Spirituality in Nursing and Health: A Historical Context, Challenges, and Way Forward.

This article aims to share the historical context of spirituality in nursing, meanings and expressions of spirituality, and different models of spirituality along with its significance in nursing education and practice. Several challenges and tools for the successful integration of spirituality in education and practice are also discussed.

Treatise on the influence of theism, transhumanism, and posthumanism on nursing and rehabilitation healthcare practice.

Reservations concerning the ontologies of theism, transhumanism and posthumanism compel an explicatory discourse on their influences on Nursing and rehabilitation healthcare. Key journals in Nursing and health sciences have recently devoted themed issues on intelligent machine technologies such as humanoid healthcare robots and other highly technological healthcare devices and practice initiatives. While the technological advance witnessed has been a cause for celebration, questions still remain that are focused on the epistemological concerns. The purpose of this article is to discuss theistic ontologies such as the Judeo-Christian, Shinto-Buddhist and Islamic religious belief systems on transhumanism and posthumanism in the assimilation of symbiotic technological beings in Nursing and rehabilitation healthcare practice. In view of the approaching technological singularity dominating arguments regarding the future of human beings, a treatise on Nursing and rehabilitation health care is positioned well within the realms of human care. Theism, transhumanism and posthumanism are directing discussions regarding human beings and healthcare processes. It is imperative that the beneficial effects of these discussions be acknowledged within the highly technological world of Nursing and rehabilitative healthcare.

Depression and suicidal ideation: association of physical, mental, social, and spiritual health status.

PURPOSE: The aim of this study was to determine if multidimensional (physical, mental, social, spiritual) health status could predict the presence of depressive symptoms and suicidal ideation in the general population. METHODS: We administered a population-based, cross-sectional survey to 1200 participants from the general Korean population. The survey included the 5 Health Status Questionnaire (5HSQ) for self-rated health status, Patient Health Questionnaire-9 (PHQ-9) for depression, and a question from the PHQ-9 for suicidal ideation. Multiple logistic regression was performed to estimate the association of significant socio-demographic factors and self-rated health status with depression and suicidal ideation. RESULTS: Physical health status was associated with depression in both men and women (men: adjusted odds ratio [aOR], 4.69; 95% confidence interval [CI] 2.44-9.00; women: aOR, 2.05; 95% CI 1.13-3.72) while spiritual health status only affected men (aOR, 5.50; 95% CI 2.59-11.65) and mental health status only women (aOR, 3.92; 95% CI 2.03-7.54). Social health status was associated with suicidal ideation in men (aOR, 4.87; 95% CI 2.74-19.99) while mental health status was associated with suicidal ideation in women (aOR, 4.31; 95% CI 1.90-9.76). CONCLUSION: Physical, mental, social, and spiritual self-rated health statuses were all found to be associated with an individual's predisposition to depression and suicidal ideation with notable differences between men and women.

Associations Among Exposure to Potentially Morally Injurious Experiences, Spiritual Injury, and Alcohol Use Among Combat Veterans.

Potentially morally injurious experiences (PMIEs) are events that may violate deeply held values or belief systems. Combat engagement places service members at a heightened risk for PMIE exposure. Exposure to PMIEs may elicit internal conflict between moral beliefs and experiences and, if unresolved, conflict may manifest as feelings of guilt, shame, and spiritual or existential crisis. Further, distress caused by these experiences may promote harmful behaviors (e.g., excessive alcohol use), which may serve as attempts to cope with PMIEs veterans have witnessed or participated in. The present study examined a sequential mediation model in which combat exposure was associated with alcohol use (i.e., alcohol consumption, dependence symptoms, and alcohol-related problems) via PMIE exposure and spiritual injury (e.g., alienation from and/or anger towards respective higher power) in a community sample of 380 recent-era combat veterans. Multiple-group sequential mediation was then used to examine whether the model fit similarly across men and women. Exposure to PMIEs and spiritual injury sequentially mediated the association between combat and alcohol; higher levels of PMIE exposure and spiritual injury were associated with increased alcohol use, R2 = .17, f2 = 0.07. The multiple-group model showed that these associations significantly varied between genders such that the mediation was only significant among men. The results indicated that PMIEs and spiritual injury were associated with increased alcohol use, but these associations differed as a function of gender. Future research is needed to refine our understanding of moral and spiritual injury and explore possible risk and protective factors.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Las Asociaciones entre la Exposición a Experiencias Potencialmente Dañinas Moralmente, Daño Espiritual, y el Uso de Alcohol Entre Combatientes Veteranos EXPOSICION, DAÑO ESPIRITUAL, Y USO DE ALCOHOL Las experiencias potencialmente dañinas moralmente (PMIEs en su sigla en inglés) son eventos que pueden transgredir los valores profundamente arraigados o los sistemas de creencias. La participación en combates posiciona a los miembros en servicio en un más alto riesgo de exposición a las PMIEs. La exposición a las PMIEs puede provocar conflictos internos entre las creencias morales y las experiencias y, si no son resueltos, el conflicto puede manifestarse como sentimientos de culpa, vergüenza, y crisis espirituales o existenciales. Además, el malestar causado por estas experiencias puede promover conductas dañinas (por ej., uso excesivo de alcohol), las cuales pueden servir como intentos para lidiar con las PMIEs que los veteranos han observado o en las que ellos han participado. En el presente estudio, en una muestra comunitaria de 380 combatientes veteranos de la era reciente, se examinó un modelo de mediación secuencial en el cual la exposición al combate fue asociada con el uso de alcohol (por ej., consumo de alcohol, síntomas de dependencia, y problemas asociados al alcohol) por medio de la exposición a las PMIEs y el daño espiritual (por ej., alienación y enojo contra una deidad). Una mediación secuencial de grupos múltiples fue luego usada para examinar si el modelo se ajustaba similarmente entre hombres y mujeres. La exposición a las PMIEs y el daño espiritual mediaron secuencialmente la asociación entre el combate y el alcohol; niveles más altos de exposición a las PMIEs y el daño espiritual se asociaron con mayor uso de alcohol, R2 = .17, f2 = 0.07. El modelo de grupos múltiples mostró que estas asociaciones variaron significativamente entre los géneros, de manera tal que la mediación fue solamente significativa entre los hombres. Los resultados indican que las PMIEs y el daño espiritual se encuentran asociados con un mayor uso de alcohol, pero estas asociaciones son diferentes dependiendo del género. Las futuras investigaciones son necesarias para mejorar nuestro entendimiento del daño moral y espiritual y explorar posibles factores de riesgo y protectores.

The Spiritual Needs of Community-Dwelling Older People Living With Early-Stage Dementia-A Qualitative Study.

PURPOSE: To explore the spiritual needs of community-dwelling older people living with early-stage dementia. DESIGN: A descriptive qualitative research design with purposive sampling was used. METHODS: Ten older people who were receiving home care services from a mental hospital in central Taiwan were recruited. In-depth semistructured interviews were conducted and content analysis was performed. FINDINGS: Four themes emerged that described the spiritual wishes and needs of older people with early-stage dementia: the wish to turn back time, the need to instill meaning into past experiences, the need to rely on faith-based strength, and the wish to have one's remaining life under control. The spiritual needs centered on a strong yearning to engage in a tug-of-war with time to reverse the impaired memory and independence. CONCLUSIONS: This study provides insights into the spiritual needs of older people with early-stage dementia. They struggled to maintain a balance between independence and dependence, build a sense of self and value, seek guidance and support from religious faith, and retain control over their lives. CLINICAL RELEVANCE: The findings can be expected to help caregivers improve care of older people with dementia by empowering older people to hold onto control in their lives and providing opportunities for them to connect with others for fulfilling their spiritual needs.

Differential Diagnosis between Anomalous Experiences and Dissociation Disorder Using the Dissociative Disorders Interview Schedule (DDIS).

BACKGROUND: It is important to understand the most diverse cultural aspects related to religiosity. Scientifically, it is important to understand religious manifestations and their relation to health, and to differentiate them from psychopathological manifestations. OBJECTIVE: To evaluate the mental health of a group of mediums and compare it with that of a control group from the same religious context who do not manifest mediumship, using the Dissociative Disorders Interview Schedule (DDIS). METHODS: This was a cross-sectional study, evaluating 47 mediums (Group 1) and comparing them with 22 non-medium volunteers from the same religious context (Group 2) using the DDIS questionnaire. All results were matched with historical data from patients with dissociative identity disorder (DID) who answered the DDIS. RESULTS: Scores obtained from the DDIS were similar in both groups. The number of positive symptoms was comparable in a wide range of analyzed areas, involving but not being restricted to somatization disorder, major depressive episode, borderline personality disorder, extrasensory/paranormal experiences, physical/sexual abuse and five dissociative disorders. There were considerable differences when we compared these results with historical data from patients with DID. CONCLUSION: In agreement with the extant literature, these results showed that mediumship can be considered a non-pathological form of dissociative phenomena.

Training for awareness of one's own spirituality: A key factor in overcoming barriers to the provision of spiritual care to advanced cancer patients by doctors and nurses.

OBJECTIVE: When patients feel spiritually supported by staff, we find increased use of hospice and reduced use of aggressive treatments at end of life, yet substantial barriers to staff spiritual care provision still exist. We aimed to study these barriers in a new cultural context and analyzed a new subgroup with "unrealized potential" for improved spiritual care provision: those who are positively inclined toward spiritual care yet do not themselves provide it. METHOD: We distributed the Religion and Spirituality in Cancer Care Study via the Middle East Cancer Consortium to physicians and nurses caring for advanced cancer patients. Survey items included how often spiritual care should be provided, how often respondents themselves provide it, and perceived barriers to spiritual care provision.ResultWe had 770 respondents (40% physicians, 60% nurses) from 14 Middle Eastern countries. The results showed that 82% of respondents think staff should provide spiritual care at least occasionally, but 44% provide spiritual care less often than they think they should. In multivariable analysis of respondents who valued spiritual care yet did not themselves provide it to their most recent patients, predictors included low personal sense of being spiritual (p < 0.001) and not having received training (p = 0.02; only 22% received training). How "developed" a country is negatively predicted spiritual care provision (p < 0.001). Self-perceived barriers were quite similar across cultures.Significance of resultsDespite relatively high levels of spiritual care provision, we see a gap between desirability and actual provision. Seeing oneself as not spiritual or only slightly spiritual is a key factor demonstrably associated with not providing spiritual care. Efforts to increase spiritual care provision should target those in favor of spiritual care provision, promoting training that helps participants consider their own spirituality and the role that it plays in their personal and professional lives.

Advance care planning for older people: The influence of ethnicity, religiosity, spirituality and health literacy.

In this discussion paper we consider the influence of ethnicity, religiosity, spirituality and health literacy on Advance Care Planning for older people. Older people from cultural and ethnic minorities have low access to palliative or end-of-life care and there is poor uptake of advance care planning by this group across a number of countries where advance care planning is promoted. For many, religiosity, spirituality and health literacy are significant factors that influence how they make end-of-life decisions. Health literacy issues have been identified as one of the main reasons for a communication gaps between physicians and their patients in discussing end-of-life care, where poor health literacy, particularly specific difficulty with written and oral communication often limits their understanding of clinical terms such as diagnoses and prognoses. This then contributes to health inequalities given it impacts on their ability to use their moral agency to make appropriate decisions about end-of-life care and complete their Advance Care Plans. Currently, strategies to promote advance care planning seem to overlook engagement with religious communities. Consequently, policy makers, nurses, medical professions, social workers and even educators continue to shape advance care planning programmes within the context of a medical model. The ethical principle of justice is a useful approach to responding to inequities and to promote older peoples' ability to enact moral agency in making such decisions.

Imaging & neuropsychological changes in brain with spiritual practice: A pilot study.

BACKGROUND & OBJECTIVES: Some studies have systematically assessed the effects of spiritual practice (SP) on the brain using combined neuropsychological testing and functional imaging. The objective of the present study was to compare imaging and neuropsychological changes in healthy individuals after SP and those with only physical exercise. METHODS: Healthy adult male volunteers, aged 25-45 yr were randomized into two groups. Group 1 (SP group) underwent the SP and group 2 (controls) did brisk walk for 30 min daily. Detailed neuropsychological evaluation, resting-state functional magnetic resonance imaging (fMRI) and brain 99mTc ethyl cysteinate dimer single-photon emission computed tomography (SPECT) were carried out for both groups before and three months after intervention. RESULTS: Post-intervention, resting state fMRI showed increased connections of left precuneus (in the posterior cingulate cortex area of default mode network) in group 1 and increased left frontal connections in group 2. The neuropsychological tests showed significant improvement in 'Speed of Processing' (Digit Symbol Test) in group 1 and in Focused Attention (Trail Making A) in group 2. The SPECT data in group 1 showed significant improvement in perfusion of the frontal areas, with relatively lesser improvement in parietal areas. Group 2 showed significant improvement in perfusion predominantly in parietal areas, as compared to frontal areas. In addition, significantly improved mood was reported by group 1 and not by group 2. INTERPRETATION & CONCLUSIONS: This pilot study shows important functional imaging and neuropsychological changes in the brain with SP.

Multidimensional needs of patients living and dying with heart failure in Kenya: a serial interview study.

BACKGROUND: Heart failure is an emerging challenge for Sub Saharan Africa. However, research on patients' needs and experiences of care is scarce with little evidence available to support and develop services. We aimed to explore the experiences of patients living and dying with heart failure in Kenya. METHODS: We purposively recruited 18 patients admitted with advanced heart failure at a rural district hospital in Kenya. We conducted serial in depth interviews with patients at 0, 3 and 6 months after recruitment, and conducted bereavement interviews with carers. Interviews were recorded, transcribed into English and analyzed using a thematic approach, assisted by Nvivo software package. RESULTS: Forty-four interviews were conducted. Patients experienced physical, psychosocial, spiritual and financial distress. They also had unmet needs for information about their illness, how it would affect them and how they could get better. Patients experience of and their interpretation of symptoms influenced health care seeking. Patients with acute symptoms sought care earlier than those with more gradual symptoms which tended to be normalised as part of daily life or assumed to be linked to common treatable conditions. Nearly all patients expected to be cured and were frustrated by a progressive illness poorly responsive to treatment. Accumulating costs was a barrier to continuity of care and caused tensions in social relationships. Patients valued information on the nature of their illness, prognosis, self-care, lifestyle changes and prevention strategies, but this was rarely available. CONCLUSIONS: This is the first in-depth study to explore the experiences of people living with advanced heart failure in Kenya. This study suggests that patients would benefit from holistic care, such as a palliative approach that is aimed at providing multidimensional symptom management. A palliative approach to services should be provided alongside chronic disease management aimed at primary prevention of risk factors, and early identification and initiation of disease modifying therapy. Further research is needed to determine best practice for integrating palliative care for people living and dying with heart failure.

Spiritual beliefs, practices, and needs at the end of life: Results from a New Zealand national hospice study.

OBJECTIVE: International studies have shown that patients want their spiritual needs attended to at the end of life. The present authors developed a project to investigate people's understanding of spirituality and spiritual care practices in New Zealand (NZ) hospices. METHOD: A mixed-methods approach included 52 semistructured interviews and a survey of 642 patients, family members, and staff from 25 (78%) of NZ's hospices. We employed a generic qualitative design and analysis to capture the experiences and understandings of participants' spirituality and spiritual care, while a cross-sectional survey yielded population level information. RESULTS: Our findings suggest that spirituality is broadly understood and considered important for all three of the populations studied. The patient and family populations had high spiritual needs that included a search for (1) meaning, (2) peace of mind, and (3) a degree of certainty in an uncertain world. The healthcare professionals in the hospices surveyed seldom explicitly met the needs of patients and families. Staff had spiritual needs, but organizational support was sometimes lacking in attending to these needs. SIGNIFICANCE OF RESULTS: As a result of our study, which was the first nationwide study in NZ to examine spirituality in hospice care, Hospice New Zealand has developed a spirituality professional development program. Given that spirituality was found to be important to the majority of our participants, it is hoped that the adoption of such an approach will impact on spiritual care for patients and families in NZ hospices.

Spiritual distress of military veterans at the end of life.

OBJECTIVE: Although combat experiences can have a profound impact on individuals' spirituality, there is a dearth of research in this area. Our recent study indicates that one unique spiritual need of veterans who are at the end of life is to resolve distress caused by combat-related events that conflict with their personal beliefs. This study sought to gain an understanding of chaplains' perspectives on this type of spiritual need, as well as the spiritual care that chaplains provide to help veterans ease this distress. METHOD: We individually interviewed five chaplains who have provided spiritual care to veterans at the end of life in a Veterans Administration hospital. The interviews were recorded, transcribed, and analyzed based on "grounded theory." RESULTS: Chaplains reported that they frequently encounter veterans at the end of life who are still suffering from thoughts or images of events that occurred during their military career. Although some veterans are hesitant to discuss their experiences, chaplains reported that they have had some success with helping the veterans to open up. Additionally, chaplains reported using both religious (e.g., confessing sins) and nonreligious approaches (e.g., recording military experience) to help veterans to heal. SIGNIFICANCE OF RESULTS: Our pilot study provides some insight into the spiritual distress that many military veterans may be experiencing, as well as methods that a chaplain can employ to help these veterans. Further studies are needed to confirm our findings and to examine the value of integrating the chaplain service into mental health care for veterans.

Dissociation: adjustment or distress? Dissociative phenomena, absorption and quality of life among Israeli women who practice channeling compared to women with similar traumatic history.

This study aimed to explore the relationship between traumatic history, dissociative phenomena, absorption and quality of life among a population of channelers, in comparison with a population of non-channelers with similar traumatic history. The study sample included 150 women. The measures included Traumatic Experiences Scale, Dissociative Experience Scale, Absorption Scale, Brief Symptom Inventory and Quality of Life (QOL) Assessment. Channelers presented significantly higher levels of dissociation, absorption and psychological health compared to the other group. Dissociation and absorption were trauma-related only among the comparison group. Hence, dissociation has different qualities among different people, and spiritual practice contributes to QOL.

Do existential variables mediate between religious-spiritual facets of functionality and psychological wellbeing.

Religiosity has been related to psychological wellbeing outcomes. Although this relationship is primarily based on studies of church attendance or prayer and wellbeing, more recent work has focused on the potential mechanisms that may mediate the religion-wellbeing findings. One of the major function of religion is finding of meaning of life and improving hope. Recent studies have indicated that hope and meaning of life are the potential variables mediate between religion and wellbeing. It was hypothesized that one pathway through which religiosity may exert its positive influence on psychological wellbeing is through finding meaning of life and improving hope. One study was conducted examining the relationships among spiritual experiences, hope, meaning of life and psychological wellbeing operationalized as satisfaction with life, positive affect and negative affect. The following research tools were used: Daily Spiritual Experiences Scale, Purpose in Life Test, Hearth Hope Index, Cantril Ladder, Positive and Negative Affect Schedule. Meaning of life and hope were noticed to mediate between spiritual experiences and satisfaction with life as well as between spiritual experiences and positive affect. Spiritual experiences were not related to negative affect. Both meaning of life and hope predicted negative affect. This study found meaning of life and hope to be an important factors in the religion-wellbeing relationship and related to positive psychological outcomes, including improved satisfaction with life and positive affect as well as reduced negative affect.

Study of the spiritual intelligence role in predicting university students' quality of life.

The aim of the study is to investigate the spiritual intelligence role in predicting Quchan University students' quality of life. In order to collect data, a sample of 143 students of Quechan University was selected randomly enrolled for 89-90 academic year. The instruments of the data collecting are World Health Organization Quality of Life (WHOQOL) and Spiritual Intelligence Questionnaire. For analyzing the data, the standard deviation, and Pearson's correlation coefficient in descriptive level, and in inferential level, the regression test was used. The results of the study show that the spiritual intelligence has effective role on predicting quality of life.

The Need to Widen the Concept of Health and to Include the Spiritual Dimension.

For many, the World Health Organization's (WHO) definition of health does not reflect their own understanding of health, because it lacks aspects such as spiritual wellbeing. Responding to these concerns, the WHO called in 2023 for a vision of health that integrates physical, mental, psychological, emotional, spiritual, and social wellbeing. To date, medical practitioners are often reluctant to consider spiritual aspects, because of a perceived lack of statistical evidence about the strength of relations. Research on this topic is emerging. A recent study among 800 young people living with HIV in Zimbabwe showed how study participants navigated three parallel, at times contradicting health systems (religious, traditional, medical). Conflicting approaches led to multifaceted dilemmas (= spiritual struggles), which were significantly related to poorer mental and physical health. This illustrates the need for inclusion of spiritual aspects for health and wellbeing in research, and of increased collaboration between all stakeholders in healthcare.

A phenomenological study of spontaneous spiritual and paranormal experiences in a 21st-century sample of normal people.

Summary.-This paper presents a phenomenological study using the methodology of Woodard's phenomenological and perceptual research. This method examines individuals' internal meanings during spontaneous spiritual and paranormal experiences, as described from their point of view. A group of 40 adults was phenomenologically interviewed after they responded to a newspaper announcement in New Hampshire asking for volunteers who had had spiritual and paranormal experiences. Using the method, Six Individual Situated Structures and a General Structure were identified and examined. Nine major themes were explicated during the participants' spontaneous experiencing: unexpectedness, contrariness to belief, certainty, contradictory experiencing, language as a barrier to expression, external influences, internal dialogue, evil as separateness, and some social psychological influences. Several themes observed in hypnotic experiencing, such as the characteristics of the Adequate Personality in Perceptual Psychology, are interpreted and discussed. This research illustrates how subjective experience can be adequately researched in a qualitative manner outside the confines of the laboratory setting. Limitations of the study and suggestions for further research are given.

Association of strength of religious adherence with attitudes regarding glaucoma or ocular hypertension.

BACKGROUND: To evaluate the impact of religious adherence on a patient's outlook on disease in a glaucoma population. METHODS: A prospective survey analysis of patients with open-angle glaucoma or ocular hypertension evaluating self-reported global religious adherence, adherence to specific basic activities and knowledge of faith ('maturity') and 'comfort' (ability to cope, attitude toward glaucoma, motivation to take medication and God's concern). This specific analysis was limited to self-professed Christians. RESULTS: 248 patients were included and religious adherence was correlated to religious activity and knowledge (p < 0.0001). Patients who scored as adherent on at least 1 of 4 maturity questions had greater benefit than less adherent patients from each of the 5 comfort questions (p < 0.0001). We found an increased statistical separation on each of the 5 comfort questions between religiously adherent and less adherent individuals for patients who scored as adherent on any 2 (n = 40), 3 (n = 50) or all 4 (n = 57) of the maturity questions (p < 0.001). CONCLUSIONS: This study suggests, at least for the Christian faith, that religious patients are subjectively more prone to cope with treatment and that religiosity increases the self-confidence, and possibly the quality of life, of patients with glaucoma or ocular hypertension. Whether this necessarily translates into better glaucoma practices remains to be demonstrated by further studies.

We fall down: the African American experience of coping with the homicide of a loved one.

Rates of homicide among African Americans are much higher than those of other racial or ethnic groups. Research has demonstrated that homicide can be psychologically debilitating for surviving family members. Yet, exploring the experiences of homicide victims' surviving loved ones has received little attention. This study examined the coping strategies of African American survivors of homicide. Qualitative interviews were conducted with 8 African American family members (ages 18-82) of homicide victims. Survivors were recruited from the Massachusetts Office of Victim Services and from homicide survivor support, school, and community groups throughout the New England area. Interviews were conducted using open-ended questions derived from coping, support network, grief, and bereavement literatures. Results indicate that the primary coping strategies utilized by African American survivors of homicide victims are spiritual coping and meaning making, maintaining a connection to the deceased, collective coping and caring for others, and concealment. Implications for research and practice are discussed.

Hospitalized Patients' Perspectives on Spiritual Assessment: A Mixed Methods Study.

BACKGROUND: Research shows that spirituality is important, but patients report that nurses rarely address spiritual issues, and research from the patient viewpoint is limited. AIM: The research objective was to gain knowledge about hospitalized patients' perspectives on spiritual assessment by nurses. METHOD: This is a mixed methods exploratory study reporting on quantitative/qualitative aspects of the patient perspective. Norwegian nurses in an acute care hospital distributed a 21-item spiritual assessment survey to patients they felt would not be burdened by completing it. Patients' demographic data were not identifiable, survey packets were returned anonymously via hospital mail by 157 hospitalized patients. Each survey item and several variables on the demographic sheet had space for comments. Quantitative analysis used SPSS 21, qualitative data were thematically analyzed. FINDINGS: Statistically significant correlations were found with all survey items. Hospitalized people reported high comfort with spiritual assessment by nurses. Qualitative findings revealed that patients had differing views on if, when, and how nurses should ask spiritual questions of them. CONCLUSIONS: It is important to identify patients' perspectives in order to provide patient-centered holistic care. Understanding patient views will enlighten nurses and may promote spiritual care and improve patient health outcomes.