1. Introduction

Spirituality, a complex concept, encompassed the whole human being. Spirituality transcended the religiosity of individuals. The transcendence of religion was vital in understanding spirituality. Historically, religion divided individuals, whereas spirituality encompassed broad ideas and individualized components transcending the barriers of religion. Spirituality encompassed a broad belief system that included human rights, religion, experiences, and culture. When healthcare workers practiced according to their spirituality a higher power connected healthcare workers to the surrounding community, which allowed the individuals to recognize their specific purposes [1]. The advanced practice nurse’s (APN) spirituality was a core component of the provider’s resilience. A broad range of emotional and physical demands, such as supporting patients during births, terminal illness diagnoses, and end of life care saturated the APN’s profession. According to Brown [1], spirituality was a cornerstone for people to thrive in stressful or traumatic environments.

In healthcare, much of the research focused on the patient’s experience with spirituality. However, this concept analysis focused on the APN’s spirituality, which was necessary to prepare and equip APNs with a clear understanding of the concept. According to Goldsmith [2], spirituality served an important role for healthcare professionals and occurred in all parts of life. After reflecting on the authors’ professional and personal experiences, spirituality was a reoccurring and significant concept. The authors encountered spirituality within the nursing profession.

2. Concept Analysis

3. Relating Theory to Practice

Spirituality within the APN was present during encounters with hospital staff, patients, and visitors. While some nursing theories incorporated dimensions of spirituality, theories failed to elaborate on the necessary components of spirituality within the healthcare provider. Instead, the nursing theorists mainly focused on the patient’s spirituality. The authors experienced difficulty finding a theory that discussed the spirituality of the health care provider, including the APN, and were not successful in finding such a theory. However, various theories regarding an individual’s spirituality, unrelated specifically to the nursing field, existed. Watson, Ray, and Batty each developed different theories that alluded to and utilized the concept of spirituality in nursing.

In Human Science and Human Care: A Theory of Nursing, Jean Watson [5] stated that an individual’s spirituality increased as a person matured and as the surrounding world changed. When the APN nurtured his or her spirituality, they promoted the human to strive [5]. The nurse’s engagement in spirituality enhanced the level of human care [5]. As a result, Watson’s theory called for the APN to take an active role in recognizing and fine tuning the spirituality that existed deep within the self. Disharmony within an individual’s spirituality led to anxiety and inner turmoil [5]. A possible struggle that stemmed from not engaging in spirituality had the potential for serious consequences such as poor job satisfaction, burnout, providing incompetent patient care, poor resilience, and illness.

Ray’s [6] bureaucratic caring theory described nurses as holding the patient in the nurse’s hands. The theory presented a tool that aided nurses in assessing the multiple and multidirectional components of a patient to provide spiritual, ethical caring [6] ultimately. Developing the APN’s spirituality led to more competent care regardless of an individual’s culture or religion [6].Ray [6] described spirituality as an inner tranquility with the realization of a higher being, but this realization and tranquility did not exclude individuals from hardships and turmoil. Knowing that spirituality did not shield anyone from life’s personal or professional hardships prepared the APN for the brokenness of the world.

Battey [7] created the theory of spiritual care for nursing practice to promote resilience and coping within patients during difficult situations or crises. Battey [7] stated that the theory required facilities to provide and increase education regarding spirituality as a means of spiritually caring for patients. Although the theory mainly focused on the patient, Battey [7] concluded, “health people, including nurses, need spiritual care” (p. 263). The theory of spiritual care provided a foundation for leaders to enact spirituality as a regular practice in their environments.

4. Definitions and Uses of Spirituality

Barnum [8] concluded that spirituality was difficult to define due to the abstract nature and the lack of concrete yes or no answers. For example, Merriam-Webster Online Dictionary [9] provided a limited definition of spirituality. Merriam-Webster Online Dictionary [9] defined spirituality as “the quality or state of being concerned with religion or religious matters: the quality or state of being spiritual.” The definition provided a narrow view of the concept of spirituality. The definition focused only on religious aspects of spirituality.

Brown [1] defined spirituality as:

Recognizing and celebrating that we are all inextricably connected to each other by a power greater than all of us, and that our connection to the power and to one another is grounded in love and compassion. Practicing spirituality brings a sense of perspective and purpose to our lives. (p. 64).

Spirituality consisted of a conscious decision to let an individual show their true self [1]. The authors considered Brown’s definition to include great insight into the concept of spirituality. Brown [1] considered spirituality highly personal, but spirituality also allowed individuals to see past their personal needs to others around them.

Dossey and Keegan [10] defined spirituality as:

A broad concept that encompasses values, meaning, and purpose; one turns inward to the human traits of honesty, love, caring, wisdom, imagination, and compassion; existence of a quality of a higher authority, fighting guiding spirit or transcendence that is mystical; a flowing, dynamic balance that allows and creates healing of body-mind-spirit; and may or may not involve organized religion. (p. 24).

Dossey and Keegan’s [10] definition incorporated religion but was very personalized for each person. According to Dossey and Keegan [10], spirituality increased an individual’s humanity by creating reflection on honesty, love, caring, wisdom, imagination, and compassion. Increasing these characteristics in the APN advanced care and personal growth.

5. Attributes

According to Walker and Avant [3], precise attributes, or characteristics, led the individual to think of a concept instantly. The attributes of spirituality included the human being, belief, enlightenment, and a decision. The attributes served as the criteria for the concept of spirituality to be present.

Eriksson [11] defined the human being as a being of the physical body, soul, and spirit. According to the authors, the human being was a spiritual and a physical being that interacted with an external environment. The higher level of consciousness developed spirituality and existed within the human being. Every human being contained spirituality within the self. Spirituality recognized humans as all encompassing and related to the environment and to a higher being, which helped individuals find their purpose [4]. Spirituality enabled the APN, as a human being, to capture their purpose and ultimately become fulfilled.

According to Merriam-Webster’s Online Dictionary [12], a belief was “a feeling of being sure that someone or something exists or that something is true,” “a feeling that something is good, right, or valuable,” or “a feeling of trust in the worth or ability of someone.” A belief was an inherent or a formed conviction that influenced a human being’s deliberate actions, unconscious behavior, and thoughts. The belief served as the seed and nurtured the growth of spirituality. A belief of spirituality had the potential to change the APN’s past views and future actions. A belief in spirituality reflected within the APN’s practice.

Merriam-Webster’s Online Dictionary [13] defined enlightenment as “the states of having knowledge or understanding.” Enlightenment revealed a deeper self-awareness. The awakening and application of an individual’s belief led to enlightenment. After the individual incorporated beliefs into his or her consciousness, enlightenment revealed a phenomenon that was once hidden to the individual. The APN’s beliefs in the practices of spirituality led to glimpses of enlightenment [14]. Each human’s experience with enlightenment was individualized and was dependent on culture, religion, and past interactions.

Finally, Merriam-Webster’s Online Dictionary [15] defined a decision as “a choice that you make about something after thinking about it: the result of deciding,” “the ability to make choices quickly and confidently,” and “the particular end of a legal or official argument: a legal or official judgment.” The individual’s decisions, which consisted of a conscious choice, stemmed from personal beliefs, past experiences, and the individual’s culture. When the APN decided to engage in spirituality, they also adopted changes into their lifestyle.

6. Antecedents and Consequences

The definition of an antecedent was an event “that must occur or be in place prior to the occurrence of the concept” (p. 167) [3]. The antecedents of spirituality were a higher being, self-reflection, spiritual awareness, and desire. The belief or connection to a higher being was vital to spirituality [16]. A higher being, or entity, was not limited by time, space, or knowledge. Self-reflection allowed the person to gain enhanced insight into the concept of spirituality. Self-reflection required a critical awareness of oneself [17]. Spiritual awareness required having the knowledge that all humans were spiritual beings and depended on a decision to act upon this knowledge. Spiritual awareness pursued harmony with both internal and external environments [18]. A desire was the strong innate sense of want or need. A desire initiated an active step in the journey towards spirituality.

Walker and Avant [3] defined consequences as “those events or incidents that occur as a result of the occurrence of the concept- in other words, the outcomes of the concept” (p.167). The consequences of spirituality were a higher level of care, resilience, transcendence, open-mindedness, burnout, and persecution. When a healthcare professional incorporated spirituality, theyprovided a higher level of care and attended to a patient’s physical, spiritual, and emotional needs. Transcendence consisted of surpassing the constrictions of the physical and material world [5]. According to Watson [5], transcendence expanded the mind and soul to connect to the higher sense of self. According to Brown [1], resilience helped an individual overcome hardship. A human being gained the ability of resilience after the person practiced within their spirituality. Brown [1] also stated that spirituality was an element of resilience. Cultivating hope, practicing awareness, and removing the numbing feelings associated with vulnerability, discomfort, and pain emerged from spirituality and were attributes of resilience [1]. Open-mindedness was the ability to accept the individual’s environment, including others’ beliefs and actions and the individual’s limitations. Open-mindedness was the vulnerability within everyone and created connections with peers. Open-mindedness produced an exchange of ideas and beliefs without prejudice. Burnout appeared when powerlessness, anxiety, and a lack of control overwhelmed an individual [1]. When burnout presented, there was no sense of connection, purpose, or meaning in an individual’s actions. Finally, persecution was the disapproval of an action orbelief. Persecution occurred when an individual responded cruelly to another’s beliefs and when prejudice existed [1]. Persecution deterred an individual’s development of spirituality and hindered personal growth.

7. Model Case

According to Walker and Avant [3], a model case contained the attributes and an example of a concept. A family nurse practitioner, FNP X, provided care for Mr. and Mrs. A for the past four years. Mr. and Mrs. A were devout Catholics who relied heavily on their spirituality. FNP X was Muslim and practiced self-observation and meditation every day. Recently, FNP X diagnosed Mr. A with advanced pancreatic cancer and admitted Mr. A into an acute care facility.

FNP X found Mr. A very upset in his room. FNP X sat on Mr. A’s bed, and they spoke about financial burdens involving hospital bills and funeral costs. FNP X spoke to the financial counselor and found resources regarding financial assistance for individuals with pancreatic cancer. FNP X called and updated the chaplain on Mr. A’s condition before returning to Mr. A’s bedside to offer comfort. The chaplain arrived, and the three of them discussed Mr. A’s concerns. After, the chaplain led the group in prayer. FNP X left the bedside and reflected on Mr. A’s case and how emotionally vulnerable the provider was when a provider-patient relationship developed over the years. FNP X acknowledged the challenge of accepting the limitations in healing and providing care. FNP X’s decision to believe in a higher being created resilience, which allowed for FNP X to care for other patients in similar situations.

8. Borderline Case

According to Walker and Avant [3], the borderline case of a concept analysis was inconsistent and contained, not all, but most of the attributes of a concept. A Catholic acute care nurse practitioner, ACNP X, on the palliative care team cared for Mr. Y. Mr. Y checked into the hospital with complaints of pain due to lung cancer and deteriorated quickly. The staff nurse reported Mr. Y experienced a high level of pain, and ACNP X ordered a morphine drip. Shortly after the staff nurse started the infusion, Mr. Y rested comfortably. Mr. Y’s family, who spoke Arabic, called ACNP X to the bedside and discussed pain management. The family wanted Mr. Y to be more alert and awake during the last days. ACNP X called an interpreter to bedside to educate the family on palliative care management. ACNP X informed the family that decreased pain medication allowed Mr. Y to be more alert, but Mr. Y may experience severe pain. Mr. Y’s eldest son and power of attorney opposed the current pain medication, but Mr. Y’s wife supported the current pain regimen. The eldest son wanted Mr. Y to be awake during his last days. The ACNP X called the chaplain to discuss the matter and tried to come to a resolution. ACNP X consoled Mrs. Y regarding Mr. Y’s condition. Mrs. Y expressed gratitude to ACNP X for trying to develop the best plan of care for her husband.

ACNP X was torn between the eldest son’s wishes and the ACNP X’s personal belief son the best palliative care management. During the discussion with the family, Mr. Y died. The eldest son blamed ACNP X for killing Mr. Y with the high dose of pain medication. ACNP X tried to console the son, but the son resisted ACNP X’s attempts. ACNP X questioned personal beliefs on palliative care and wondered if the pain medication ordered killed the patient and limited Mr. Y’s time with his family. ACNP X questioned what the healthcare provider’s role was if God ultimately controlled a patient’s fate. ACNP X struggled with managing pain in new palliative care patients due to the challenging emotional nature of end-of-life care. ACNP X partially blamed herself in this instance and doubted her practice. A more developed spirituality would not make these challenges easy but would have allowed an enhanced coping process to work through emotional issues.

9. Contrary Case

The contrary case of a concept analysis failed to contain any of the attributes of the concept. According to Walker and Avant [3], contrary cases were helpful and allowed readers to see what the concept was not. A pediatric nurse practitioner, PNP X, lost a daughter three years ago to cancer, which caused PNP X to renounce God and dismiss previous spiritual beliefs. PNP X tried to cope, but the absence of spirituality limited PNP X. PNP X was in the process of walking out of the primary care clinic. As PNP X approached the exit, the patient care technician held the hand of a mother who had recently experienced the death of her young daughter. The patient care technician and the mother smiled and asked PNP X to join them in prayer. PNP X, who was late for dinner with friends, walked faster and pretended not to see the technician and the mother. The technician called for a staff nurse to stay with the mother as the technician confronted PNP X outside the clinic. Before PNP X entered the car, the technician asked PNP X ifthey could help console the patient. PNP X stated that PNP X was not religious and that the mother’s daughter was not a patient anymore.PNP X did not want to become emotional and upset before spending time with friends. On the way to the restaurant, PNP X tried to push back any emotional ties to the mother seen earlier.PNP X feared the vulnerability felt with patients with deceased children and struggled not only with finding meaning in practice but also in relationships outside of work. Upon the arrival to the restaurant, PNP X drank heavily to numb any emotions related to the mother encountered earlier.PNP X internally struggled with the loss of the patient but expressed all of the personal emotions negatively.

Since PNP X decided to renounce any spiritual and religious ties, PNP X limited the care provided and the ability to be openminded. PNP X’s lack of spirituality left the patient’s mother in need of care. PNP X experienced burnout and numbing due to the lack of spirituality, which would have allowed resilience to occur. With spirituality present, PNP X would have been able to better process and work through the challenging vulnerability that came with being a PNP.

10. Empirical Referents

Empirical referents allowed an individual “to recognize or measure the defining characteristics or attributes” (p. 268) [3]. For example, the empirical referent of a human being was a physical living being. Watson [5] stated, “human life in this instance then is defined as (spiritual-mental-physical) being-in-the-world which is continuous in time and space” (p. 49). An empirical referent for a belief was the driving force behind an individual’s action. For instance, an empirical referent for a belief in an afterlife provided better coping when faced with the death of loved ones [14]. For enlightenment, an empirical referent was meditation. Meditation allowed an individual to access the higher sense of self more readily through emotions,the mind, and internal environment [5]. An empirical referent for a decision was the conscious and deliberate thought of choosing an action [1]. For example, the decision for an adult to get baptized involved the deliberate thought and action.

11. Impact of Concept of Spirituality

The need for increased utilization and research on spirituality within the APN existed. The absence of education on spirituality in graduate schools affected the APN negatively and limited the scope of practice. According to Barnum [8], many graduate curricula resisted including spirituality as a topic because of negative reactions from physicians and other individuals who viewed nursing as an unprofessional or an artsy field. Due to a paradigm shift that occurred in the nursing profession, many individuals accepted both the non-scientific and scientific aspects of nursing. The public expected APNs to differentiate themselves from other providers by focusing on holism [8]. Barnum [8] suggested that instructors who taught spirituality were more effective than instructors who did not teach spirituality. Barnum [8] recommended that instructors introduce case studies involving spirituality and assign students to patients who experienced crises within their personal spirituality. According to Barnum [8] “Most contemporary studies of spirituality/and or religion use research tools with quantitative measurements” (p. 63). Barnum [8] questioned the effectiveness of the research methods and believed the research and the concept did not match well. The current ineffective and limited research surrounding nursing hindered the APN and those around him or her. The APN was responsible for nurturing spirituality, for he or she experienced it often in a professional or personal manner. A clearer understanding or more concrete definition of spirituality had the potential to encourage more individuals to research spirituality within the APN more effectively; researching a concept was difficult if confusion was present.

12. Model

The authors defined spirituality’s attributes as a human being, belief, enlightenment, and a decision. For the concept of spirituality to occur, the attributes needed to be present. If APNs applied this model to their practice, they recognized and incorporated spirituality into their practice. The authors emphasized the attributes so that the APN could define the presence of spirituality in the environment easily. Developing a simplified model made spirituality more feasible and promoted APNs to incorporate spirituality into practice and everyday life. The authors included the attributes of spirituality within the following model (Figure 1).

Figure 1: Model of Spirituality

13. Discussion

In conclusion, spirituality was a vital component to the APN, which ranged from practice to the personal life of the APN. Various definitions and perceptions from nursing and other disciplines convoluted the concept of spirituality. Due to the individualized nature of spirituality, the definition remained dynamic about the individual’s needs. The APN’s professional demands fluctuated constantly, but spirituality allowed for flexibility and change. As such, the APN’s incorporation of spirituality into practice enhanced both the professional and the personal aspects of the APN’s life.

Competing Interests

The authors have no competing interests with the work presented in this manuscript.