in Western traditions, while reality is conceived as a unified whole in Eastern metaphysical traditions of monism. Engebretson notes that the polarization of science and religion found in the West reflects the institutionalization of dualism. She emphasizes the importance of recognizing the impact of these assumptions on perceptions, definitions, and expectations of the spiritual experience within health care. She is especially concerned about labeling spiritual issues as pathology, or not recognizing them at all because they do not fit a familiar paradigm.

Increased interest in spirituality and health over the past two decades has generated many definitions and descriptions of spirituality within the healthcare literature. In many ways, however, trying to define spirituality is like trying to lasso the wind. The wind can be felt and its effect on things seen, but it cannot be contained within imposed boundaries, conceptual or otherwise. The similar nature of spirituality poses a particular challenge for minds that feel more at home with phenomena that can be categorized, quantified, and measured. Understanding spirituality requires opening to many ways of knowing, including cognitive, intuitive, aesthetic, experiential, and deep inner sensing or knowing.

The healthcare literature provides no single agreed-upon understanding of spirituality. Elements of spirituality found in broad descriptions of the concept include the essence of being, a unifying and animating force, the life principle of each person, a sense of meaning and purpose, and a commitment to something greater than the self.²,⁹,¹⁰,¹¹,¹²,¹³ Spirituality permeates life, shapes our life journey, and is vital to the process of discovering purpose, meaning, and inner strength. Although matters of spirit transcend culture, a person’s cultural perspective influences personal expressions of spirituality. Personal values are rooted in and flow from spirituality and are reflected in a cultural perspective. Spirituality helps to ground one’s sense of place and fit in the world. Because it is practical and relevant to daily life, people experience spirituality in the mundane as well as in the profound, the secular as well as the sacred.

A sense of trust that people have or are given the resources needed for dealing with whatever
comes their way—expected or not—is a manifestation of spirituality. These resources include both strength and guidance from within and support from sources beyond themselves. Through encountering obstacles along their life path, learning through experiences, and developing new awarenesses, people gain appreciation for the ways that spirituality shapes and gives meaning to their unfolding life journey. To reach this point, people may find it necessary to reconcile new experiences with previously held values, resulting in new values and understandings. Often, the pattern of the journey and the meaning of life events become clear only in retrospect.

A sense of peace, often described as inner peace, is a spiritual attribute. Peace in this context implies a deep confidence and an ability to remain calm in the midst of the storm, to know somehow that all is well. Spiritual peace is experienced in the space of the heart and may not make sense to the cognitive mind. In the Judeo-Christian tradition, references to “a peace which passeth understanding” flow from an awareness of life beyond immediate circumstances and unbounded by the past. In the Zen tradition, practices of mindfulness foster connection with the peace that is available in every moment within every life experience. Peace is a product of living in relationship with the Sacred Source, others, and all creation in a way that acknowledges and nurtures the soul in the midst of all that life brings.

Research continues to demonstrate that people express and experience spirituality in the context of relationships with the Sacred Source, Nature, others, and the self.²,¹⁴,¹⁵ The Sacred Source may be experienced as a person, a presence, or as a mystery that is beyond words. The inadequacy of language is especially apparent when we try to discuss or describe that which is within and among us, yet beyond and a power greater than us. From before the beginning of recorded history, humanity has searched and sought to understand the mystery of the Sacred Source. Various cultures, faith traditions, individuals, and groups use names such as Life Force, Source, God, Allah, Lord, Goddess, Absolute, Higher Power, Spirit, Vishnu, Inner Light, Tao, Great Mystery, Tunkasila, the Way, Universal Love, and the One with No Name to refer to that in which we live, move, and have our being. For this discussion, this Being or Sacred Mystery is referred to as God or the Sacred Source.

A connection with the Sacred Source is at the heart of one’s being. Our rational minds cannot think or grasp God, and any descriptions or words used to speak of the Sacred Source are lacking. God is far more than anything the human mind can conceptualize. Words and descriptions are, however, tools of the rational mind that can point us toward God or the Sacred Source. Concepts of God developed by the rational mind may be personal or shared within a group. Persons find and name the Sacred Source in ways that are authentic to them, using terms and language that reflect their experiences and perspectives. Connecting with the Sacred Source may involve such things as prayer, ritual, reconciliation, and stillness. Teachings of various religious traditions offer their own perspectives and guidance on how to be in relationship with the Sacred Source. Understanding how persons seek and experience connection with the Sacred Source and the obstacles they may encounter are important in spiritual caregiving.

The concept of reverence is associated with many understandings of the Sacred Source. Reverence arises from a deep appreciation of human limitations and a sense of awe in relation to what is understood to be outside our control—God, truth, the natural world, even death. Awareness that the sacred is intrinsic and omnipresent engenders reverence toward the Sacred Source and all of life.¹⁶ Reverence acknowledges that we are in and of God, yet, as Woodruff notes, it also keeps human beings from trying to act like gods.¹⁷ Some persons do not claim a religion or give a name to that which they hold most sacred. However, they may experience a sense of reverence in their recognition of that which is beyond and greater than their own understanding, but with which they experience an often mysterious relationship.

Spirituality is frequently expressed and experienced in and through a sense of connectedness with Nature, the environment, and the universe. Relationship with creatures of the Earth, both wild and domesticated, provide meaning and
joy for people of all ages. Awareness of all beings of the Earth, and their place within the natural order, is a way of connecting with the spiritual in all of life.¹⁸ Beavers at work on a dam, red rock canyons, or bees among the flowers all illustrate the wonder of various life forms that may provide deeply spiritual experiences.

Awareness of a connectedness with the Earth and, indeed, the entire cosmos is particularly evident within indigenous spiritual traditions. A speech attributed to Chief Seattle emphasizes that all things are connected.¹⁹ Individuals are not the weavers of the web of life; rather, each is a strand in the web. What they do to the web they do to themselves. Thus, what happens to the Earth and the environment affects them, and conversely, their choices and actions in all levels of their being affect the Earth.¹⁶,²⁰ Understanding the interconnectedness of spirit and matter is basic to some traditions and known at some level in all spiritual traditions, particularly among the mystics.

Many people, particularly those who live close to the land, experience a sense of connection with the Sacred Source through Nature, regardless of their religious background. Paying close attention to the natural world and living in conscious relationship with the other-than-human beings of the world is a way of attuning more to one’s own soul and spirit. People often express a particular feeling of closeness to their spiritual selves while walking on a beach, sitting by their favorite tree, viewing a sunset, listening to flowing water, watching a fire, caring for plants, and otherwise experiencing the natural order. Nature can be a source of strength, inspiration, and comfort, all of which are attributes of spirituality. A sense of awe at the wonder of life and a feeling of connectedness with all things, with or without a belief in a divine being, is an experience of spirituality. For some, connection with Nature flows from a sense of finding God in all things; many experience a relationship with the Earth and all its creatures at an energetic level. Appreciating, respecting, and caring for the Earth and all its inhabitants are elements of spirituality.

Spirituality is known and experienced in and through relationships, with the comfort, support, conflict, and strife that mark those connections. People express and experience spirituality through an appreciation of a common bond with all humanity and in their particular relationships with others. Spirituality is shaped and nurtured within one’s experience of community, beginning with one’s family. The many communities, both formal and informal, in which people live provide a context for spiritual expression and development. Communities provide an opportunity for sharing spiritual journeys.

People often speak of their spirituality in terms of their relationships, both harmonious and discordant. The formation, work, nurture, and healing of relationships are an important part of one’s spirituality. Being with others in loving and supportive ways is an expression of spirituality, as is struggling with painful and difficult relationships with family, friends, and acquaintances. Relationships that need healing are as important to spirituality as those that provide support and comfort. Spirituality embraces both the joys and sorrows of relationships and prompts reconciliation where connections have been frayed. Lack of connections often produces a dispiriting sense of aloneness and isolation and may lead to spiritual crisis.

Spiritual connectedness with others involves both giving and receiving. Receptive openness to Love, Light, Life, and the Sacred Source is a spiritual stance. Although it is common to think of spirituality in terms of doing for another, being able to receive from others, both the gift of themselves and the things that they do or say, is also an expression of spirituality. Indeed, the genuine presence that someone shares with another, with its implicit loving honesty and intimacy, is a manifestation of spirituality.⁷,²¹,²²,²³ Spirituality is evident in both common experiences of daily living and special times shared with others: times of joy, sorrow, ritual, loving sexuality, prayer, play, encouragement, anger, reconciliation, and concern. Relationships as a source of growth and change are integral to spirituality.

Advances in technology have brought distant and isolated countries and cultures together into a world community. As a result, understanding factors that create and support community has become essential. The ability to connect with people around the globe enables better understanding of how personal and collective decisions impact the larger human family. Social
structures that provide a context for relationships with others often are instrumental in nurturing the spiritual dimensions of community life. Structures such as health care, educational institutions, faith-based services, social organizations, informal affiliations, and Internet links with others are often places that mediate and support the spiritual dimensions of life.

Spirituality infuses the ever-unfolding awareness of who one is—of self-becoming. The ability to be in the place of awareness that flows from spirit or soul is a pivotal element of connectedness with self. Awareness opens people to the experience of living in the moment, present to their own bodymindspirit, and allows them to receive all aspects of themselves without judgment. They experience awareness through Being, the art of stillness and presence with self, others, the Sacred Source, and Nature. Being simply is. Being includes experiencing the present moment more deeply, aware from the physical experience of all levels of one’s bodymindspirit energetic self in interaction with all in the environment. Being is bringing one’s whole self—alert and aware—to an experience, allowing one to pay attention to the quiet place inside and find inner peace, synchrony, harmony, and openness. Attentiveness to being allows a person to attune to sources of inner strength and deepest knowing.

Spirituality manifests and is experienced in knowing, which includes cognitive, intuitive, and energetic dimensions. Knowing provides ways of understanding our multidimensional nature and our relationships to the Sacred Source, self, others, Earth, and the cosmos. Knowing flows from a stance of openness and attuning to an inner source. It involves actively seeking knowledge and insights and maintaining an openness and receptivity to the lessons life offers. Spirituality reflected in one’s knowing includes appreciation of life as a gift and a sense of connectedness to all creation.

From being and knowing flows doing, the outward and more visible aspect of spirituality. Because doing is more tangible and measurable, it is the manifestation of spirituality that is most often addressed in healthcare literature. Generally, the concept of doing brings to mind activities such as attendance at religious services or ceremony, scripture study, prayer or meditation, participation as student or teacher in religious education, and spiritual reading. Spirituality can be demonstrated as well through actions such as assisting others, gardening, becoming involved in environmental concerns, attending to the sick, caring for family, spending time with friends, taking a walk, taking time to nurture one’s own spirit, and creating sacred space for self and others.

The concept of sacred space applies both to one’s inner being and to places in one’s environment. Although to “create” sacred space suggests doing something, inner sacred space is often the result of being in awareness and stillness. Buildings such as religious edifices or monuments represent sacred space for many. Special places in Nature are often experienced as sacred. Any place can become sacred space if one intentionally brings awareness of the spirit into the setting. Words, actions, sounds, scents, colors, and objects may shape such spaces. A sacred space is a home for the spirit, providing rest, stillness, nurture, and opportunities for opening to various connections. A special plant in a sunlit space, a garden or workshop, a room for prayer or meditation, a corner of a porch with a rocking chair, family surrounding a loved one in a hospital bed—each space touched by the intention of those who arrange it—are examples of sacred spaces.

Experiences of grace contain elements of surprise, awe, mystery, and gratitude. Grace is often experienced as a support that is unplanned and unexpected. An experience of grace may touch one’s spirit in deep and profound ways and may be life changing. Grace opens one’s awareness to the experience of wholeness, healing, and connectedness. Grace is reflected in statements such as the following:

Although some see such happenings as coincidence or chance, others sense something deeper that connects persons within the web of life and enables us to find acceptance, courage, peace, and endurance beyond our own making or understanding. Grace is often spoken of as a gift from the Sacred Source, or from Life itself, that enables, assists, and empowers a person in the midst of difficult and sometimes seemingly overwhelming circumstances. The experience of grace as a blessing that comes into one’s life unearned calls forth a response of gratitude.

An expression of the spirit, prayer is a deep human instinct that flows from the core of one’s being where the longing for and awareness of one’s connectedness with the source of life are blended. Prayer represents a longing for communion or communication with God or the Sacred Source. The most fundamental, primordial, and important language that humans speak, prayer is an endeavor that starts and ends without words. In this understanding, prayer flows from yearnings of the soul that rise from a place too deep for words and move to a space beyond words.

Forms and expressions of prayer are as varied as the people who pray. Prayer, which is intrinsic to many religious traditions and rituals, may be public or private, individual or communal. It is not always a fully conscious activity. Speaking (sometimes silently), singing, chanting, listening, waiting, moaning, being attuned to what is going on in the present moment, and being silent can all be elements of prayer. Prayer includes petition, intercession, confession, lamentation, adoration, invocation, thanksgiving, being, and showing care and concern for others. Some people incorporate processes and techniques such as relaxation, quieting, breath awareness, focusing, imagery, and visualization into their prayer. Movement such as walking, dancing, or drumming may be expressions of prayer. A reminder of our nonlocal, unbounded nature, prayer is infinite in space and time. It is divine, the universe’s affirmation that we are not alone.³²

That prayer is an appropriate consideration for nursing is grounded in the writings of Florence Nightingale.³³,³⁴ Research affirms the truth that people have known for ages: Prayer can affect healing.³⁵,³⁶,³⁷ Both directed prayer, which focuses on a specific outcome, and nondirected prayer, which focuses on the greatest good of the organism, can affect healing and other outcomes, although nondirected prayer may be more effective. Even at a distance, prayer alters processes in a variety of organisms, including plants and people. Furthermore, the observed effects of prayer do not depend on what the one prayed for thinks. In his book Be Careful What You Pray For, Dossey reminds us that prayer is a potent force that is best used thoughtfully, with care and discernment.³⁸