Qualitative Health Research

Volume 18 Number 7
July 2008 928-938

An Experiential Theory of Spiritual Care in © 2008 Sage Publications

10.1177/1049732308318027
http://qhr.sagepub.com
Nursing Practice hosted at
http://online.sagepub.com

Lisa Burkhart
Nancy Hogan
Loyola University Chicago, Chicago, Illinois, USA

Spiritual care has been recognized as integral to nursing care for centuries, as described by Florence Nightingale, and has
been studied in both medicine and sociology. Health care institutions, particularly faith-based health systems, also have
recognized the importance of spiritual care. Both qualitative and quantitative research support the importance of spiritu-
ality in patient health. Although the profession, health care institutions, and research support spiritual care, there is no
empirically derived theoretical framework to guide research in spiritual assessment and spiritual care. We used focus
group data from registered nurses who care for the chronically ill (n = 25) in a large Midwestern academic health center
to generate a grounded theory of spiritual care in nursing practice. What emerged from this study was a beginning theo-
retical framework to guide future spiritual care research.

Keywords: grounded theory; spiritual care; spirituality; nursing

S piritual care has been foundational in nursing since

modern nursing began with the Catholic religious
orders and Florence Nightingale (Calabria & Macrae,
statistical associations with other variables (Corrigan,
McCorkle, Schell, & Kidder, 2003; McClain, Rosenfeld,
& Breitbart, 2003; Tuck, McCain, & Elswick, 2001).
1994; O’Brien, 2003). However, it has been only This supports the assumption that spirituality and reli-
recently that researchers have studied spirituality in rela- giosity are different concepts. Spirituality is the expres-
tion to health. sion of meaning and purpose in life, and religiosity is the
The literature is inconsistent in its definition of spiri- expression of faith rites and rituals.
tuality. The majority of the literature differentiates spiri- Much of the current research in spirituality has
tuality from religiosity. Spirituality is associated with been descriptive and has shown that spirituality is asso-
finding meaning and purpose in life, transcendence ciated with better psychological dimensions (Fry, 2001),
beyond the physical body, and/or experiencing a sense social health indicators (Corrigan et al., 2003), and
of connectedness with self, others, nature, literature, physical symptoms of chronic illness (Meraviglia,
arts, and/or a power greater than oneself (Burkhart & 2004). Qualitative research also indicates that people
Solari-Twadell, 2001; Carson, 1989; Carson, Winkelstein, with chronic illness and those at end of life have identi-
Soeken, & Bruinins, 1986; Englebretson, 1996; Haase, fied spirituality as important in coping with disease and
Britt, Coward, Leidy, & Penn, 1992; Labun, 1988; Lane, treatment, particularly including hospice patients
1987; Mickley, Soeken, & Belcher, 1992; Narayanasamy, (Keeley, 2004; Marshall et al., 2003; McGrath, 2003;
1996; Reed, 1991). Religiosity is associated with human Tan, Braunack-Mayer, & Beilby, 2005), people who
expression of the rites and rituals of a particular faith tra- have experienced death of a loved one (Gamino, Sewell,
dition. Some researchers do not differentiate religiosity & Easterling, 2000), and people with HIV (Denzin,
from spirituality; instead, they assert that meaning and 1989), cancer (Ferrell, Smith, Juarez, & Melancon, 2003;
purpose are found through the rites and rituals, and the Logan, Hackbusch-Pinto, & De Grasse, 2006), diabetes
two concepts cannot be separated (Koenig, George, & (Polzer & Miles, 2007), chronic renal failure (Walton,
Titus, 2004; Pargament, 1999). Other studies measuring 2002), and stroke (Bays, 2001). However, little has been
both spirituality and religiosity yield different significant done to study the provision of spiritual care.
Health care systems internationally have long been
associated with religious traditions. In Europe,
Authors’ Note: The grounded theory study was funded by the Christian religious orders provided nursing care dat-
Palmer Foundation and the Niehoff School of Nursing, Loyola ing back to the mid-1600s (e.g., the Daughters of
University Chicago. Charity of St. Vincent De Paul, Sisters of Charity,
928

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 Burkhart, Hogan / Spiritual Care in Nursing Practice 929

Sisters of Mercy, Kaiserswerth Deaconnesses, Sisters of United States (Commission on Collegiate Nursing
Bon Secours, and Missionaries of Charity; O’Brien, Education, 2003; National League for Nursing Accredi-
2003). In the United States, many health systems were tation Commission, 2004). Leading textbooks include
founded by religious organizations. These faith-based little on spiritual care. For example, Lewis, Heitkemper,
health systems view spiritual care as central to their mis- Dirksen, O’Brien, and Bucher (2007) allocated approxi-
sions. As the largest not-for-profit and private health sys- mately 1 page on spirituality out of a 1,884-page medical/
tems in the United States, Catholic institutions have surgical textbook, and that page is primarily associated
identified spirituality and faith as central to their with complementary/alternative care and end-of-life
Catholic identity (Burkhart & Solari-Twadell, 2005; care. The medical–surgical text, by Smeltzer, Bare,
Giganti, 2004; see also the Catholic Health Association Hinkle, and Cheever (2007), allocates approximately
Web site, http://www.chausa.org). The Catholic Health five pages to spirituality and spiritual care. Spiritual care
Association published a statement declaring that is inconsistently integrated into only a few chapters (i.e.,
Catholic identity includes caring for the whole person, leukemia, surgery, and end of life). Research is needed
including physical, psychological, social, and spiritual to determine educational content and methods of spiri-
dimensions (Giganti, 2004). The Joint Commission, an tual assessment and interventions that promote spiritual
accrediting body in the United States, also recognizes well-being and patient health. Nursing theory can guide
the importance of spiritual care by including a standard this research. Research indicates that spiritual well-
that requires the provision of spiritual care in a multidis- being is linked to better health indicators. Many health
ciplinary environment, particularly for patients at end of systems view spiritual care as part of their mission.
life (Standard RI.1.2.8; Clark, Drain, & Malone, 2003; Nursing has historically embraced spiritual care since the
Joint Commission on Accreditation of Healthcare 1600s with religious orders and Florence Nightingale,
Organizations, 2003). Not only do faith-based institu- and nurses are in the position of providing spiritual care.
tions view spiritual care as central to their missions, all However, little is known about how to best provide spir-
U.S. institutions are required to provide spiritual care. itual care in nursing practice. It was the aim of this study
Nursing, as defined by the American Nurses Associa- to explore nurses’ experiences of providing spiritual care
tion (2003), is concerned with human response to illness within a health system.
as well as the promotion, protection, and optimization of
health and abilities. Promoting one’s spirituality within
a nursing paradigm can be one way to promote and opti- Design
mize health, particularly in response to illness. Press
Ganey, an independent company that measures patient The grounded theory method developed by Glaser
satisfaction posthospitalization, identified that patient and Strauss (1967) was used to explore nurse perception
satisfaction data significantly correlated emotional/spir- of spiritual care in nursing practice within a health sys-
itual care and satisfaction with nursing care, suggesting tem. Data were collected in a U.S. health system from
that nurses have a significant role in providing spiritual focus groups of nurses who care for the chronically ill.
care (Press Ganey, 2006). As the single largest health The study was approved by the health system’s
care discipline with access to patient/clients often 24 hr Institutional Review Board, to ensure the protection of
a day, nurses have an opportunity to address spiritual human rights.
needs when and where spiritual questions are immanent.
However, little is known about how spiritual care is
implemented in daily nursing practice. A few rationally Sample
derived grand theories include spirituality content (e.g.,
Watson, 1998); however none provided a method and The participants in the original four focus groups
framework to study spiritual care empirically, particu- included 25 registered nurses who cared for the chroni-
larly in terms of spiritual assessment and spiritual inter- cally medically ill, as research indicates that patients
ventions (Watson, 1988). with chronic medical disease view spirituality as impor-
Nursing education also lacks guidance in teaching tant in coping with the stressors inherent in their health
students how to provide spiritual care. Research indi- condition. These staff nurse participants worked across
cates that health care providers do not know how to pro- the continuum of care, including intensive care, medical/
vide spiritual care (Fletcher, 2004). Although spiritual surgical nursing, home health, ambulatory care, rehabil-
care is a Joint Commission requirement, currently spiri- itation, and hospice. Participants worked in both pedi-
tual care is not required content in nursing schools in the atric and adult settings. Sample inclusion criteria

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930 Qualitative Health Research

were designed to maximize generalizability to nursing Table 1

care for patients with chronic medical illnesses but were Scripted Focus Group Questions
specific to direct care providers. Four focus groups were Number Question
held in summer 2005 (n = 5, 6, 6, 8). The sample was
primarily Caucasian (88%), with 12% Hispanic. The 1 Think of a time when you provided spiritual care
and tell us the story.
majority of the sample was Roman Catholic (68%), with
2 When you think of spiritual care, what comes to
20% non-Catholic Christians; one individual stated no mind? What does “spiritual care” mean to you?
religion. The average age was 42.84, ranging from 25 to 3 Finish this sentence: “Spiritual care is important
58. The number of years working in nursing averaged 18 for nursing because . . . ”
years, with a range of 1 to 38 years. The highest nursing 4 Tell me about how you have learned how to
degree completed was associate degree (20%), diploma provide spiritual care.
5 Tell me some of the ways that a health care
(12%), BSN (52%), and MSN (16%). An additional institution can support spiritual care.
focus group of nine nurse managers represented units 6 What would help you provide ongoing
across the continuum of care. spiritual care?
7 Tell me about resources outside of the health
system that support you giving spiritual care?
Procedure 8 How do you know you have been successful in
providing spiritual care?
9 Who cares for your spirit?
Flyers inviting registered nurses to participate in 10 Is there anything else that you would like to say
the study were distributed to staff nurses who work in about spiritual care that we haven’t talked about?
settings caring for the chronically ill. These settings
included intensive care units, medical surgical units, out-
patient oncology clinics, home health, hospice, and reha-
bilitation units. Presentations describing the project were Therefore, theoretical sampling was done by adding one
also held at staff meetings on those units without the additional focus group consisting of nine unit-based
managers being present. nurse managers (Glaser, 2001). Both researchers ana-
Four staff nurse focus groups convened for 2 hr in lyzed the data individually and compared results to max-
a comfortable environment. Two researchers were pre- imize reliability. Data guided model revision. Saturation
sent: one to facilitate the focus group and the other to was reached with the fourth focus group. No additional
observe and take notes. Participants in each focus group codes of the theory emerged from the fourth focus group
were asked scripted questions. Additional questions were data analysis. The additional nurse administrator focus
added as collection and data analysis proceeded and group verified the conceptual categories, processes, and
the researchers became more theoretically sensitive to subprocesses that appeared relevant to the conceptual-
the data. Questions, as shown in Table 1, were designed ization of spiritual care in nursing practice.
to explore perceptions of spiritual care in nursing and
institutional and noninstitutional initiatives that support
spiritual care. Participants provided examples of their Theory Categories and
encounters with patients that exemplified spiritual care. Subcategories/Subprocesses
Focus groups were audiotaped, transcribed, and
assessed for accuracy. Data analysis began after the first This beginning theoretical framework consists of a
focus group, and upon initial analysis, a beginning the- purposeful process following seven categorical phases
oretical framework began to emerge from the data. Data and related subcategories or subprocesses. A schematic
from each focus group were analyzed and coded indi- description of the beginning theoretical framework is
vidually and sequentially to develop categories, proper- presented in Figure 1, and a taxonomy of the spiritual
ties, and hypotheses simultaneously, as required by the care in nursing practice categories and subcategories is
Glaser and Strauss (1967) theory discovery method. presented in Table 2. The categories are cue from
Subsequent focus groups were analyzed individually patient, decision to engage or not engage in spiritual
and compared to the emerging model using constant encounter, spiritual care intervention, immediate emo-
comparison techniques. Data analysis revealed that the tional response, searching for meaning in encounter,
nurses believed that administrators’ perceptions of spiri- formation of spiritual memory, and nurse spiritual well-
tual care might be relevant to the emergent theory. being. This is a process whereby positive nurse–patient

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 Burkhart, Hogan / Spiritual Care in Nursing Practice 931

Figure 1
Spiritual Care in Nursing Practice Theoretical Framework

Positive
immediate
emotional
response
Decision
Search for Formation Nurse
Cue from to engage Spiritual care
meaning in of spiritual spiritual
patient in spiritual intervention
encounter memory well-being
encounter
Negative
immediate
emotional
Decision not response
to engage in
spiritual
encounter

Table 2 spiritually distress-filled memories that can decrease the

Categories, Processes, and Subprocesses of the nurses’ spiritual well-being. Participants stated that after
Theoretical Framework the encounter, they search for meaning in the encounter.
Category Question This search for meaning is integral in forming the
growth-filled or distressing memory, which is consistent
1 Cue from patient with the definition of spirituality as the expression of
2 Decision to engage/not to engage in spiritual
encounter
meaning and purpose in life. Some participants formed
Deciding to engage in spiritual encounter spiritually growth-filled memories from distressing spir-
Deciding not to engage in spiritual encounter itual encounters after reflecting on the experiences and
3 Spiritual care intervention finding new meaning in the encounters. Meaning-filled
Promoting patient self-reflection memories of spiritual encounters lead to greater nurse
Promoting connectedness between patient
spiritual well-being. A stronger spiritual well-being sup-
and family
Promoting patient connectedness with ports the nurse’s ability to recognize a patient’s need for
Higher Power or God spiritual care in the future.
Promoting religious rituals
Prayer
4 Immediate emotional response Cue From Patient
Experiencing positive emotions The first category in the theory is cue from patient.
Experiencing negative emotions
5 Searching for meaning
The patient must invite the nurse to provide spiritual
Reflecting with self care. Nurses can create an atmosphere to increase the
Reflecting with supportive people likelihood that the patient will offer this invitation by
Faith rituals assessing their patients with a spiritual openness of
Prayer love, hope, and compassionate caring. Participants
Religious rituals
described this as “conveying a sense of unconditional
6 Formation of spiritual memory
Forming spiritually distress-filled memories love and hope to people” and “compassion, caring, with
Forming spiritually growth-filled memories a little bit of tenderness.” This provides an atmosphere
7 Nurse spiritual well-being conducive to spiritual care, inviting the patient to spiri-
Faith belief tually connect. One participant described, “Where that
Memory of meaningful experiences comes from in me is maybe different from where it
comes from in them, but you can still convey that same
message and that same sensitivity.” This practice pat-
spiritual encounters can lead to positive spiritually tern is a prerequisite condition to identify a patient cue;
growth-filled memories that will increase nurses’ spiri- it is not spiritual care in and of itself.
tual well-being. In contrast, spiritually distressing Patient cues occur when the patient verbally or non-
nurse–patient spiritual encounters can lead to negative, verbally invites the nurse to share a deeper spiritual

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932 Qualitative Health Research

connection. Nurses purposefully read situations to deter- physical pass.” If the nurse chooses not to enter the spir-
mine if the patient needs spiritual care. One participant itual encounter, the nurse does not provide spiritual care
described this as, “You have to let them open the door. and the spiritual care process stops.
They bring up some sorting [searching for meaning] here
and see what they want to take from that.” Another par- Decision to engage in spiritual encounter. Most par-
ticipant stated that the nurse needs to “be a window that, ticipants described situations when they chose to enter
if it [need for spiritual care] happens, then I will be able into a spiritual encounter. At these moments, both the
to give them something spiritual.” Identifying a patient patient and nurse entered into a relationship of mutual
cue is giving “them an opportunity to be able to use spiritual connectedness: “We get right in there.”
whatever spiritual aspect they have to help themselves to Participants consistently considered entering into
come to grips with what they have physically.” spiritual encounters as a “privilege.” One participant
Participants described nurse–patient encounters when described how “when they experience the treatment
patients need spiritual care and require a heightened sen- sometimes we pray together and I feel privileged to talk
sitivity to recognize patient cues. Participants described about God.”
these encounters as situations commonly associated with
times of patient and/or family crisis or change. These Spiritual Care Intervention
include occasions when patients and family members The third category is characterized by the spiritual
learned of a life-threatening diagnosis, had to make crit- care intervention data. This is the point when spiritual
ical decisions related to treatment, were in the process of care is actualized. During a spiritual encounter both the
carrying out that decision (e.g., transplants, chemother- nurse and patient allow a spiritual connection to occur.
apy), and immediately after death. There were also times The nurse provides the patient with the opportunity after
when patients experienced a change in lifestyle or the patient cue to explore meaning at this time of crisis
appearance that increased vulnerability (e.g., inability to or life change. One participant described the patients as
perform activities of daily living, sudden dependence, “searching for meaning and understanding of what’s
hair loss). going on, what they’re heading for exactly, acceptance
of a life issue and we are part of that experience for
Decision to Engage or Not Engage in them.” There is a mutual connection during the spiritual
Spiritual Encounter encounter. Another participant described this meaning-
The second category of the theory occurs when the filled connection with a pediatric patient:
nurse decides to not engage or to engage in spiritual care-
Sitting at a bedside, talking with a four-year old, who
giving. The nurse perceives a cue that the patient is in dis-
was dying, who, told me that her angels visited her,
tress, and the nurse makes a conscious decision whether and I listened and I believed her, and then she passed
to enter into a spiritual encounter with the patient. in the morning. And that was probably one of the
most meaningful experiences I’ve had . . . ever.
Decision not to engage in spiritual care. Data
revealed that some nurses either do not choose to enter The spiritual intervention category has three subcate-
into spiritual encounters or feel a barrier in providing gories describing the types of spiritual interventions:
spiritual care. Participants found that time constraints, promoting patient self-reflection, promoting connected-
“busyness,” or “the speed of things” prevented them ness between patient and family, and promoting patient
from engaging in spiritual care. They also identified that connectedness with a Higher Power/God. Participants
a lack of collegial support inhibits the provision of spir- described that once they entered into a spiritual
itual care. Participants called this a “trickle down effect encounter with a patient and/or family, the participant
. . . if someone had a bad attitude, and they blasted off purposefully chose to intervene in some way. The inter-
on you, it’s hard to just brush that off and not let that vention was based on the needs of the patient and family
dump on top of you, and then you turn around and dump and the circumstances of the situation.
it on top of somebody else.” Participants also found that
personal spiritual exhaustion can hinder the provision of Promoting patient self-reflection. The first sub-
spiritual care. One participant described this situation: category, promoting patient self-reflection, involved
“There’s only so much you can give of yourself, and discussions that promote the patients’ understanding
then you don’t have any more to give, then the compas- of the meaning in their illness experience. At times
sion is gone. The wall goes up and then it is just a patients are searching for answers to life questions

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 Burkhart, Hogan / Spiritual Care in Nursing Practice 933

and the meaning in their life experience: “I can remem- that many patients find meaning by gaining connected-
ber talking all night about spiritual things with this guy ness with God in two ways: by facilitating adherence to
. . . we almost had just discussions about life and more religious rites and rituals and through prayer. Facilitating
philosophical discussions, which I remember today.” religious rituals requires the nurse to assess religious
needs and meet those needs. Participants shared stories
Promoting connectedness between patient and of lighting candles during the Jewish High Holidays,
family. Participants stated that many patients and baptism in the NICU, and communion. At times, meet-
families need to maintain a spiritual closeness with ing that need required a chaplain or collaborating with
loved ones. Promoting patient–family connectedness other hospital departments.
occurs in many ways and is contingent on patient and In other situations, participants stated that they
family needs. The nurse assesses those needs and indi- promote spiritual connectedness with God through
vidualizes the care to promote meaningful relationships prayer. Participants prayed both for their patients and
based on that need. One participant described promoting with their patients. One participant described a spiri-
connectedness by eliminating barriers inherent in the tual encounter when prayer helped both the patient
health care environment: and the family promote meaning in life and death:

His wife said, “He’s gonna go tonight,” and I said, The brother-in-law was in the room with the patient
“OK,” and she’s like, “All I want to do is give him a and he called me in because the respiration started
hug.” But she was scared, because of all the tubes and changing dramatically, and I went in there and I
all the equipment everywhere, and I said, “I’ll tell you could tell that he was taking his last breaths, so I was
what, we’ll let you get into bed with him and give him able to feel his pulse—it was bad—and while I was
a hug,” she said she just wanted to hold him. So, I’ve doing that, out loud I prayed the Lord’s Prayer, and I
never done that before, so I did the best that I could, think that made a difference to the brother-in-law
and she, we got her into bed, and she just, she hugged because there was nobody else there and there was
him all night long and he died in her arms. some spiritual care as he left this world.

Mother–baby relationships provide unique oppor- Immediate Emotional Response

tunities to promote patient–family connectedness by
facilitating a meaningful relationship between mother The fourth category delineates the nurse’s immedi-
and child. One participant described a common situ- ate emotional response after the spiritual encounter,
ation in the neonatal intensive care unit (NICU): which became the catalyst for the fifth category. Data
indicated that nurses are immediately affected by
The patients that I deal with have never been home. spiritual encounters in one of two ways: nurses expe-
They’re like—their whole life is spent in the NICU, rience positive emotions or negative emotions.
until they go home, so they’ve never had holidays at
home, or birthdays at home, or anything, so their Experiencing positive emotions. Participants stated
whole life is there, and if, you know, we find out that they felt positive emotions immediately after the spir-
it’s the parent’s birthday, we’ll make a little card from itual encounter when the nurse perceived that the
the baby, or, if it’s Mother’s Day, we make a little card patient experienced a positive spiritual encounter.
from the baby to the mom, and maybe put a little foot- Emotional feelings of happiness immediately follow
print on, and that is just—they just, you know, can’t get these encounters: “That was really neat, so I think we
over that. And no matter what the outcome is, they can help in little ways, whether it’s just being there
appreciate that and they don’t forget it. for the prayer, or helping them feel a little more com-
fortable” and “I’m glad to be a part of it.”
Promoting patient–family connectedness to foster
meaning in relationships also extends to attending funer- Experiencing negative emotions. Participants also
als and wakes. It helps the families validate meaning in identified stories that lead to distressing negative feel-
the patient’s life and gain a greater connectedness with ings, including a sense of failure and sadness. While
their deceased loved one during bereavement. describing and reliving these stories, many participants
cried. “I remember the first time I had a patient who
Promoting patient connectedness with a Higher died. . . . You feel like you failed.” During each focus
Power/God. Nurses also facilitate patients’ connection group, several participants cried describing their stories,
to a Higher Power, when appropriate. Data indicated particularly while describing stories of patients dying,

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934 Qualitative Health Research

“He was just days old, and very young parents, very, around, and it was like the quietest place, and you just
very young parents, and it’s so sad. . . . It’s very hard to sit there and it’s like finding your center again . . . and
get through it sometimes.” guidance to be able to provide good, safe care, and I
think also care support from God to help you.”
Searching for Meaning in Encounter
Formation of Spiritual Memory
The fifth category is searching for meaning in
encounter. Participants stated that they search for mean- The sixth category is formation of spiritual memory.
ing after the spiritual encounter and emotional response. Spiritual memories are the long-term, meaning-filled
Participants described this meaning-seeking process: “I memories of the spiritual encounter. This process is a
think that if you don’t take that time for yourself and real- critical point in the theory in determining whether the
ize that it’s OK. . . . I can think, ‘What did I learn from encounter will be a spiritually growth-filled memory or
it? How did I deal with it?’” and “If you don’t take care distress-filled memory. Participants described this tran-
of yourself and don’t have a piece of that understanding sition as “once you have it happen to you, directly, then
of yourself, it’s really hard.” you know how to do it. That changes your whole life. It
Participants identified three subprocesses describing changes your whole nursing career. And it changes how
methods they used to search for meaning in those you look at things.”
encounters. These subprocesses are similar to the spiri- Participants identified three pathways between the
tual care interventions nurses perform to promote spir- immediate emotional response and the formation of
itual connectedness for their patients: reflecting with meaning-filled memories: (a) experiencing an initially
self, reflecting with supportive people, and faith rituals. negative emotional response that became a spiritually
distressing memory, (b) experiencing an initially posi-
Reflecting with self. Participants stated that they spent tive emotional response that became a spiritually
time self-reflecting to find meaning in the spiritual growth-filled memory, and (c) experiencing a initially
encounter, such as at the loss of a patient. It can happen negative emotional response that became a spiritually
when the participant is alone, for example, “in the growth-filled memory.
shower,” “in the car,” “gardening,” or “at quiet times.”
“My thoughts . . . to just slow them down . . . explore the Negative emotional response leading to spiritually
questions in quiet.” distress-filled memories. Participants identified spiri-
tual encounters that elicited negative emotions and
Reflecting with supportive people. Participants iden- that, upon searching for meaning, continued to be
tified fellow nurses, or “comrades always help painful. These became spiritually distressing, painful
immensely, and they’ll always have an aspect or an idea memories, when the participant could not find mean-
that would not have crossed my mind, will help me ing in the encounter and was immersed in feelings of
understand it better, will help me deal with the situation pain and guilt. One participant described why she left
better.” Several participants found chaplains helpful in the profession for a time:
searching for meaning during the reflective process, par-
ticularly at the point of care. One participant described, A little boy had coded and didn’t make it, and he [the
“I think pastoral care does a great job as well with that physician] looked right at me and he said, “Well, if you
can’t handle the heat, get out of the kitchen,” and it’s
on the spot. . . . I mean, they’re constantly there for you,
just because I took it personally, I—thinking I missed
and they’ll take the time out of whatever they’re doing something. And I needed to hear from him the physio-
to make sure that they will minister to you as well.” logical point of it that sometimes kids with increased
[intracranial] pressure, you don’t see the symptoms.
Faith rituals. Prayer and religious rituals support Because I was thinking I missed it. I took—I felt guilt,
spiritual connectedness with God/Higher Power. I had a lot of guilt associated with somebody dying,
Participants found prayer to be important in spiritual that, that really monopolizes the pain.
healing, and the majority of the participants stated that
they prayed. One participant described, “During my Other participants described situations when they
break, lunch break, I’d go down to the chapel and I felt that they failed in providing care: “You don’t
prayed. . . . It calmed me down inside.” Several partici- know what to do, you feel like you failed.” Partici-
pants found church to be a place for reflection. “I would pants also stated that finding meaning is critical in
go to the chapel . . . and there would not be a soul avoiding burnout: “We do have to learn to take care of

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 Burkhart, Hogan / Spiritual Care in Nursing Practice 935

ourselves, and I think a lot of times nurses don’t, and participant remarked, “You’re putting so much of your-
that’s why they burn out and they quit.” self into your work, which—I don’t like that word
work—into your profession, and, I see why nurses kind
Positive emotional response leading to spiritually of get burned out, they just put so much into it, it’s ever-
growth-filled memories. Participants described spiritual present.” Participants stated the process of sharing one’s
encounters that elicited a positive emotional response spirituality is central to nursing: “It gives us, spirituality,
that became a positive spiritually growth-filled mem- direction in a way that we go about our daily activity,
ory. Spiritually growth-filled memories were created how we handle the patient, how we approach the patient,
when the participant learned and found a deeper mean- it’s important.”
ing in the spiritual encounter. Participants described, “I Participants described that nurses have varying
was really proud of myself at that point in nursing, like levels of spiritual well-being that can change with
spiritually, to help somebody” and “I was at peace with nursing experiences and can support future spiritual
myself. . . . That person let me in, and I did my best, and care encounters. The nurse spiritual well-being cate-
I feel good about it. . . . You helped them not only in the gory has two subcategories—faith belief systems and
care of their body but their spirit as well, and you get a memory of meaningful experiences.
sense of helping them deal with it. You just feel like it
worked.” Faith belief system. Participants stated that their per-
sonal faith belief system provided a framework for rec-
Negative emotional response leading to spiritually
ognizing meaningful events and providing spiritual
growth-filled memories. Participants described how
care: “I was pulling into my faith—but I was also
emotionally distressing spiritual encounters became a
pulling into my faith because they shared my faith base,
spiritually growth-filled memory after finding meaning
but even if it would have been a different faith, I would
in the encounter. Self-reflection at the point of care
have drawn into mine.” Another participant described
helped participants find meaning after sad spiritual
how faith affected her spiritual well-being when she
encounters: “I think it helps you to work through all the
became a nurse. “I was in nursing school, I became
things that you see in the time you are working . . . to
more active in my faith, I—I went to a church that was
realize you know, that a sacred thing [death] has hap-
a faith that I did not grow up in, but it taught me a lot,
pened.” Reflection with others helped create a spiritually
and, I think I just built on that, and I’ve been building
growth-filled memory, as one participant described:
on that.”
“There were a lot of sad things on the burn unit, too, of
course, but I think just those unknown mentors through Memories of meaningful experiences. Participants
your life and your experience, that just brings out the stated that memories of past spiritual experiences
spirituality in you.” Faith rituals also helped create a spir- throughout life affected not only nurses’ interpretation
itually growth-filled memory. “The closure to it is going of spiritual care situations but also their own spiritual-
to that [memorial] service and having people come back ity. Participants reported, “We bring in our life experi-
and just memorializing their person and, in the church ence, which therefore touches our spirituality and
service, and it just kind of makes everything OK.” touches us in the avenue of relating to the patient in
their spiritual life.” Participants stated that the memory
Nurse Spiritual Well-Being of past experiences taught them how to provide spiritual
The seventh category, nurse spiritual well-being, is a care. “I just think you just keep learning more about it
personal dimension of oneself in which one expresses as you get older and have more experiences.” Some
meaning and purpose in life, and that dimension can nurses learned how to provide spiritual care vicariously
support the ability to provide spiritual care to others. The by watching more experienced colleagues. Participants
process of providing spiritual care and finding meaning stated, “I’ve learned a lot of my spirituality, like how [to
in spiritual encounters can help the nurse promote his or provide] spiritual care to patients from a lot of the older
her own spiritual well-being: “When I give it, what I get nurses” and “There were other people who mentor
back is so much greater, and that is the gift to me, every- you.” The ability to provide spiritual care changes over
day, that the combination of my spirituality and my time with experience, as participants stated. “I’m defi-
nursing offers, for me, and that’s probably why it’s so nitely much better at it than when I was a brand new
rewarding for me.” Providing spiritual care can also grad” and “Experience gives you a lot of that guidance,
challenge the nurse to search for meaning on a daily and each day is another day.” Although participants
basis and can decrease one’s spiritual well-being. One agreed that spiritual care can be learned, when asked

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936 Qualitative Health Research

directly, few of the participants believed that nursing Some participants said negative encounters contributed
school prepared them or taught them strategies for pro- to their leaving previous nursing positions or the profes-
viding spiritual care. sion entirely. The search for meaning through the reflec-
tive process had the capability of creating a spiritually
growth-filled memory from a sad patient encounter
Discussion (e.g., death). These memories have the capability to
affect the nurses’ spiritual well-being, which can support
Focus group participants were willing and open to an ability to provide spiritual care.
discussing spiritual experiences, which supports the Evidence-based practice is the gold standard for the
existence of spiritual care in nursing practice. Although nursing profession; however, few empirically derived
practicing nurses have had spiritual experiences with theories exist that guide nursing practice. This begin-
patients, spiritual care has been ignored in nursing edu- ning theoretical framework provides guidance to fur-
cation, accrediting agencies are requiring the provision ther study methods for assessing and providing spiritual
of spiritual care, and the literature lacks research sup- care through research. As nurses care for patients 24 hr
porting spiritual care as a valuable contribution in nurs- a day and can be present when spiritual needs arise, it
ing care. There is also no theoretical framework is a professional responsibility to further study this
specifically designed to study spiritual assessment and aspect of nursing care. Further research can explore
spiritual care in nursing—it has been invisible. Spiritual spiritual assessment verbal and nonverbal skills
care has been difficult to articulate because there have designed to recognize subtle cues as they emerge and
been no research-based studies to develop a theoretical how to integrate spiritual assessment within the
framework. This study provides a basis for studying moment-by-moment practice of nursing. Empirically
spiritual care in nursing practice. derived theory is needed to guide this research.
The spiritual care in nursing practice beginning theo- If spiritual care is important in promoting health and
retical framework derived from the grounded theory well-being (as suggested by the current literature) and
study revealed the interaction that takes place between if nursing plays an important role in determining spiri-
nurse and patient when a spiritual encounter occurs, its tual needs and providing spiritual care (as suggested by
antecedents, and its aftermath, as shown in Table 2. Data the Press Ganey, 2006, reports), more work needs to be
showed that the antecedent condition for spiritual care to done to first identify what techniques accurately iden-
occur was an ability to identify patient cues. Once the tify patient cues and what interventions promote spiri-
patient invites the nurse to provide spiritual care, some tual well-being. Once these are determined, additional
participants chose not to engage in spiritual care, research is needed to guide and integrate these tech-
explaining that they did not have time, did not have the niques into nursing education. Participants described
supports, or were spiritually exhausted. The majority of learning how to provide spiritual care by experiencing
participants, however, stated that they chose to engage in spiritual encounters and reflecting on those encounters.
spiritual care as part of their nursing practice. These This implies that spiritual care can be learned through
encounters typically began when the nurse addressed an experiential reflective pedagogy. Rather than leaving
the patient’s spiritual needs by promoting the patient’s it to chance, learning how to provide spiritual care can
self-reflection, connectedness between patient and be included in nursing school and institutional pro-
family, and connectedness with a Higher Power/God. gramming. This study provides a beginning insight into
Connectedness with a Higher Power included nurse and the content of that programming and provides a begin-
patient engaging in prayer and/or religious rituals, such ning theoretical framework for measuring the impact of
as communion or lighting Sabbath candles. Spiritual those educational programs.
encounters elicited an immediate positive or negative Health care management also needs to recognize
emotional response in the participants. Participants were the education and time required in providing spiritual
affected by spiritual encounters and searched for mean- care. Although nursing has strong roots in spiritual
ing in those encounters through a reflective process or care since the 1600s, focus group participants found
faith rituals. This search for meaning affected the partic- that time, collegial support, and spiritual exhaustion
ipants’ memory of those encounters as either a spiritu- had deterred the decision to engage in spiritual
ally growth-filled or a distress-filled memory. Some encounter. Identifying specific assessment and inter-
participants remembered the encounter as distressing, vention techniques, the time involved in spiritual
which decreased the participants’ spiritual well-being. assessment and intervention, and resources needed to

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 Burkhart, Hogan / Spiritual Care in Nursing Practice 937

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