A good research Study on meaning of Spirituality

The Meaning of Spirituality Among
Nonreligious Persons With Chronic Illness
■ Eileen Creel, DNS, RN ■ Ken Tillman, PhD, RN
A phenomenological approach was used to uncover the meaning of spirituality for 11 nonreligious participants with
a chronic illness. Spirituality for these participants was revealed through the themes of beliefs, spiritual awakening,
and spiritual enhancement. This study supports each person as uniquely spiritual with spiritual needs that could be
enhanced. KEY WORDS: chronic illness, nursing, spirituality Holist Nurs Pract 2008;22(6):303–309
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See text on pp. 310–311
Spirituality has been defined as a multidimensional,
pervasive quality of the inner person that is uniquely
interpreted by each individual.1 It is a phenomenon of
interest to nurse researchers, nurses, and patients
worldwide.2 Spirituality may be characterized by a
person’s beliefs; search for meaning and purpose of
life; sense of transcendence; and relationships with
self, others, and/or a Supreme Being.1,3,4 The concepts
of spirituality and religion are often used
interchangeably, but a person’s religious affiliation is
more commonly associated with the person’s
connection with a set of values, beliefs, practices, or
rituals prescribed by a religious order in which there is
belief in a supernatural power, God, or gods.5
According to the American Religious Identification
Survey6 conducted by the Graduate Center at City
University of New York, 14%, or 29.4 million people
in the United States, identified themselves as having
no religious affiliation. Even though this was a small
portion of the total population of the United States, the
center estimated that it is the fastest growing segment
of the population. Compared with the results of a
similar survey, the National Survey of Religious
Identification6 conducted 10 years earlier, the number
of people who identified themselves as having no
religious affiliation has doubled. Similar findings have
been reported by researchers in other countries. In her
commentary to MacLaren,7 Narayanasamy cited that
Author Affiliation: School of Nursing, Southeastern Louisiana University,
Hammond.
The authors have no conflict of interest.
Corresponding Author: Eileen Creel, DNS, RN, Southeastern Louisiana
University, School of Nursing, SLU 10835, Hammond, LA 70402
(ecreel@selu.edu).
as many as 50% of people in Great Britain do not
claim to be a member of an organized religion.
The number of persons who do not claim
to be a member of an organized religion is increasing.
However, people may still consider themselves to
be spiritual beings even if they do not identify with an
organized religion. The Princeton Religion Research
Center8 found in a survey that 30% of people who
identified themselves as not religious did consider
themselves to be spiritual. Such findings underscore
the importance of addressing the spiritual care needs of
all patients within the bounds of ethical care, regardless
of affiliation status with an organized religion.
Although the literature reflects our current society’s
view that spirituality is broader than the religious
affiliation of a person, much of nurses’ understanding
of spirituality is based on research that has used
samples predominantly composed of patients or
nurses with a religious affiliation.9–15 MacLaren7
questions how nurses can attend to the patient’s
spirituality in a multicultural and multifaith society.
Patients without a religious affiliation have lacked
voice and may not be receiving appropriate spiritual
care because there are no studies published that have
reflected the unique meaning of spirituality for this
rapidly growing segment of our population. Therefore,
the purpose of this qualitative research was to describe
the meaning of spirituality for ill patients who
self-identify as having no religious affiliation.
BACKGROUND
Illness creates a time of crisis that may result in an
increased expression of spirituality and increased use
303
304 HOLISTIC NURSING PRACTICE • NOVEMBER/DECEMBER 2008
of spiritual support as a coping mechanism.10,16 The
nurse is often the healthcare professional most
accessible to the patient and the one to whom that
person will turn in a time of spiritual crisis. Spiritual
care is an obligation and duty of the professional
nurse, but many feel uncomfortable with this aspect of
care.17 For example, Narayanasamy and Owens14
found that only 25% of 115 nurses believed they
provided adequate spiritual care and half of the nurses
surveyed by Kuuppelomaki12 said that they were
poorly prepared to meet the spiritual needs of their
patients. Failure by nurses to identify and meet the
spiritual needs of patients contributes to a situation in
which the person is at risk for developing spiritual
distress. Understanding the spiritual needs of patients
is dependent on the nurses’ own spiritual awareness
and often an area where nurses feel the need for
additional consultation.18
Holistic nursing practice requires the nurse to
address the spiritual, physical, and emotional needs of
patients. The literature supports appropriately meeting
the spiritual needs of patients as a means of increasing
mental and physical health and well-being,2,16 as well
as the quality of life of the dying.10,19 In addition,
spirituality has been linked to the emotional
well-being of patients and is a vital component in the
care of the ill person.16,20 However, Dunne21 stated
that most caregivers equate the spiritual with the
religious and overlook issues important not only to
those patients who are religious but also to those who
are not religious.
Nurses equate spirituality with an individual’s
religion, and nursing literature often does not separate
spirituality and religion.15,22 However, authors agree
that religion is only 1 component of spirituality.1,4,7,23
McBrien asserted in his concept analysis of
spirituality that spirituality is “distinct from
religion.”3(p45) Wright24 found a wide range of
nonreligious spiritual care requirements cited by
patients in his study of chaplain services in hospices
and hospitals of England and Wales. Patients who
self-identify as having no religious affiliation are
poorly represented by the samples used in research
studies conducted on spirituality.9,11–13,25 No studies in
nursing or other disciplines were found, which
focused exclusively on the spirituality of ill patients
who denied identification with an organized religion.
This lack of research focus represents a gap in nurses’
knowledge of how to care for the unique needs of the
person who is not affiliated with an organized religion.
Given the trend of increasing numbers of people
reporting no religious affiliation, nurses clearly need
to address this neglected subgroup of our society.
METHODS
Study designs
Phenomenology as used in this research came from
the philosophical tradition based on the Heideggerien
view of the person. Heidegger states that
phenomenology is a turning “to the things
themselves.”26(p24) Leonard further describes this
philosophy as focusing on the ontological question of
“what it means to be a person.”27(p45)
Phenomenological research has also been described as
aiming to uncover the knowledge that is within a
person who is already in the world.28 In this research,
the focus was on uncovering what it means to be a
spiritual person with no religious affiliation
experiencing an illness.
The method used for this research was van
Manen’s28 6 suggested researcher activities that are as
follows: (1) turning to a phenomenon of serious
interest, (2) investigating the phenomenon as it was
“lived” not as it was conceptualized, (3) reflecting on
the essential themes that characterized the
phenomenon, (4) describing the phenomenon through
writing and rewriting, (5) maintaining a strong
relationship with the phenomenon during research and
reflection, and (6) balancing the research by
considering the parts and the whole.
Before implementing the study, approval to conduct
the research was granted by an institutional review
board. Participants were recruited through
announcements placed in newsletters of local
organizations and flyers posted at healthcare and
academic institutions. This allowed participants to
self-identify for possible inclusion in the study. A total
of 11 participants were interviewed before saturation
of the data, or no new themes emerged from the data,
was reached. Of the 11 participants interviewed, 3
participants were recruited by response to newsletters,
2 by response to flyers, and 6 by word of mouth.
Written informed consent was obtained from all
participants prior to interviews. The following
questions represent the core of the interview for the ill
individual: (1) What meaning does spirituality have
for you? (2) In what ways has your illness changed or
affected your thoughts about your spirituality? Probes
were used as necessary to uncover specific examples
of spirituality.
The Meaning of Spirituality Among Nonreligious Persons 305
Eleven interviews were conducted at locations,
such as offices, homes, hospital rooms, or even a
public library, private and convenient for the
researcher and the participants. The interviews were
audiotaped and lasted from 1 to 2 hours. Immediately
following each interview, the researcher wrote
anecdotal notes. These included relevant facts about
the interview, the setting, and the participant’s
condition or demeanor, as well as the researcher’s
impressions. As soon as possible after the interview,
transcriptions of the interview audiotapes were typed
by a professional transcriptionist.
Sample
Criteria for selection of the sample included (1)
participants’ self-identification as having a diagnosis
of an illness that was chronic (lasting for at least
6 months) or terminal (a diagnosis in which there is no
reasonable expectation of recovery), (2) participants’
self-identification of their lack of religious affiliation,
and (3) participants’ willingness to share their lived
experience of spirituality. Participation was voluntary,
and all participants were older than 21 years.
Participants were given fictitious names to allow for
the presentation of their statements and ensure
confidentiality. Of the 11 participants, 7 were women
and 4 were men. All participants were white and
ranged in age from 30 to 71 years with the mean age
of 47.4 years. Participants were well educated. All but
1 participant had a college degree and 6 had advanced
degrees; 1 participant had a high school GED. Seven
participants were currently married, 2 were divorced,
and 2 were single. Three participants lived alone,
7 lived with a spouse or significant other, and 1
participant lived with a spouse and children.
Diagnoses for participants included (1) 4 with cancer,
(2) 1 with AIDS, (3) 3 with cardiovascular disease,
(4) 2 with diabetes, (5) 1 with infertility and a skin
disorder, and (6) 1 who did not wish to disclose her
diagnosis. Three participants had more than
1 diagnosis. Most participants identified themselves as
having been previously associated with a religion in
childhood; 5 were previously Catholic, 4 were
previously Protestant, 1 was previously Jewish, and
1 did not report a previous religious affiliation.
Data analysis
Data analysis for this study was conducted using
recommendations by van Manen.28 Data management
was assisted by the use of a computerized
word-processing program, but no data analysis
software program was used.
The following steps were used during data analysis.
Transcribed tapes were read and listened to, to ensure
accuracy of wording and authentic representation of
the participant’s experience. After accuracy was
ensured, transcripts were read and reread several times
to begin the dwelling process as described by van
Manen.28 Phenomenological reflection allowed the
researcher to grasp the meaning of the experience of
spirituality for ill patients with no religious affiliation.
This process was conducted on each interview
individually and then across cases. In addition, data
displays, which included the use of concept mapping
and tables, allowed the researcher to organize textual
data and draw conclusions.
During the interview, descriptive validity29 was
ensured through careful questioning of participants
about any unclear aspect. Summarization and
reflection of participants’ narratives were used to
verify accuracy with the participant. In addition, the
researcher was open to triangulation of data from
multiple sources besides the verbal responses obtained
through the interviews. Examples included
observations of spiritual practices and art in
1 participant’s home, listening to spiritual tapes used
by another participant, and review of writings used by
a third participant.
Eight participants were sent information requesting
a member to check where the participants reviewed
the findings to validate that the collective results were
representative of their personal experience. The
researcher was not able to contact 3 of the participants.
Those not contacted were participants who had
terminal illnesses, so this lack of response may have
represented a burden or loss of interest in the research
by the participant. Members who were contacted were
asked to verify whether the collective results “ring
true” or if they could “hear” themselves in the results
in terms of their lived experience of spirituality. They
were asked to provide feedback on the “rightness” of
themes for them or on any themes that they felt
misrepresented their experiences. Members responded
that the findings did indeed represent their spirituality.
One strategy to facilitate interpretive validity29 was
the use of participants’ own words and language. In
addition, peer review by 2 professors knowledgeable
in the use of phenomenology and 1 who was an expert
on spiritual nursing care was used to establish
interpretive validity.
306 HOLISTIC NURSING PRACTICE • NOVEMBER/DECEMBER 2008
Theoretical validity, as described by Maxwell,29
relates to construct validity, and it includes the validity
of concepts applied to the study and their
relationships. This validity rests with the
persuasiveness of the arguments that support the
interpretation of the findings.
An audit trail was maintained throughout the study.
This audit trail included audiotaped interviews, their
transcripts, and checking for consistency of wording
between the recorded interview and the transcription.
Field notes were taken during and immediately
following interviews. These notes were aimed at
capturing the context of the interview, including
setting and participant observations, as well as the
researcher’s immediate impressions. Memoing was
done for all phases of analysis; these memos included
references how themes were chosen, what the
researcher’s thoughts on themes were at the time, and
alternative speculations. Data source triangulation and
peer reviews added to dependability of data.
Triangulation added depth to the textual data when the
researcher incorporated the review of art, journaling,
and audios used by participants to the analysis of the
transcript data. Peer review allowed the researcher to
be open to other possible interpretations, which
enhanced clarification of meaning.
Findings
Five themes emerged from the analysis of the data:
beliefs, disillusionment with religion/religious people,
spiritual awakening, spiritual enhancement, and
reflective awareness. Findings with participant quotes
to validate the theme follow.
Beliefs
The participants defined spirituality as their belief
system. The participants described their belief system
as the “essence” of “who you are” as a person. Their
belief system was their set of “core beliefs” and their
“guiding force.” It determines “how you live your life”
and “how you act.” Gail said: “I believe that we have
free will, and I think that the way we exercise that free
will is guided by our spirituality, so the decisions we
make are guided by this compass that I call . . .
spirituality.” These beliefs had been “seriously”
considered and are “cherished” by the participants.
Participants’ beliefs consisted of 5 dimensions
(subthemes) about which the beliefs centered: (1)
connections to God/others/nature, (2) spiritual
feelings, (3) beliefs about an afterlife, (4) finding
meaning in events, and (5) beliefs about a higher
being.
Beliefs about a connection to God/nature/others
Most participants shared with the researcher how
their spirituality was a connection with God, others, or
nature. These connections were spiritual experiences
and were part of their spirituality.
Abby said the following: “Spirituality is how I
connect with God in the universe” and “a sense of
connecting with nature.” Emily felt spirituality was
related to nature: “There’s something about sitting in
my rose bed. That things grow, and become, and die,
and start again; the circle of life I guess. There’s
something spiritual about nature or any kind of nature
to me.”
Beliefs about spiritual feelings
The dimension of spiritual feelings was identified
by most participants as special positive internal
feelings. Abby described a special day that was
spiritual for her: “As I was walking home. . . . it was
just such a gorgeous day . . . and at that moment . . . I
felt complete peace, inner joy, and happiness.”
Beliefs about an afterlife
All but 1 participant talked about beliefs related to
an afterlife. One participant (Henry) felt that after
death there was “nothing; nothing,” and 2 participants
(Ian and Emily) felt that we did not know what
happens after we die. Gail concluded, “We’re just not
here; we’ll be in other places as well.”
Beliefs about finding meaning in events
For several participants their spirituality and beliefs
led them to find meaning in events or to look for signs
in their life. Kate said: “There is some kind of
meaning to events, perhaps that are in your life . . .
they have meaning. And that simple things have more
meaning than they appear to on the surface.”
Beliefs about a higher being
All participants expressed beliefs about a higher
being. Five of them called this higher being “God,” one
said there was a “higher power,” and Claire described
God as the “highest positive energy.” Abby, Barb, and
Frank expressed their spirituality as relating to God.
Two participants believed there was no higher power,
The Meaning of Spirituality Among Nonreligious Persons 307
although Ian and Emily were unsure. Ian said, “I don’t
believe that you can know that there is a higher
being or force. I don’t think there is enough evidence
to prove that. . . . I don’t think you can know for
certain.”
Disillusionment with religion/religious people
Several participants experienced disillusionment
with religion or religious people. This disillusionment
with various religions to which they had been exposed
in the past contrasted with their lived experience of
spirituality. Participants’ disillusionment with
religion/religious people contributed to their
development of their current beliefs and how they
defined spirituality. Both Emily and Dave experienced
disillusionment as a result of an organized religion’s
views on homosexuality. Emily said, “First of all
there’s a whole bunch of churches I can’t go to
because they preach against homosexuality, and my
son’s gay. . . . They want to pick and choose groups
not like them and think they are going to hell.” Dave
told a similar story of being “shunned” by his church
as a young man when he was seen having dinner with
a “known homosexual.” In Henry’s opinion, religion
“was pathetic hoca.”
Spiritual awakening
Nine participants cited events in their lives that they
considered as spiritual awakening. This spiritual
awakening emphasized or clarified their beliefs for
them. The spiritual awakening was integral to the
formation of their own spiritual beliefs or validated for
them the “rightness” of their beliefs. For Dave, his job
provided this awakening: “This job actually has been a
big factor in my spiritual awakening . . . because you
start to realize the impact that we each have on others’
lives.” Frank told about the effect his divorce had on
his spiritual beliefs:
I divorced . . . . I lost everything . . . that was a
changing point in my life. That was a very awakening
experience . . . the only thing that I had was . . . my
spiritual belief in my soul of who I was and how that
related to the world.
Spiritual enhancement
Nine of the participants talked about activities that
they engaged in that could be considered as spiritual
enhancement. Three participants said they prayed, and
2 additional participants said they “think about God
more” (Barb) or “talk to Her [God] about it in your
rose garden” (Emily). Five participants found reading
to be a spiritual experience. In addition, several
mentioned that they find it “spiritual when I walk by
myself” or being outside. Abby said: “I actually have
a feather journal. A book that I have . . . all these
special feathers and the date of when I found the
feather and why I needed that feather that day.” Jane
also used journaling as a spiritual activity.
Reflective awareness
When the participants were asked to share the effect
that illness had on spirituality, there was a range of
responses. Most participants had reflected on their
illnesses, their spirituality, and the effect that
spirituality had on the illness or that the illness had on
spirituality. Reflection led the participants to an
increased awareness of their beliefs, how these beliefs
guided their lives, and their own mortality.
Dave said: “I’ve become more in touch with my
spiritual side because of it [illness] and having a
realization of where I could be at this point had I not
decided to take this along a positive path as opposed to
a negative path.” For other participants illness created
a time of reflection when they experienced an
affirmation of their beliefs. Kate shared:
I remember when I was diagnosed . . . everybody was
saying that thing about people – you could be a
nonbeliever (laughing) but when you face
death . . . (laughing), you are going to change your
mind . . . . And so I thought well okay here it is. And I
didn’t change; I felt the same.
DISCUSSION
It is important to remember that 1 of the primary
findings of this research is that, even though this
sample self-identified as having no religious
affiliation, they all considered themselves to be
spiritual. This study supports those authors who have
conducted concept analyses of spirituality and its
components.3,4 Participants echoed the findings that
spirituality includes dimensions of connections to
God/others/nature, finding meaning in life or events,
as well as spirituality being manifested through
feelings of joy, peace, and comfort. It is important to
recognize that persons with no religious affiliation do
not necessarily lack belief in God. Even those
participants who did not believe in God had certainly
thought about their beliefs. Lack of belief in God did
not equate with a lack of contemplation on a higher
being or higher power.
308 HOLISTIC NURSING PRACTICE • NOVEMBER/DECEMBER 2008
A finding from this study rarely seen in the literature
is the theme of spiritual awakening. McBrien,
however, did identify “pivotal life events”3(p45) as an
antecedent of spirituality in his concept analysis.
These events were cited as a possible reason for
spiritual awareness and growth. In addition, Martsolf
and Mickley30 included a theme named “becoming” in
their review of the literature pertaining to spirituality
and one other researcher identified a similar theme,
which was called “prompts.”25(p127) Maybe persons
with no religious affiliation come to their unique
spiritual beliefs differently than those with a religion.
All participants in this study had at one time or
another been exposed to a formal religion but had
chosen not to stay affiliated with it. The recognition
and ability to identify specifically with events of
spiritual awakening transcended religious experiences
for these patients. The fact that an event had
significant meaning in relation to spiritual beliefs may
reflect a greater appreciation in assigning unique
beliefs to the experience.
These ill patients felt that the effect of their illness
was an increase in reflective awareness of their
spirituality. This awareness was not seen as negative
or positive for these participants, although previous
studies found people with a religious affiliation felt a
negative effect on their spirituality. The notable
exception was Albaugh’s9 participants who had all
positive comments about spirituality in relation to
their life-threatening illnesses. Negative findings may
be because of the external nature of participating in a
religion, with those without a religion, practicing their
spirituality more privately and uniquely. Also, in
contrast with Katsuno’s11 participants, who cited an
expectation for God to protect them from their
diagnoses and felt disappointment or even anger at
their outcomes, these participants with no religious
affiliation did not cite any such expectation or place
blame for their experiences on God or a higher power.
Finally, this sample of ill patients also clearly
reflected the literature’s separation of religion and
spirituality as 2 different but related concepts. They
described the differences between the 2 concepts in
their own words, even when not solicited. Their
experiences with an organized religion led to
disillusionment with religion/religious people.
Unfortunately, researchers in the past have used the 2
concepts interchangeably and limited themselves to
samples with predominately religious affiliations.
Some striking, but not surprising, differences between
previous literature and this study included the lack of
religious practices described by these study
participants and especially less emphasis on prayer.
Because previous researchers have relied so heavily on
samples with religious affiliations, results show a
preponderance of those religious practice preferences.
This is misleading to nurses caring for patients who
may have no religion or even those not religiously
active.
This study was conducted to understand the lived
experience of spirituality from the never before heard
voices of ill patients with no religious affiliation. The
findings are relevant for the body of knowledge of
nursing related to spirituality for persons living with
chronic or terminal illness. Additional
phenomenological research on the experiences of
spirituality among other groups, cultures, and
ethnicities needs to be conducted for an increased
understanding of this complex phenomenon. Future
researchers should make every attempt to include
persons without a religious affiliation in research.
Consciousness raising related to the provision of
spiritual nursing care for ill patients with no religious
affiliation needs to be done among nurses because
these participants supported spirituality as a universal
need and not limited to religion. In addition, programs
of nursing education should examine curricula for
inclusion of spirituality at all levels of education and
classes should not be limited only to the study of
various religious practices, but should include
spirituality from a more individual, human-to-human
perspective.
Finally, funding for continued research into the
effects of spirituality for ill patients with no religious
affiliation, as with all areas of spirituality, should be
considered because this segment of the population has
doubled in the last 10 years, and this upward trend is
expected to continue. The mean age for participants in
the sample was 47.4 years. This may indicate a trend
wherein younger people are more likely to have no
religious affiliation. As this segment of the population
ages over the next 20 years, research funding needs to
keep pace with changing needs of our changing
population.
Factors that may have limited this study include the
fact that some participants may have been better able
to articulate their experiences of spirituality and the
researcher’s previous knowledge, assumptions, and
experiences may have influenced her ability to find
meaning from collected data. The geographical
location of this study may have influenced the “world
view” of the participants and their unique beliefs
The Meaning of Spirituality Among Nonreligious Persons 309
about spirituality. The findings from this study were
produced by the researcher’s use of interpretive
phenomenology; other approaches may have yielded
different results. Finally, the sample was a
homogenous group of well-educated Caucasians and
findings cannot be generalized to others with no
religious affiliation. Given the significance of this
limitation, research is needed to uncover the meaning
of spirituality among those with no religious affiliation
in other cultural and ethnic groups.
CONCLUSIONS
The lived experience of spirituality for the ill person
with no religious affiliation is contained within the
themes identified through phenomenological
reflection: (1) beliefs, (2) disillusionment with
religion/religious people, (3) spiritual awakening, (4)
spiritual enhancement, and (5) reflective awareness.
Much of what was discovered is supported by the
conceptual literature; however, within nursing
research, marked differences can be found. This study
supports the premise that all persons are uniquely
spiritual and have spiritual needs that could be
enhanced.
This exploration has allowed insight into the
unique, previously unstudied lifeworld of ill patients
with no religious affiliation. It is the profound hope
that this new nursing knowledge may be utilized to
improve spiritual nursing care not only for ill patients
with no religious affiliation but also for all that nurses
encounter because every nursing encounter has the
potential to help support ill persons in the search for
spirituality.
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