Spirituality is the search for answers to questions regarding the foundations of existence and life (1). Various definitions have been proposed for spirituality. Spirituality as a bipolar concept is implicitly defined as both a religious and non-religious construct (2), a concept beyond religious dependence (3), ideology, and intrapersonal/interpersonal relations (4).
Hardy (1979) and Hay (1994) believe that spirituality must be observed from a more extended point of view, hence attributing spirituality to biological origins (5, 6). They have suggested the following reasons to support their claim. Firstly, spirituality tends to come into play as a basic human need in times of illness, emotional stress, physical pain, agony, and/or death.
Secondly, both religious and non-religious people may feel the necessity of spirituality in form of a need for meaning, purpose, identity, or a feeling of coordinated connection (7). Lastly, spirituality has been increasingly defined at odds with religion and religiosity. In fact, spirituality is described as an individual's orientation (8), while religion usually denotes an organized and natural system of beliefs and conducts (9), mostly in relation with a supreme being and/or God. Also, religiosity often designates communal acts and codes of conduct such as prayer and/or worship.
Considering the diversity of views regarding spirituality, it seems difficult, if not impossible, to reach a unanimous decision as to the exact meaning of this concept (10). According to Narayanasamy (2002), scholars agree upon two major points. First, humans are spiritual beings, and second, spirituality and well-being are somehow connected (11). According to previous research, a higher level of spiritual health is correlated with greater well-being (12). Moreover, most patients seek the attention of healthcare professionals and personnel to their spiritual needs (13).
The diversity of views on spirituality has led to disparate interpretations of the reality of spirituality and its origins and consequences. To provide proportionate levels of spiritual care, nurses need to extend their knowledge and understanding of spirituality and integrate spirituality into their nursing care routines (14, 15). Considering the importance of integrating the results of textual reviews in practice and defining a distinct classification, in the present study, we aimed to review the available approaches and paradigms in the realm of spirituality.
The present study is an integrative literature review. This method of inquiry was selected to include articles with different methodologies (e.g., quantitative and qualitative studies). This integrative review comprised of the following stages: identifying the problem, searching for relevant texts, evaluating the data, and presenting the findings (16).
The primary search was conducted in national and international databases, including Science Direct, PubMed, Google Scholar, Scopus, Sage, Medline, Wiley, SID, MagIran, IranMedex, and IranDoc, using the keyword, "spirituality", without considering any time limits. Only English and Farsi articles, which represented a certain approach or view to the concept of spirituality and were published in peer-reviewed journals, were included. On the other hand, articles published in languages other than English or Farsi, editorials, and studies published in non-peer-reviewed journals were excluded from the study.
Among the retrieved articles, 70 studies met the objectives. The research team reached a consensus regarding the inclusion of the selected studies. After a full review of the articles, the available approaches to spirituality were classified.
Since ancient times, spirituality has been sporadically discussed in human intellectual and artistic artifacts. This concept was expanded as an independent, systematic, and conscious movement since the second half of the 19th century in Europe, USA, and Canada. The diversity in motives and approaches to spirituality has led to different interpretations of its reality, origins, and consequences. Overall, the three prominent approaches to spirituality include religious, secular, and holistic health perspectives (Table 1).
Table 1. Comparison of religious, secular, and holistic health approaches to the study of spirituality
1) Prioritizing sublime values; 2) holding a divine attitude towards the universe; and 3) living a loving life.
1) Rationality; 2) belief in the metaphysical dimension of the universe; 3) belief in the existence of a unique God whose presence transcends the possible; 4) belief in resurrection; 5) belief in mankind's free will and the possibility for his/her ascendance and/or fall; 6) belief in the purposefulness of creation; and 7) belief in the influence of deeds on forming the inner reality of mankind.
Discovering, understanding, experiencing, and communicating with the Holy.
A tendency to love and to be loved, to help others, to experience joy, to have an ultimate purpose, and to experience perfection and peacefulness.
1) Distinct spiritual interactions including love, trust, honesty, and righteousness; 2) integrity; 3) respect; 4) sacrifice and compassion; 5) experiences in nature creating a sense of closeness and affinity with the natural world; and 6) communication with certain supreme forces, or the power that guides the universe, and/or a personal deity who knows the individual and protects him/her.
Holistic health approach
The relationship between spirituality and religion is among the most controversial issues in philosophy of religion and research on spirituality. Reasons leading to a tendency towards religious spirituality in this era include: 1) exposure of defects and negative impacts of secular sciences; 2) revelation of religion's personal and social effects; 3) incapability of post-Renaissance philosophies to answer mankind's fundamental questions; 4) failure of empirical sciences to solve physical and spiritual problems; 5) personal and social predicaments as a result of modern lifestyle; and 6) new inquiries in the areas of psychology and metapsychology (17).
Spirituality is the common product of all monotheistic religions; consequently, it gives a sense of meaning and direction to human life. The presence of spirituality in all aspects of humanity eradicates pain and distress and paves the way for ultimate satisfaction (18). In fact, spirituality and religion are universal threads within the texture of human experience.
Even though each culture and religion has its unique way of defining and describing spirituality, there is tremendous homogeneity and solidarity in their core arguments, i.e., there is a more comprehensive pattern to understand existence beyond human consciousness; this pattern connects everything through a more coherent coordination. All religions expect their followers to recognize the limitations of their vision, which restrain them to a particular time and place, and invite them to have an inclusive perspective towards life so that they can satisfy their more fundamental needs and dispositions (19).
Religion and spirituality give meaning to human values, conducts, experiences, and structures (20). In a book entitled, "The Spiritual Life", Underhill puts spirituality at the heart of any religion. To her, spiritual life is a complete authentic life, built exclusively for the sake of humanity (21). Overall, in religious studies, spirituality has various definitions. Some have claimed that only the plurality of spirituality can be discussed from a historical and comparative view. Nevertheless, familiarity with some of the proposed definitions can be valuable for forming a more comprehensive image of the intellectual milieu of spirituality scholars:
Based on the recent inclusive definition of spirituality, the ultimate goal is not restricted to peacefulness, happiness, sanguinity, or liberation from pain and agony, as drugs can also liberate humans from the pain and sufferings of life, albeit for a limited period of time. Also, materialistic orientation, living a life of trivial ends, and addictive ecstasy, despite their transient practicality, cannot be considered as the manifestations of true spirituality (17).
It should be also noted that the epistemological system of our universe is faith-based. Consequently, spirituality, as one of the most important layers of one's life, cannot be accompanied with doubt or uncertainty. Similar to other aspects of life, spirituality has its fair share of rational principles, delineating its propositions. It is not possible to confirm a certain phenomenon without the help of rational principles. Even the false claim that "spirituality is the essence of religion, beyond the rules and principles set by rationality" is not entirely unrelated to the principle of paradox. Therefore, any interpretation of spirituality, which necessitates relativity, skepticism, epistemological pluralism, denial of faith, and principle of contradiction, is false.
Ascension towards transcendental realities is impossible without an accurate identification of the purpose, means, and methods to materialize that purpose. Furthermore, identification of each of these realities necessitates the implementation of rational principles. Also, adherence to the framework of rationality prevents the emergence or development of false spirituality (17). In fact, a form of spirituality, which is not established upon rational principles (or conflicts with them), cannot influence the human spirit beyond transient peacefulness. In other words, true spirituality is neither at odds with commonsensical principles nor conflicts with their definite consequences (17).
In an unbalanced battle with the modern world, the only authentic spirituality is that joined with religious rationality (27). Therefore, based on rational principles, it is safe to claim that true spirituality is characterized as follows: 1) rationality; 2) belief in the existence of a metaphysical dimension to life (any interpretation that would analyze spiritual reality through positivist principles is excluded from this framework); 3) belief in the existence of a wise, almighty, and loving God, who is beyond all entities in the whole universe and whose distinct existence prevails the possible; 4) belief in resurrection; 5) belief in mankind's free will and the possibility of ascendance and/or fall; 6) belief in the goal-directedness of creation; and 7) belief in the influence of outside deeds on the development of the inner reality of mankind (17).
In a religious approach, the mission of spirituality is not mere provision of mental peacefulness and ecstasy without wisdom. Spirituality, devoid of any spiritual interpretation of human reality and existence, is impossible (17). Also, religion paves the way for one's journey from the outside to the inside, connection to the world of unseen, and a loving attitude towards God and universe.
Religion provides the epistemological background of spirituality and differentiates it from pure sentimentality through shedding light on the origins of creation, resurrection, reality of human beings, and purpose of life. Moreover, it supplies the faithful with a legitimate and rational self-purification through its specific religious orders and rituals.
Religion seeks self-development, supported by rational principles, devoid of social indifference, uni-directionality, or illegitimate physical harms. In other words, emergence of physical and spiritual virtues is impossible without acting in accordance with religious principles. Therefore, perseverance in applying religious orders and rituals may result in the achievement of spiritual excellence.
Some consider spirituality to be not only different from religion, but also contradictory to or even in conflict with it. To these scholars, religion and spirituality are two incompatible and irreconcilable phenomena. The reason for this particular intellectual orientation may lie in the failure of monotheistic religions, such as Christianity and Judaism, to fulfill human's spiritual needs. Also, a number of Western religion philosophers believe in the contradiction between religion and spirituality to the extent that they consider the phrase "religious spirituality" as an entirely paradoxical combination (17).
It appears that the result of a secular approach is the emergence of a certain type of spirituality, which is defined on an individual level and may end in the degeneration of spirituality and loss of spiritual identity. With this new definition of spirituality, various forms of spirituality, determined by the individual, begin to emerge.
In recent years, religious and devotional aspects of spirituality have deteriorated to various extents. The recent transformation in the concept of spirituality is a reflection of a mostly secularized view in which the search for connection to every living soul is a deviation from the prevalent religious belief system (28). Some believe that spirituality in nature is a personal experience, distinct in form from one person to another. Based on this view, common themes found in every spiritual reality include a tendency to love and to be loved, to help others, to experience joy, to have a major life goal, and to experience perfection and peacefulness (29-31).
Some of the spiritual pioneering systems in the Western world have discarded the existence of God as the core element, propagating a certain type of spirituality where its advocates are encouraged to live according to moral values with an aesthetic orientation. This approach has a personal view to beliefs, values, and predispositions. Accordingly, the modern man has opted to use meditational exercises, oriental medicine, organic nourishments, Yoga, psychotherapy, drug-induced mysticism, and various newly-emerged secular theosophies.
Secular spirituality convicts religion of historicity, choosing to set it aside altogether. The rejection of a unique God, belief in pantheism, substitution of resurrection with reincarnation, changes in the principles of religious prophecy, and acceptance of religious pluralism are a few deficiencies, besides intrinsic contradictions such as the lack of an epistemological system and unproved claims of false mysticism (17).
Development of a distinct and unique interpretation for the concept of spirituality is a product of secularism, which is itself a major representation of modernist movements. The emergence of modernism can be mostly attributed to internal debates within Christianity in Europe. In fact, modernism with two major components of philosophical intellectuality and empiricism disputed religious traditions.
Modernism has challenged many philosophical-religious beliefs. Logical reasoning, importance of the tangible consequences of one's decisions and behaviors, and empiricism are all among the essential components of modernism. Pargament describes spirituality as the search for the Holy, which is the integrating force behind these disparate paths. The Holy is anything beyond the commonplace, and as such it deserves veneration and admiration. The Holy can be a time (Christmas Eve), place (e.g., mosque or church), event (e.g., birth or death), material (e.g., cross or beads), cultural product (e.g., music or literature), individual (e.g., a religious leader), psychological trait (e.g., spirit or seeking meaning), social trait (e.g., sympathy or philanthropy), or different roles (e.g., marriage, work, or child rearing). A person who starts a journey in hope of discovering, understanding, experiencing, and connecting with the Holy has all the characteristics of a spiritual being (32).
Holistic health approach
At present, spiritual health has been incorporated in most health models (28). This approach is under the influence of a holistic view to mankind. Based on this approach, healthcare professionals should not only aim to improve humans' biological aspects, but also should help promote their mental, social, and spiritual realities.
In the Islamic Iranian culture, health and spirituality were intertwined to the extent that one of the most important necessities for medical professionals was to have superior knowledge of humanities (including philosophy and dialectics), which enabled them to transcend the limited sphere of disease treatment and pay attention to the metaphysical aspects of mankind.
The historical intertwinement of spirituality and health has been frequently and thoroughly observed in the works of many Muslim medical figures (33). Assignment of the title “Hakim” to distinguished physicians in some historical periods is yet another sign of the close connection between medical practice (and its stakeholders) and "Hikmat" or “practical rationality”, which is basically rooted in moral perfection and balance between different existential aspects; in this sense, the words "physician" and "Hakim" are sometimes used interchangeably.
With advances in science and scientific knowledge, both in quantity and quality, in European and American countries from the 18th to 20th century, philosophers began to gradually disconnect physical phenomena from spiritual-devotional experiences. Physical health improvement was researched as a subject of scientific inquiry, while spiritual-devotional phenomena were confined to the churches and other religious centers.
With the progressive empowerment of secular beliefs and their subsequent influence on the Western academic culture, the distinction between sensory phenomena and spiritual-devotional experiences was even more apparent (34). Until about 40 years ago, a number of studies noted the connection between religious and devotional aspects of mankind and physical outcomes such as health. Thereafter, other indices were applied in defining health, which were gradually granted more prominence in scientific works (35).
Many theories have been proposed regarding the function of spirituality in health provision. Spirituality bestows happiness upon believers in grave times of decision-making and tension, helps find answers to important questions about the philosophy of teleology and the ultimate purpose of creation, provides social support for the believers in all divine and human aspects, develops optimism, sanguineness, meaningfulness, goal-directedness, hopefulness, and motivation among its advocates and followers, raises the individual's potentials and capabilities, and increases dominance, endurance of pain, and coping with anxieties and predicaments. These features, which are the outcomes of religiosity and one's tendency towards a virtuous lifestyle, are necessary for all patients.
Research has confirmed the effectiveness of the mentioned factors in improving patients' well-being and health in biophysiological, immunological, and sociopsychological aspects (36). A spiritual viewpoint can affect one's beliefs, attitudes, values, and behaviors and influence the biochemistry and physiology of the human body; these effects on the human body and soul are recognized as spiritual health (37).
In spite of a great number of studies on spiritual health in recent decades, lack of an acceptable theoretical or operational definition of spiritual health is strongly felt. Moreover, identifying, describing, and assessing spiritual health remain untouched (38, 39). Spiritual health, in its true representation, is not restricted to the impact of prayers or spiritual dispositions on disease treatment or replacement of common medical treatments and/or complementary medicine.
According to Russell, spiritual health can have various manifestations: 1) everyday communication with others; 2) certain spiritual interactions through love, trust, honesty, and righteousness; 3) integration, respect, dedication, and compassion; 4) experiences in nature creating a sense of closeness and affinity with the natural world; 5) communicating with the spirits of the dead; and 6) communicating with certain supreme forces, or the power guiding the universe, and/or a personal deity who knows the individual and protects him/her (29).
In recent years, there has been a growing interest in spirituality as the human aspect of individuals and the role it plays in human well-being (40). In times of illness, people are concerned with the meaning and purpose of life and their relation with God and people. Life's threatening situations such as disease can sometimes trigger complicated spiritual questions (41), and patients may be inclined to entrust nurses with these questions.
An individual's earlier beliefs about life and health may be challenged in times of difficulty. Through spiritual beliefs, patients learn to understand and cope with their pain. This process can help raise their awareness of the bigger image of pain and feel pacified by connecting to the ultimate source of power. Such beliefs can lead to spiritual vigor and hope (42), morale boost, peacefulness and calm, liberation from a feeling of guilt, and affinity to God (43).
Based on progressive evidence, those who enjoy higher levels of spiritual health tend to be more physically, mentally, and socially sane. In particular, a higher level of spiritual health is correlated with greater observance of dietary preferences (44), lower distress (45), less pain (46), lower anxiety (47), higher quality of life (48), and lower mortality rate (46). Especially among cancer patients, a higher level of spiritual health is correlated with greater health (12), hopefulness (49), adjustment (50), social performance (51), better health self-evaluation (52), higher quality of life (53), lower psychological stress (54), lower depression rate (55), lower financial pressure (52), and fewer suicidal thoughts (56).
The significance of spirituality in the area of health has been increasingly emphasized, indicating its important place in disease treatment and its great potential to improve the quality of life, alleviate disease symptoms, and reduce mortality rates. The World Health Organization (WHO) has added a spiritual dimension to disease classification in The International Classification of Diseases-10 (ICD-10). In other words, similar to the intertwinement and mutual influence of physical, mental, and social dimensions, human's spiritual dimension and spiritual health are also interconnected and influence other aspects of health.
Despite the growing acceptance of the spiritual aspect of health, this dimension remains unnoticed or discarded in public health and health improvement debates, decisions, and programs (except for a few interventions in patients with terminal diseases or those in the final stages of life). Furthermore, the findings have not led to any tangible changes in medical sciences or nursing educational courses. Also, the spiritual aspect has not been incorporated in the provision of routine medical or healthcare services.
Based on the available literature, religious, secular, and holistic health approaches are three prominent perspectives in the study of spirituality. According to studies conducted in the area of spirituality, it can be concluded that this concept has been described in different forms, sometimes even with contradictions, depending on the context and cultural and historical backgrounds of particular societies.
Comparison of the results of previous studies would lead us to an understanding of how effective particular contexts and cultures can be in altering research results. Each of the discussed studies has looked at the concept of spirituality from a distinct point of view, depending on the intellectual paradigms and philosophical orientations of the researchers. It is worth noting that the context-based nature of these studies impedes the generalization of the results and encumbers unanimous decision-making on the concept of spirituality.
Recent ideologies concerning spirituality are extremely affected by existentialism, post-modern thinking, and transpersonal psychology. Here, the nature of spirituality is solely described on the basis of subjective experiences (57). Under this definition, spirituality is what the individual believes when there is no right or wrong. In this ideology, the ultimate source of spirituality is the individual's subjective experience.
Scientific councils and WHO have assigned a particular importance to the spiritual and non-physical dimensions of health. However, considering the absence of a single agreed-upon definition for spirituality, development of a spiritual health ideology and its incorporation in national health programs, routine health care, and disease treatment have not been free of challenges, despite the connection between spiritual and religious beliefs and the diversity of universal religious beliefs.
Also, in nursing practice, even though spirituality has always been an integral part and the primary motive of most people entering this profession, a major inclination has been observed in studying spirituality and spiritual care in nursing textbooks and literature ever since the spiritual dimension was incorporated in health definition as the ultimate purpose of nursing practice (58).
The growing interest in research on spirituality and spiritual care in recent decades has been considerable, making spirituality a major component of scientific discourse within different areas of nursing practice. Today, considering the holistic view towards humanity as the building block of holistic nursing care, there is a progressive realization that spiritual concerns cannot be ignored (59).
Implications for Practice
Owing to the importance of spirituality for patients, it is always necessary to place enough emphasis on the cultural description of the concept of spirituality. Needs of patients, as unique individuals, are highly affected by their cultural beliefs and are developed by particular methods and views within a certain culture (60). Also, the International Council of Nurses has assigned great importance to the role of nurses in establishing and improving an environment where the individual, family, social rights, and spiritual beliefs are respected (61). Therefore, nurses and other healthcare professionals should pay particular attention to the unique spiritual dimension of their patients.
We would like to gratefully thank Mashhad University of Medical Sciences And Tarbiat Modares University Departments of Interlibrary Loan and Article Delivery that helped us retrieve the full-texts of the articles.
Conflict of interest
The authors declare that there is no conflict of interest.