The concept of spirituality has become very popular within the international nursing literature. I would assert that spirituality has acquired a central, prominent place within the provision of global health care. Recently, within the UK, we have seen guidelines being published by the Scottish Office (Scottish Executive Health Department 2002) and recently the DoH (2003) have published their new guidelines NHS Chaplaincy Guidance: meeting the spiritual and religious needs of patients and Staff. This activity supports the assertion that ‘spirituality’ is fixed in the national and international healthcare agenda. Despite all this interest there still seems to be some uncertainty and unease with the seemingly blanket institution, and acceptance of what is meant by the term ‘spirituality’.

The meaning and language associated with ‘spirituality’ or precisely the ‘spiritual dimension’ are now, thankfully, being challenged. A host of academics, chaplains, and practitioners are recognizing that generalizations in this area cannot be made. The appropriateness of applying and transferring the concept of ‘spirituality’ directly in health care are being debated and contested at several levels, theoretically, educationally and clinically. It would appear that the usefulness and, to a lesser degree, the relevance of the term are being brought into question. An air of cautious optimism has been cultivated, and the necessity of evaluation and retrospective review are being encouraged so that this important area is managed effectively and efficiently for all parties. There is a realization that to continue on its present course, without questioning, refining and evaluating all the positive achievements to date would be like ‘steering a ship blindly and hazardously in thick fog’. Without these evaluative processes future developments associated with the ‘spiritual dimension’ may not be ‘totally’ inclusive, but exclusive in that the voice and views of some key stakeholders, for example, patients regarding spirituality may not be reflected or evident within contemporary health care. With these points in mind it was with some delight that I was invited to provide this commentary. I write not as a theologian nor as a biblical scholar but as a nurse who over several years has grappled with the mysterious and elusive, yet magnificent, concept of ‘spirituality’.

Firstly, I would like to thank Dr Anthony Bash for providing a critical and objective analysis of ‘spirituality’, it is timely and welcomed. The stance taken is refreshing and one must applaud Bash's bold, forthright manner in which he systematically questions the credibility of the term. Having said this, I do not feel that this philosophical, theological and biblical exegesis will be helpful in resolving some of the persistent questions raised by nurses who are attempting to address this concept within the practice arena. Therefore, I would like to draw attention and raise some questions in relation to ‘Spirituality: the emperor's new clothes?’

Bash's paper explores the concept of spirituality with reference to the Patients’ Charter (DoH 2001). While the Patients’ Charter was and still is one of the drivers that has led to the development of interest in spirituality within nursing in the UK this neglects to acknowledge some of the other complex drivers that have placed spirituality on the ‘international’ nursing agenda. Simply mapping spirituality against the Patients’ Charter or the UK political agenda means that there is a failure to acknowledge much of the ‘international’ activity. For example, the historical heritage, drives and innovations that have been instigated by nurses over several decades. Bash's contextualization of spirituality is very narrow, and is not totally exhaustive and therefore, perhaps not representative of the full picture.

There is a understanding that one of the motivators is the dissatisfaction with the institution of the medical model within nursing and medicine. Implicit in this view is a desire to establish holistic care. There is no real acknowledgement of the rich spiritual heritage that has been associated with and more recently divorced from nursing (Bradshaw 1994). Neither is there any appreciation of how nursing theory, models and education have sought to integrate the ‘spiritual dimension’ (Martsolf & Mickley 1998). In Bash's defence he does articulate that he writes as an ‘outsider’ to the nursing and medical profession and therefore he may not be as familiar or aware of all this activity that nurses have engaged with and undertaken.

Furthermore, the complexities and difficulties in articulating, and defining spirituality have been well documented and the debates have continued, and probably will do so indefinitely. Bash (2004, p. 15) does not really give any real credence to the achievements of nursing in instigating, leading the pioneering exploration of this subjective dimension of people's lives:

If we are claiming that there is an over-arching, inclusive description of spirituality that fits all – or even the majority of patients, and clients we are mistaken.

The nursing literature is full of theoretical and conceptual papers that strongly contest a ‘one size fits all approach to spirituality’. There is an acute awareness within nursing of the need to mange the area of spirituality sensitively and at an individual level.

The consensus within nursing is that there is no real authoritative definition (Narayanasamy 1991). Indeed Kellehear (2000, p. 149) proposes a need for ‘a certain level of definition’ but precision with regard to what constitutes spirituality ‘may be an ongoing source of debate’. I would plead that a certain level of definition has now been achieved and the continued desire at a achieving consensus with regard to what constitutes ‘spirituality’ is totally idealistic and something which should now be put to rest. One can transpose this argument onto some of the issues raised in Bash's paper. What Bash seems to be implying, either consciously or unconsciously, is that energies should perhaps be directed to listening to the voice of patients and users thus resolving some of the practical implications raised during academic discourse: a stance I fully sanction.

There is a suggestion that spirituality can be described and explained in health care by three categorizations: the non-theistic, the theistic and the via media. These categorizations of spirituality are not new in that other nurses and non-nurses have explored the discourses surrounding the language of ‘spirituality’ (Burnard 1988, Cawley 1997, Walter 2002, McSherry & Cash 2004). However, what has changed is the label attached to the differing categories. We are informed that there is no real ‘quarrel’ with the first two. The third ‘via media’ is the attention of some criticism. The main objection is this answer ‘engages with the transcendent but denies this has anything to do with ‘spirituality’. My concern is, just like ‘spirituality’ the word ‘transcendence’ has many interpretations, meanings and philosophical implications. There seems to be an inference that ‘transcendence’ is only associated or to be experienced through belief in a God or deity and indeed some higher power or through religious affiliation. This narrow ‘theistic’ viewpoint could be construed or interpreted as a judgment, in the sense that it implies that there is only one form of transcendence which can be associated with spirituality. Again the nursing and healthcare literature would suggest the contrary in that there may be different forms of transcendental need (Kellehear 2000).

The entire premise of the arguments presented appears to be based on the assessment of one or two nursing definitions of spirituality (Murray & Zentner 1989, Males & Boswell 1990).

Maintaining the theme of defining or elucidating what constitutes spirituality. There is an articulation that spirituality can be explored at two distinct levels, phenomenological –‘what is spiritual experience’ and scientific –‘what measurable effect that spiritual experience can have on a person.’ Bash argues that the former is more helpful in dealing and discussing matters of spirituality a view that I subscribe to and fully endorse. There is also indication that it is satisfactory to develop and refine assessment tools to establish views and feelings of peoples’ spirituality which represent ‘a construct of the personality’. I totally disagree with this judgement.

We are all entitled to our opinion and to be ‘provocative’. However, this provocation could itself be interpreted as a form of ‘reductionism’. By adopting such a ‘fundamentalist’ position there is a failure to view spirituality as an integrating and unifying force that permeates all aspects of the individual, something residing within all people (McSherry & Draper 1998). If one accepts this premise then logically it must follow that spirituality must be evidenced through personality, views, feelings and behaviours, which are manifestations of an individuals’‘spirituality’. In Bash's proposition there appears to be a separation or polarization of spirituality from the notion of being a ‘holistic being’.

If expressions are purely ‘constructs of personality’ then how are nurses to identify individuals who present with a spiritual need? One of the main principles of spiritual assessment is the use of verbal or non-verbal measures to identify whether a person is experiencing spiritual distress (Carson 1989, McSherry & Ross 2002). If these indicators are only to be perceived as expressions or constructs of personality then spirituality is purely a production of psychological processes. Kellehear (2000, p. 154) talks about the blending of dimensions suggesting this is characteristic of ‘good medicine’ which implies it may be difficult to differentiate the spiritual from the psychological.

As with any form of assessment tool there are inherent dangers, and Bash is right in urging caution in this area. While I agree that spirituality may not be measured or measurable per se, once cannot discard the contribution scientific investigation has made in advancing this area of practice. The ‘scientific’ and the ‘phenomenological’ both have an important role to play in developing insights into the concept of spirituality. However, to argue one is superior over the other is competitive and divisive (Kellehear 2000). It is probably far more beneficial to nursing that both the phenomenological and the scientific are seen as ‘heads’ and ‘tails’ of the same coin.

Bash indicates that spirituality may be located in the non-cognitive and unconscious part of our being. This implies that some individuals may not recognize, articulate, or even be aware of their own spirituality. I agree wholeheartedly with the statement ‘that there may well be as many spiritualities as there are people’. However this diversity should not prevent scientific enquiry. Indeed it is from ‘empiricism’ that the importance of spirituality has been established within the context of nursing.

Bash illustrates some of the diversity that exists within the Judeo-Christian tradition by highlighting the difficulties and discrepancies that exist within biblical traditions and interpretation regarding what constitutes ‘spirituality’. Bash concludes that there is a great deal of ambiguity and bewilderment. While this section provides some useful information regarding the usage, and antecedence of the word I do not think this will have any direct relevance for nursing practice nor will it assist in resolving some of the conceptual and theoretical muddle surrounding the term. However one useful observation is the realization of a need to involve all world religions or faith communities in the dialogue surrounding meaning and use of the word ‘spirituality’. Furthermore, Bash's account demonstrates that perhaps the next phase regarding the development of spirituality within the context of nursing is to explore its relevance with all religious communities. Until recently there has been a noticeable absence of this within the nursing arena. By widening, adopting a ‘culturally sensitive’ standpoint we may establish what spirituality means not just from a Judeo-Christian or Anglo-American perspective (Markham 1998) but for all faith communities.

Bash concludes by describing that the emperor is wearing new spiritual clothes. Through the arguments presented he establishes himself as the boy (observer) in the children's story, pointing out to the nursing community the errors of its ways, in terms of how it perceives spirituality.

While much of what Bash argues has a resonance of truth. He fails to acknowledge that nursing recognizes there is not an overarching, inclusive description of spirituality that fits all. Nursing is very conscious that spirituality is often defined and unique to the individual. Therefore Bash's position could be construed as ‘patronizing’ because while cautioning the nursing profession of the dangers of imposition, meaning projecting its own understanding of spirituality upon others who undoubtedly will have differing or even opposing views, does exactly the same. Furthermore, Bash, by adopting such an individualistic approach fails to give any credence to the fact that there may well be components of spirituality that are common to all people, and that spirituality may be culturally determined. The emperor (spirituality) is indeed wearing new spiritual clothes, which I argue will continue to be redesigned and refashioned as new insights are gained.


  1. Top of page
  2. References
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