Research progress in the definition, assessment tools, and practice of spiritual care

Abstract To promote the development of nursing spiritual care and humanistic care, this article introduces the current status of the definition, assessment tools, and practice of spiritual care at home and abroad.


Introduction
With the development of a modern medical model, the connotation of nursing has extended to provide holistic care for patients at four dimensions: physical, psychological, social, and spiritual. 1 Spirituality has attracted the attention of nursing science since the 1960s, and research about spirituality has gradually become a hotspot in the past 20 years. In 1995, WHO added spirituality to the concept of health. Spiritual care is the core element of physical-psychological-social-spiritual pattern and the integrating energy of the other three aspects. 2,3 The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), The Association of American Medical Colleges (AAMC), 4 ICN ethics, 5 and Malta Nurses' ethics 6 pointed out that spiritual care is an important part of high-quality nursing service, and nurses are the main providers of spiritual care. 7 It is also proposed by the National Health and Family Planning Commission (2017) that provide physical, psychological, spiritual, and social support for patients with care and humanistic care services. 8 However, spiritual care, as a key element of humanistic care, has not received enough attention in China. Therefore, this article reviews the definition, assessment tools, and clinical practice of spiritual care to provide a reference for clinical nursing and research.

The definition of spirituality
Spirituality is an abstract, subjective, and complex. Scholars have not yet reached a consensus on the concept: Villagomeza 9 believed that spirituality is an inherent trait of an individual, which could promote optimal health and stability. Weathers et al. 10 pointed out that spirituality is a way of being that enables individuals patients to achieve the best health outcomes. It can be concluded that spiritual care is an activity for nurses to evaluate and alleviate patients' spiritual distress with the guidance of their spiritual values, which could help patients to find out the meaning of life, self-realization, hope and creation, faith and trust, calm and comfort, prayer, love and forgiveness, spiritual tranquility, and comfort. 3,20

Nursing theory related to spiritual care
Nightingale, the pioneer of nursing science, pointed out that 21 spiritual care is essential to meet human health needs and promote rehabilitation. Henderson 22 classified the human basic needs into 14 items at the three levels of body, mind, and spirit. Nurses should help patients to achieve the highest level of spiritual comfort. In 1969, Maslow revised the theory of human basic needs (XYZ theory), 23 which involves spiritual needs, and he also agreed that spirituality is a part of an individual's self-identity, inner core value, and satisfactory life. In Neuman's system model, 24 "holism" includes five interrelated items: physiology, psychology, social culture, growth and development, and spirituality. All of these are coping mechanisms of stress stimulation. Spirituality can help individuals to find the meaning of life, experience happiness and hope, and develop interpersonal relationships. Watson's theory 25 of human caring also indicates that spiritual care is a force that promotes individuals to discover self-worth and achieve the harmony of body-mind-spirit.

The significance of spiritual care
Spiritual care is of great significance for both nurses and patients. As for patients, spiritual care can help them to explore the source of internal strength, increase the ability to cope with diseases, rebuild and maintain the integrity of body-mind-society-spirit, 26 promote the integration of patients with heaven, others, environments, and self so that to promote the level of hope, 16 alleviate negative emotions such as anxiety and depression, and increase resilience, cherish the meaning and value of life, gain inner peace and comfort, and improve the quality of life. 4 On the other hand, providing spiritual care for patients can inspire nurses to reflect on their spiritual belief system, think about the significance and value of nursing work, cultivate their spirituality, and improve the ability of humanistic care. In addition, dealing with patients' spiritual issues can also increase nurses' sense of achievement to stabilize the nursing team and reduce the loss of nursing staff. [27][28][29][30] to experience the connection with themselves, others, nature, or super-energy and to discover the meaning of life and transcend suffering in difficulties. Fawcett and Noble 11 held that spirituality is much broader than religion, and it focuses on inspiration, meaning, and purpose of life. When individuals face emotional stress, physical illness, or death, spirituality becomes the focus. Although the definition of spirituality has not yet been unified, it is agreed that spirituality is a process of seeking meaning, pursuing integrity, uniqueness, and inner harmony. 12 Spirituality is multidimensional and individualized. Shan 13 indicated that spirituality is the feeling of peace in the process of integration, which also refers to the pursuit of harmony between individuals and heaven, others, environment and the individual, the exploration of eternal meaning and value of life, the maintenance of harmonious relations, and the transcendence of current difficulties. Above all, the spirituality can be described as attaining the purpose and meaning of life, guiding the value orientation, and helping individuals to achieve self-transcendence. 14

The definition of spiritual care
Because of the complexity and abstraction of spirituality, the definition of spiritual care is also controversial. Sawatzky and Pesut 15 pointed out that spiritual care is an instinctive, interpersonal, and altruistic integrated care based on the transcendental dimension of nurses' life. This concept reflects the essence of spiritual care; nurses seek available spiritual resources to help patients discover the purpose and significance of life within a better nurse-patient relationship. Mok et al. 16 believed that spiritual care is a highly dynamic process of interpersonal communication between nurses and patients, and during the caring process, nurses should treat patients without any distinction, respecting their unique values, satisfying their spiritual needs, and promoting their spiritual health. Edwards et al. 17 held that spiritual care is not a simple nursing mission, but a way of caring to help patients to discover the meaning, hope, and strength of life. The Royal College of Nursing 18 pointed out that spiritual care is nurses' duty to identify and satisfy patients' spiritual needs for meaning, self-worth, and belief support when he/she is faced with trauma, illness, and grief. Govier 19 used 5R to define the concept: Reason and Reflection: helping patients to think and explore the meaning of life; Religion: guiding patients with religion to depend on their belief system, values, and etiquette practice as a way of spiritual expression; Relationship: establishing a constant connection with self, others, and supernatural power; Restoration: providing spiritual care to enable

Assessment tools for spiritual care
Identifying patients' spiritual needs and providing individualized spiritual care depend on nurses' awareness and skills of spiritual care. Therefore, it is necessary to evaluate the spiritual care status of nurses. A relatively well-designed evaluation system has been established.

Spirituality and spiritual care rating scale (SSCRS)
McSherry et al. 31 34 is also based on the SSCRS, which has excellent psychometric properties and can be used to evaluate the status of nurses' spiritual awareness in China.

Spiritual care competence scale (SCCS)
van Leeuwen et al. 35 developed the scale to assess nurse's spiritual care ability. The scale includes 27 items and 6 dimensions (evaluation and practice of spiritual care, spiritual care quality improvement, patient support and counseling, professional referrals, spiritual care attitudes, and communication), the Cronbach's a was 0.56-0.82, the homogeneity of each item was higher, the correlation coefficient between the items was >0.25, and the test-retest reliability was better. It has been translated into multiple languages. Research 36 with clinical registered nurses in China supports the high degree of internal consistency, split-half reliability, and validity, all of these demonstrate its great value for further research.

Spiritual care-giving scale (SCGS)
In 2012, Tiew and Creedy 37 developed the scale to evaluate the attitude of nurses/nursing students in providing spiritual care. The scale includes 35 items and 5 dimensions (spiritual care value, spiritual care attitudes, key aspects of spiritual care, spirituality perspectives, attributes of spiritual care). The scale was compiled in a multicultural context with good internal consistency (Cronbach's a = 0.86). The shortcoming lies in that some of the items evaluating the subject's spiritual view does not truly reflect their willingness to provide spiritual care, which needs further improvement.

Spiritual care attitude scale (SCAS)
Chiang et al. 38 developed this tool in 2014, which contains 15 items and 3 dimensions (spiritual growth, core concepts, and practices of spiritual care). The Cronbach's a was 0.96, the correlation coefficient was between 0.55 and 0.82, and the content validity was also within the normal range. During the process of scale psychological testing, the author took full account of the diversity between Eastern and Western and deleted the items related to religion so that the applicability is much better in China.

Nurse spiritual care therapeutics scale (NSCTS)
In 2015, Mamier and Taylor 39 developed the scale to assess the frequency of nurses providing spiritual care, including 17 items, the internal consistency, and the aggregation efficiency of the scale was ideal, the CVI was 0.88, the Cronbach's a was 0.93, and the total correlation coefficient of the item was between 0.40 and 0.80. However, there was no dimension in the scale, and the item did not specify the time and effect that the nurse should spend in providing spiritual care either. Nevertheless, compared with other scales, NSCTS involves the least religious content and the best structural validity, which is an ideal spiritual care assessment tool.

Nurses' spirituality and delivery of spiritual care (NSDSC)
The development of the scale is based on the Eastern cultural background, 26 which is used to assess nurses' perceptions of self and transcendence dimensions and their perspectives and practice about spiritual care, which contains 27 items and 4 dimensions (understanding of transcendence, self, spiritual care, and spiritual care practice), the CVI was 0.80, test-retest reliability was 0.89, Cronbach's a was 0.80, all of these shows that the scale is characterized by good psychometric properties.
Other similar spiritual care assessment tools that have not been widely used include spiritual care inventory (SCI) 27 and spiritual care perception and practical scale (SCPPS). 2 The aforementioned scales mostly aim at evaluating nurses' spiritual care knowledge, attitude, and ability. The individualization of spiritual care leads to great differences in different assessment tools. Most of the scales are based on Western Christian cultural background, which is not compatible with Chinese national conditions. Moreover, the items of these scales are indistinct from the contents of psychological care. Based on the research objective and national conditions, we should choose or revise appropriate spiritual care assessment tools to explore the level of nurses' spiritual care properly.

Clinical application of spiritual care
Based on the nursing process, spiritual care is a procedure that the nursing staff adopts the humanistic communication skills to develop a harmonious nurse-patient relationship, giving more attention to patients, making patients' physical, psychological, social and spiritual needs satisfied, no matter, so that the patient is comforted and cherish the meaning and value of life.
Most of the research on spiritual care is to guide patients to review their life and reconstruct cognition, explore and understand the meaning of life to achieve inner peace finally. In 2010, Ando et al. 40 conducted a 1-week life review interview with 38 patients diagnosed with terminal cancer, recalling, and recording their life. As a result, the life review was effective in improving the spiritual well-being, alleviating psychosocial distress, and promoting a good health outcome of terminally ill cancer patients. In 2011, Chochinov et al. 41 treated 165 dying patients with dignity therapy to assist them in recalling the most meaningful events and expressing wishes in their lives. When the intervention finished, most of the patients expressed spiritual comfort and the depression and sadness were also relieved. In 2012, Breibart et al. 42 carried out a seven-stage meaningful therapy for 64 patients with advanced cancer, guiding them to explore the meaning of life and illness. In the short term, the spiritual health and quality of life of patients were improved significantly. In 2017, Kuru 43 found that laughter therapy can also improve patients' overall health, which refers to the physical, psychological, social, and spiritual well-being. At present, there is no principle standard for spiritual care. The diversification of spiritual care prompts us to explore the optimal mode of spiritual care and conduct multicenter, large-sample, and high-quality research and verify its long-term effects.

Conclusions
Foreign research on spiritual care has tended to be mature, including concept analysis, theory research, development of assessment tools, and empirical application, but little qualitative research has been done. Domestic research on spiritual care is still in its infancy, which limited to introducing spiritual-related concepts, assessment tools, and intervention methods. The literature reviews are mostly described. Due to the deficiency of localized spiritual assessment tools, qualitative interviews are often used to explore patients' spiritual feelings. Chinese culture is deeply influenced by Confucianism, Buddhism, and Taoism. Accordingly, the spiritual care conditions are greatly different from the development of Western religious culture. Therefore, the growth of spiritual care in China should adhere to the principle of localization. Here are some suggestions: (1) Defining the localized connotation of spiritual care. (2) Establishing distinctive spiritual care courses (elective/compulsory) in universities to cultivate the spiritual care ability of nursing students, promote the formation of correct spiritual cognition, increase their spiritual sensitivity, and lay the foundation for providing holistic physical, psychological, social, and spiritual care in the future.

Ethical approval
Ethical issues are not involved in this article.

Conflicts of interest
All authors declare that there is no conflicts of interest exist.