A Systematic Review about Spirituality in Nursing Care: Avoiding a Specific Illness Care Environment

Later, the concept of spirituality has been approached frequently by nursing researchers and other health sciences in the last few decades showing a lack of agreement [5], due to the different perspectives they took. For instance, some of them do not consider that is possible to reach an agreement, according to its subjectivity, different cultures, and belief system, as stated by Jon Paley [6] and Antony Bash [7].


Introduction
Nursing has been characterized by seeking holistic care -including spiritual care-for its patients for decades [1,2]. Notwithstanding, cultural changes in Western world led to spirituality and sexuality being relegated [3,4]. Thus sexuality was integrated into nursing care; meanwhile spirituality and spiritual attention were fearfully addressed [5].
Later, the concept of spirituality has been approached frequently by nursing researchers and other health sciences in the last few decades showing a lack of agreement [5], due to the different perspectives they took. For instance, some of them do not consider that is possible to reach an agreement, according to its subjectivity, different cultures, and belief system, as stated by Jon Paley [6] and Antony Bash [7].
Moreover, there are various definitions of the term influenced by a belief system that were established by different authors [8][9][10], meanwhile other researchers consider that it should be clarified, from a non-religious perspective [11,12], or related to referent people or relatives [13][14][15]. More recently, Harold Koenig goes further comparing his previous research in 2010 with the effects of spirituality and religion, from a medical perspective, on three different areas [16]: (1) Mental health-well-being, purpose in life, hope, optimism, selfesteem, depression, anxiety, suicide, and substance abuse.
Additionally, he reviewed the prevalence of studies on spiritual needs, and studied the effectiveness of cognitive-behavioural therapies religious.
Afterwards, spirituality was occasionally differentiated from religiosity, or was related to it: on the one hand, related to spiritual and religious need [17]; on the other hand, the relationship established between religiosity and spirituality as an influence factor affecting physical and psychological health was explored critically by Berry [18], where religiosity was related to a specific group of people or doctrine, whereas spirituality was related to an individual experience.
Lastly, spirituality related to nursing care was been approached mostly focused on different cultures [19], pathologies [20,21], nursing diagnostics [22][23][24], stages of life or palliative care [25][26][27], and measuring instruments [28,29]. This review aims to avoid all of these relations, trying to find a unique perspective, the one related to nursing care.

Background
It seems necessary to approach the terms soul, spirit and spirituality to better understand the meaning of this last one. Rendering to this, it is also needed to know the origin of the term spirituality, its translation into different languages and what was the approaching carried out by classical philosophers to better understand its meaning and different interpretations according to the diverse translations that anyone could interpret as a singular sense. According to all of this, different sciences, such as anthropology, psychology, theology or philosophy offer varied connotations.
First of all, the notion of spirituality belongs to the lexical family of spirit, which is sometimes used interchangeably with soul.
Besides, the term soul comes from the Latin word animuis-I, which has different meanings, the first one refers to vital principle; de second one to the mind and thinking. Nevertheless, it can refer to encouragement, feeling and passion. Moreover, in other cultures and religions, is the spiritual and immortal substance of human being. All of these words have evolved to acquire different translations ( Table 1).
The different vision of these notions present in Ancient Philosophy -in contrast to the human corporality-, help us to understand the different meanings established nowadays. For instance, pre-Socratic philosophers considered the man as the one who had the capability of reason, when body and soul were integrated. Plato stated that the soul was a vital principle and the spirit is something essentially immaterial and endowed with reason. Socrates stated that the soul was the base of reason and ethical activity of the human being [30].
Among Jewish-Christian Tradition, biblical translations into spirit -either from the Hebrew term ruah or the Greek pneuma-, mean the subtle reality of breathing [31], even if it refers to the wind or the respiration. To the Christian, this wind comes from God, and at the same time, for everyone there is a spirit, which gives them life.
To sum up, the theological meaning of spirituality provides some dissimilarity with religiosity [29], although this two words have been used interchangeably. Thus, this notion can be understood like an act of reflection about the religious knowledge, the experience with the absolute or the last values, which transcend to the human being. Indeed, spirituality is as inherent to the human being as corporality, sociability or praxicity [32][33][34][35].

Spirituality and nursing care
The concept of spirituality related to nursing care has been approached mostly focusing on different cultures, pathologies, nursing diagnoses, stages of life or palliative care, and measuring instruments: (1) Spirituality related to different cultures -such as Islamic, Latino, Native American and Asiatic-, has been frequently been adapted from their original belief system perspective and the specific way they express their spirituality and spiritual needs to allow nurses to respect and understand it, in different multicultural environments, as we found trough this research.
(2) Spirituality in Nursing diagnostics was approached mostly from a holistic perspective considering that patients need an integral attention provided by nurses, and also need to cope with their illness process or to avoid spiritual distress [24,25]. Moreover, Caldeira worked on a bibliographic review of the concept and defining characteristics of spiritual suffering, concluding that a proposal for a new definition of the nursing diagnosis of Spiritual Suffering was needed [23].
(3) Spirituality has been overtaken by different chronic illnesssuch as oncological, HIV, heart or neurological diseases-according to its implication for nursing care, as we found trough this research.
(4) In the context of the stages of life, spirituality has been approached in paediatric care, young adults, adults and elderly people. In this manner, according to children, the way they express their spiritual need is related to the development process [26]. Notwithstanding, there is paucity of research, specifically about adolescent and young adults spirituality, consolidated by a lack of instruments to measure their spiritual issues [25]. Moreover, in both geriatric and palliative care environment, various authors agree about the importance of asses the spiritual need of patients [21], due to its relation with epidemiological evidence that proves there is an association between spirituality and mental and physical health, as well as functional health status [36].
(5) There are several literatures, which relate spirituality and spiritual needs with some measuring instruments, according to the different dimensions of the concept [28,29]. Nevertheless, in the last few years, the amount of publications linking different cultures with measuring instruments has increased. The Review

Aim
The aim of this systematic review is to examine the concept of spirituality related to nursing care. More specifically, our goal is to analyse the meaning of the concepts "spirit" and "soul", from the perspective of different dictionaries and ancient philosophy, the meaning of spirituality approached by different authors and their relation with nursing care: (a) To discover how the concept of spirituality is approached by different authors.
(b) Which are the main topics related to this topic and nursing care.
(c) To know about different debates on this term stated by nursing research.
(d) To contrast dissimilar meanings on the concepts of spirit and soul from different dictionaries and ancient philosophy.

Design
A systematic review with a narrative synthesis was performed, according to PRISMA-P statements.

Search methods
Firstly, the concepts of spirituality, spirit and soul were underscored in the Ancient Philosophy bibliography. Afterwards, the meaning of these terms was explored in dictionaries from different languages. Moreover, the concept of spirituality was defined within the main disciplines. Finally, a literature review of the concept "spirituality" was carried out via PUBMED, Web of Science (WOS), CUIDEN and DIALNET to discuss the differences among the conceptualizations related to nursing.

Search strategy
On the one hand, the following key words "spirituality" and "nursing" and "conceptual analysis review". In addition, "spirituality" and "care" and "conceptual analysis review" were used for the searching of the papers found in both PUBMED and WOS. On the other hand, the following key words "Espiritualidad" and "cuidado" and "analisis conceptual".
There were 35 articles identified in PUBMED and 31 in WOS in the first search, and subsequently, 34 in PUBMED and 23 in WOS as a result of the second one. Furthermore, when carrying out the search in the Spanish databases, 1 article was identified in CUIDEN and 2 articles in DIALNET. The period of time for all the searches was between 1993 and 2015.

Inclusive and exclusive criteria
Studies were considered eligible for inclusion if they met the following criteria: Papers that stated, specifically, a review on the concept of spirituality related to nursing care, with no relation to a specific illness, vital stage, or concrete process.

Exclusion criteria included the following items:
(1) Papers that stated a review on the concept of spirituality related to nursing care, with relation to a specific illness, religiosity, vital stage or concrete process.
(2) Papers in which a term related to spirituality was approached, but where it wasn't used the word "spirituality".

Literature search
There were 35 articles identified in PUBMED and 31 in WOS out of the first search, and subsequently 34 in PUBMED and 23 in WOS out of the second one. On the other hand, in the search performed using Spanish databases, 1 article was identified in CUIDEN and 2 articles in DIALNET. As a result, among all of the databases, 126 records were found, from all of these, there were 74 duplicated and deleted. Finally, there were 6 articles that really followed the established inclusion criteria (Figure 1).
Among all of the articles found, -including those which did not follow the inclusion criteria-, spirituality was related with the subsequent topics: (1) No relation to a specific illness process, concrete culture, or living stage (Selected).
(2) Related to a specific illness process, concrete culture, or living stage.
(3) Approached terms related to spirituality but not this term: religiosity, spiritual care, spiritual needs, or spiritual distress.
(4) Discussed about another term with a similar meaning: Religiosity, transcendence, resilience, or hope.  Nevertheless, on the 6 articles selected and reviewed, the main characteristics were the stated here below: (1) The majority of the authors preferred to use international data basis on nursing and other disciplines. They all include details about data basis consulted, inclusion and exclusion criteria, final sample, context, and the aim of the study [37].
(2) Every paper is contextualised in a determined period of time, and the comparisons between all of them allow us to validate how the term was approached and if there was any recent modifications, new descriptors or attributes on the concept. Henceforth, a definition on the concept was proposed by Tanyi and Buck [37,38], all the rest stated different characteristics and attributes on the concept and related terms.
(3) According to the kind of analysis, nursing academic articles were reviewed by Pike [9]. On the contrary, Chiu et Al. discussed the topic from different perspectives and analysed different measuring instruments and all of its components and characteristics [26]. Nevertheless, Buck and Pike explored nursing articles [9,38]. However, all the rest of authors reviewed other health science disciplines such as Psychology and Physiology, and Tanyi focused on Theology and Social Work [37].
(4) In most of the articles reviewed, Walker and Avant, Chin and Kramer and Rodgers, the methodology was stated clarifying this notion. Moreover, no distinction between "spirituality", "spiritual needs" and "spiritual care" were found. On the contrary some authors pointed out, using a rigorous methodology, that spirituality was a very abstract concept but did not make a complete classification of this term following a guideline, as stated by Hardy [39].  [26]; and Tanyi between 1972 and 2002 [37]. As can be seen, Seesana and Buck coincided on most of the time and Tanyi's period was also occupied by Chiu (Figure 1).
Subsequently, we present a table that includes the main characteristics of the articles reviewed ( Table 2):

Quality appraisal
Next, we present a table with the different quality criteria stated on a bibliographic review (Table 3).
Subsequently, we expose a table with the preferred reporting items for a systematic review and meta-analysis protocols (PRISMA-P) stated in 2015 (Table 4).

Discussion
This review has provided a narrative synthesis of evidence about the concept analysis of "spirituality", related to nursing care. There were found some limitations in these studies due to the lack of continuation with the first open lines about the confirmation of some of the attributes and characteristics of the term "spirituality". For instance, Paley stated that some of the metaphysical assertions, such as transcendental force, universal human phenomenon, or human being essence, were not justified or measured by different scholars [6]. On the one hand, Clarke -as mentioned by Weathers et al. acknowledged that many definitions of spirituality are too general, and can produce some bias on nursing literature [5]. Moreover, many definitions made from a nursing perspective not always agree with who experienced illness. On the other hand, there is a disagreement among different authors, because some of them consider spirituality as an inherent part of the person.
In addition, there was not found any philosophical or anthropological approach related to the vulnerability of the human body. Notwithstanding, Buck mentioned the relationship between the corporeal and the incorporeal parts as one of the five criteria established for spirituality [38]. Moreover, Bash used the metaphor of Christian Hans' tale "The emperor's clothes" in a reflexive paper to Source: Own realization highlight that the majority coincide in their ignorance -related to the conceptualization of spirituality-due to its subjectivity, and adding that the use of measuring instruments can produce erroneous assertions [7].
Some of the conceptual clarifications are rooted cultural traditions -related to facets such as existential reality, connectivity, transcendence and energy. So, they could imply following a religious dogma, although, others were related to the psychological dimension of a person and their purpose. Therefore emerged a different vision on this issue, taking in account the lack of perception of a persons' life. But some authors consider it as a sign of sadness, lack of interest or any other characteristic symptom of anxiety or depression [39].
Summarizing the research, spirituality is a variable concept that requires an operational or a theoretical definition and a measurement using measuring scales. A theoretical definition gives meaning to a term in the context of theory, allowing the reader to assess the validity of the definition. The practice explains how the concept was linked to a specific situation, and described a set of procedures that were performed to assign a value. Nevertheless, spirituality by itself is not a concept that can be passed through a measuring scale; it can be measured in association with other concepts, such as spiritual well-being or spiritual suffering.

Conclusions
There is no established agreement among nursing authors about the meaning of spirituality, but both nursing and other health sciences show the evolution of the term's vision over the years, being closely related to the Christian religion and having a growing breadth of vision, but also related to other aspects in the most recent years. This means that, in the past, spirituality was conceived as something that could be experienced through religion -in our context, the Catholic religion-. Nevertheless, through the secularization in the 1960s, openness has   Spirituality: concept analysis and model development.
An integrative review of spirituality in the health sciences.
Toward the clarification of the meaning of spirituality.

Aim
To clarify the concept of spirituality for future nursing research.
To investigate the current nursing evidence underpinning the concept of spirituality and its application.
To examine how spirituality has been used within the current body of nursing and health-related literature, clarify the meaning of spirituality by discovering what this concept's current critical attributes/characteristics are, and propose a definition of spirituality based on the concept analysis findings.
To review the nursing research on spirituality and conduct a concept analysis using Chinn and Kramer's method of creating conceptual meaning.
To explore how research on the concept of spirituality has been reported in the health literature in the past decade and develop an ontological and theoretical understanding of spirituality.
To contribute toward clarification of the meaning of spirituality in relevance to health and nursing today through a conceptual analysis process.

Main Characteristics
Literary review with the proposal of a definition of spirituality from the definition of three of the most frequent components.  emerged that leads to its conception as something that may or may not be intimately related to Religion, including any kind of religion, or even related to non-believers. A person who is not religious or who does not follow a religious doctrine has his own spirituality and can be a method of transcendence, a relational method, a purpose in life or a metaphysical experience, for instance. This also confirms that spirituality is an intimate and subjective experience. Consequently two people of the same level of studies and cultural group can experience it in a different way.
Another aspect to emphasize is the process of developing a conceptual model used by different authors. Mostly, they carry out a conceptualization on spirituality, searching both in dictionaries and previously published works. Hereafter, if they have opted for a conceptual analysis, they have done so following a specific method -such as Walker and Avant or the Of Chin and Kramer-and have referred to theoretical or operational definitions of the term, in order to provide greater clarity and understanding about its meaning.
Summarizing, they pointed out that spirituality was a very abstract concept but did not make a complete classification of it, following the guidelines established by an some author expert in the subject. As, for example, Hardy who provided a specific clarification for the concept related to nursing care [40].
To sum up, is very difficult to achieve a unique definition for the construction of "spirituality", according to its complexity, the meaning gave by any individual -according to its translation from different cultures and its relation to soul and spirit-, and the issues related to it. It was approached according to dissimilar therapeutic fields and diverse illnesses. Moreover, it evolves at the same time society does, despite all that, many authors have been able to contribute to its clarification.

Limitations
By focusing, specifically, in the concept of spirituality related to nursing care, this review disregarded some good discussions. For instance, the research made by Garcia-Reiner and Koenig, related to spirituality definitions [40] or the study made by Berry, which approached a relationship between religiosity and spirituality by a designation with both terms together, exploring critically its effects on physical and psychological health [18]. Notwithstanding, finding few records through this systematic review shows the lack of research on this specific approaching.

Funding
This research received no specific grant from any public agency, commercial or other sectors.