An Evolutionary Concept Analysis of Spiritual Competence in Nursing. — TEI-tagged view

Nadeen Sami AlshakhshirpersName, Anne L. ErsigpersName, Earlise WardpersName, Verna L. Hendricks‐FergusonpersName, Kathleen E. MontgomerypersName (2024date). “An Evolutionary Concept Analysis of Spiritual Competence in Nursing..” Journal of Advanced Nursingtitle·j.

Object of study — spiritual competenceterm·dom in nursingterm·key

Research question — what spiritual competenceterm·dom in nursingterm·key is, and what makes nurses able and willing to give spiritual careterm·key

Contribution — a definition of spiritual competenceterm·dom in nursingterm·key as a dynamic process started by spiritual awarenessterm·dom, with five attributes, three antecedentsterm·mth and personal and professional consequencesterm·mth

Full text — tagged

An Evolutionary Concept Analysis of Spiritual Competenceterm·dom in Nursingterm·key.

Abstract Clarify the concept of spiritual competenceterm·dom in the context of nursingterm·key through evidence‐based extraction of attributes, antecedentsterm·mth and consequencesterm·mth.

Concept analysis.

Rodgers' evolutionary method of concept analysis guided this analysis, and we followed the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses extension for Scoping Reviews.

An analysis of 45 studies clarified the concept of spiritual competenceterm·dom in the context of nursingterm·key. Spiritual competenceterm·dom in nursingterm·key is a dynamic process that, once initiated by nurses' spiritual awarenessterm·dom, promotes their spiritual well‐beingterm·dom, their spiritual knowledge and skillsterm·dom and their sense of spiritual‐care self‐efficacyterm·dom.

A comprehensive understanding and clear conceptual definition of the concept of spiritual competenceterm·dom in nursingterm·key will enable researchers to overcome barriers and foster nurses' development of spiritual competenceterm·dom to provide spiritual careterm·key in nursingterm·key.

The clarified concept of spiritual competenceterm·dom in nursingterm·key can help to shape education and clinical‐training programs for nurses in a way that supports their ability to provide spiritual careterm·key and promote patient well‐being and positive health outcomes.

No patient or public contribution was essential to the conduct of this research.

Keywords: competenceterm·key, nurse, nursingterm·key, spiritual careterm·key, spiritual competenceterm·dom, spiritualityterm·dom What does this paper contribute to the wider global clinical community? ○ Clarification of the concept of spiritual competenceterm·dom in nursingterm·key to guide future research, education and clinical practice. ○ Acknowledgment of the essential role of spiritual competenceterm·dom in nurses' ability to promote patient well‐being.

Background Spiritualityterm·dom is a complex construct that is related to all dimensions of being. It is defined as “a dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning, purpose, and transcendence and experience relationship to self, family, others, community, society, nature, and the significant or sacred’’ (Puchalski et al. 2009 , p.11). The construct of spiritualityterm·dom has been recognised as an essential aspect of human health and illness for decades. Florence Nightingale, the founder of modern nursingterm·key, described how spiritualityterm·dom in ill patients led to positive patient outcomes ranging from physical healing to states of transcendence (Burkhardt 1998 ).

Several professional nursingterm·key organisations have shared tenets about the importance of integrating spiritualityterm·dom into whole‐person care. The American Holistic Nurses Association ( 2016 ) have proposed that spiritual integration should be an essential part of holistic person‐centred care. The Hospice and Palliative Nurses Association ( 2022 ) provides guidelines for the integration of spiritual careterm·key into nursingterm·key practices devoted specifically to end‐of‐life contexts. A tenet of the American Association of Colleges of Nursingterm·key ( 2021 ) is that spiritual integration is an essential competency that should be cultivated in nursingterm·key education.

Spiritualityterm·dom is associated with positive health outcomes. For example, it has been shown to improve people's mental health and overall quality of life while specifically reducing people's mortality risk, depressive symptoms, suicidal behaviours and engagement in risky behaviours (e.g., smoking and substance use; Balboni et al. 2022 ; Puchalski et al. 2009 ). These positive outcomes have been observed among different age groups across the lifespan (Balboni et al. 2022 ). Because nurses are responsible for promoting the health and well‐being of their patients, and because spiritualityterm·dom is key to this task, nurses must learn how to show spiritual support to patients, particularly in times of need and distress. In ascertaining how nurses fulfil their spiritual role, it is critical to first assess their ability and willingness to perform the role.

Spiritual careterm·key is also recognised as being essential to holistic nursingterm·key care (Ramezani et al. 2013 ). Spiritual careterm·key must not only relieve spiritual distress in patients but also enable them to self‐heal through spiritual means (Puchalski et al. 2009 ). Ramezani et al. ( 2013 ) identified the following seven characteristics that spiritually competent nurses possess: (1) a healing presence, (2) a therapeutic use of the self, (3) intuitive sense, (4) an ability to explore spiritual perspectives, (5) patient‐centredness, (6) an ability to perform meaning‐centred therapeutic intervention and (7) an ability to foster a spiritually nurturing environment. Nurses can be spiritually present for patients in times of illness, loss and other forms of suffering (Baldacchino 2006 ; Ramezani et al. 2013 ). Spiritual careterm·key in nursingterm·key contexts has been found to be reciprocal in the sense that both the nurse and the patient can benefit from it (Bangcola 2022 ). For example, in one study, patients who received spiritual careterm·key from nurses reported experiencing improvement in their spiritual well‐beingterm·dom, spiritual healing, psychological adaptation and overall satisfaction and the nurses shared perceptions of experiencing increased spiritual awarenessterm·dom and job satisfaction (Ramezani et al. 2013 ). Despite the vast literature detailing the positive outcomes of spiritualityterm·dom and spiritual careterm·key for both nurses and patients, there are obstacles that may hinder nurses' realisation of the aforementioned positive outcomes. Some of these obstacles include heavy workloads, limited knowledge of spiritualityterm·dom and feelings of incompetence with respect to the provision of spiritual careterm·key (Babamohamadi et al. 2022 ; Baldacchino 2006 ; Özakar Akça, Gülnar, and Özveren 2022 ).

Competenceterm·key also applies to other aspects of nursingterm·key such as physical assessment and medication administration. Competent nurses are those who (1) possess sufficient knowledge; (2) have mastered specific patient centred focused skills; (3) use professional judgement; (4) respect and adhere to professional standards; (5) maintain positive interpersonal relationships; (6) use knowledge and skills in situationally appropriate ways and (7) evaluate success according to rigorous outcome measurements (Church 2016 ). These characteristics of competenceterm·key in nursingterm·key rely heavily on nurses' therapeutic use of knowledge, skills and the self. Because competenceterm·key in nursingterm·key involves the application of particular practices tailored to particular contexts, nurses must learn how to apply spiritual practices to contexts requiring some form of spiritual careterm·key (Church 2016 ; Damsma‐Bakker and van Leeuwen 2021 ; Ramezani et al. 2013 ). Put simply, to provide competent spiritual careterm·key, nurses must be spiritually competent (Southard et al. 2020 ; Ramezani et al. 2013 ). Despite widespread use of the term in the literature, a clear definition or conceptual analysisterm·mth of spiritual competenceterm·dom in nursingterm·key does not exist. Researchers have created three conceptual models of nurse‐based competenceterm·key in ‘spiritual careterm·key’ as a way to improve the education and clinical training of nurses with respect to spiritual careterm·key (Attard, Ross, and Weeks 2019 ; Campinha‐Bacote 1995 ; Cao et al. 2020 ). Although these conceptual models strengthen our understanding of spiritual‐care competenceterm·dom , they do not explicitly address spiritual competenceterm·dom .

Many limitations in providing spiritual careterm·key to patients have been identified in the literature. One of the most important is nurses' hesitancy to provide spiritual careterm·key to patients (Babamohamadi et al. 2022 ; Baldacchino 2006 ). Our understanding of the influence of ability and willingness on nurses' provision of spiritual careterm·key is limited. It stands to reason, however, that for nurses to be able and willing to provide good spiritual careterm·key, they must possess a reasonable degree of spiritual competenceterm·dom. Because there is still a lack of clarity regarding the possible factors influencing nurses' ability and willingness to provide spiritual careterm·key, more research is needed to clarify the concept of spiritual competenceterm·dom in nursingterm·key.

Aim We aimed to perform a concept analysis that clarifies the concept of spiritual competenceterm·dom in nursingterm·key through evidence‐based identification of attributes, antecedentsterm·mth and consequencesterm·mth and that thus improves the education and clinical training of nurses with respect to spiritual careterm·key.

Methods Rodgers' ( 1989 ) evolutionary concept analysis method guided this concept analysis. Concept analyses aim to clarify the definition of concepts in specific contexts. Rodgers' evolutionary method has three iterative phases. In the initial phase, the researcher identifies three critical factors: the concept selected for analysis, the context of the concept and the literature supportive of the proposed concept analysis. In the second phase, in which core analysis takes place, the researcher identifies three further factors: the concept's related and surrogate termsterm·mth; the concept's attributes, antecedentsterm·mth and consequencesterm·mth and examples of the concept's use. In the third and final phase, known as the ‘further analysis’ phase, the researcher identifies implications that the findings from the second stage may have for further development of the concept in research (Rodgers, 1989 , as cited in Tofthagen and Fagerstrøm ( 2010 )). For reporting the findings, we followed The Preferred Reporting Items for Systematic Reviews and Meta‐Analyses extension for Scoping Reviews (PRISMA‐ScR) checklist (Tricco et al. 2018 ).

Data Sources A search strategy was developed by the co‐authors in conjunction with an experienced medical librarian. The following online databases were searched: CINAHL, PsycINFO, PubMed, Academic Search Premier, Scopus and SocINDEX databases for the following terms: spiritual (OR) religion (OR) faith (OR) belief system (OR) religious beliefs (AND) nurse (OR) physician (OR) clinician (OR) doctor (OR) social worker (OR) healthcare worker (AND) knowledge (OR) attitude (OR) competency (OR) belief (OR) perception (OR) awareness . All database searches were limited to English‐language articles. There was no limit on publication dates for this search. We followed three inclusion criteria: (1) the study populations needed to include nurses or nursingterm·key students, (2) the study itself needed to focus on spiritual competenceterm·dom and (3) the study needed to include original empirical research.

In selecting and reviewing the articles identified through our literature search, we relied on Covidence systematic review software (Veritas Health Innovation 2023 ) to (1) screen titles and abstracts in order to select those articles most relevant to the concept of interest, (2) perform full‐text reviews of the relevant articles to ensure that the final set of articles truly focused on the concept and (3) extract data from the final set of included articles.

The results of the literature search are presented in Figure 1 using a Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) diagram. The initial search returned 3791 articles, of which 18 were duplicates. We reviewed the titles and abstracts of 3773 articles to determine their relevance to the concept of spiritual competenceterm·dom in nursingterm·key. We eliminated 3700 articles that failed to reference the concept or population and context of interest. We reviewed the full text of the remaining 73 articles: 45 of them, published between 2006 and 2023, met the inclusion criteria and were included in the analysis.

PRISMA flow diagram of the data‐collection process.

Data Extraction and Analysis The final sample of 45 articles consisted of 40 quantitative, 2 qualitative and 3 mixed‐methods studies. Most of the quantitative studies were descriptive cross‐sectional studies. All studies were in the nursingterm·key discipline and had been conducted in academic or clinical settings. Each article's data were extracted in Covidence and exported to an Excel data sheet for data management. Extracted data included surrogate and related termsterm·mth, the definition of ‘spiritual competenceterm·dom’ (if provided), study purpose, a summary of the methods section and the attributes, antecedentsterm·mth and consequencesterm·mth of spiritual competenceterm·dom identified in the article. We closely examined the identified attributes, antecedentsterm·mth and consequencesterm·mth of spiritual competenceterm·dom in nursingterm·key to determine which were essential. Figure 2 presents the identified attributes, antecedentsterm·mth and consequencesterm·mth of spiritual competenceterm·dom from the relevant articles.

Attributes, antecedentsterm·mth and consequencesterm·mth of spiritual competenceterm·dom in nursingterm·key.

Results Surrogate and Related Termsterm·mth Surrogate termsterm·mth are technical synonyms: words or phrases that have the same meaning as a selected word or phrase (Tofthagen and Fagerstrøm 2010 ). In the present study, our selected term is ‘spiritual competenceterm·dom’. Multiple articles use ‘spiritual‐care competenceterm·dom’ as a surrogate termterm·mth for ‘spiritual competenceterm·dom’. However, in meaning, the two terms differ from each other. The term ‘spiritual‐care competenceterm·dom’ refers to nurses' ability to provide spiritual careterm·key (van Leeuwen and Cusveller 2004 ; van Leeuwen et al. 2009 ). To operationalise the concept of spiritual‐care competenceterm·dom, researchers in nursingterm·key have used the Spiritual Care Competence Scaleterm·mth (SCCS) (van Leeuwen et al. 2009 ), which is based on a competency profile that can guide the design of education and training programs targeting spiritual careterm·key in the nursingterm·key profession (van Leeuwen and Cusveller 2004 ). The SCCS assesses six competencies: (1) assessment and implementation of spiritual careterm·key; (2) professionalisation and improvement of the quality of spiritual careterm·key; (3) personal support and patient counselling; (4) referral to spiritual professionals; (5) attitudes toward patient spiritualityterm·dom and (6) communication (van Leeuwen et al. 2009 ).

Because the concept of spiritual‐care competenceterm·dom focuses on care, it does not typically emphasise spiritual competenceterm·dom. This distinction is subtle yet critical, as nurses can be somewhat competent providers of spiritual careterm·key even though they possess only some degree of spiritual knowledge. In short, the concept of spiritual competenceterm·dom is broader in scope than the concept of spiritual‐care competenceterm·dom.

Related termsterm·mth refer to concepts that are associated with—rather than synonymous or nearly synonymous with—the selected concept (Tofthagen and Fagerstrøm 2010 ). Terms related to spiritual competenceterm·dom in the field of nursingterm·key include “spiritualityterm·dom” (Alshehry 2018 ; Kalkim, Sagkal Midilli, and Daghan 2018 ); “cultural competenceterm·key” (Abu‐Snieneh and Abdelaziz 2022 ; Bangcola 2022 ); “ethical competenceterm·key” (Baldacchino 2006 ; Ebrahimi et al. 2017 ); “spiritual intelligence” (Ahmadi et al. 2021 ) and “attitudes toward death” (Li et al. 2021 ). Though they are important to know, these and other related termsterm·mth are not critical to the specific focus of the present study.

Definitions Among the final 45 articles included in this concept analysis, 13 defined spiritual competenceterm·dom or spiritual‐care competenceterm·dom in nursingterm·key. We extracted these definitions verbatim from each article to preserve their meaning (see Table 1 ). Similarities in definitions included that nurses' spiritual competenceterm·dom (or nurses' spiritual‐care competenceterm·dom) requires knowledge of spiritualityterm·dom and an ability to provide spiritual careterm·key (Ahmadi et al. 2021 ; Alshehry 2018 ; Babamohamadi et al. 2022 ; Chen et al. 2020 ; Ebrahimi et al. 2017 ; Heidari, Afzoon, and Heidari 2022 ; Hsieh et al. 2020 ; Kang et al. 2021 ; Li et al. 2021 ; Özakar Akça, Gülnar, and Özveren 2022 ; Ross et al. 2016 ; Southard et al. 2020 ; Wang et al. 2022 ).

Definitions of ‘spiritual care competenceterm·dom’ and ‘spiritual competenceterm·dom’ in nursingterm·key.

Attributes Attributes are essential characteristics that define a concept (Tofthagen and Fagerstrøm 2010 ). We identified the following five attributes of spiritual competenceterm·dom in nursingterm·key: (1) spiritual awarenessterm·dom (Adib‐Hajbaghery, Zehtabchi, and Fini 2017 ; Ahmadi et al. 2021 ; Baldacchino 2006 ; Damsma‐Bakker and van Leeuwen 2021 ; Guo et al. 2023 ; Irmak and Sagkal Midilli 2021 ; Kalkim, Sagkal Midilli, and Daghan 2018 ; Ross et al. 2022 , 2016 ; Semerci et al. 2021 ; Sezer and Ozturk Eyimaya 2022 ; van der Vis‐Sietsma, de Man‐van Ginkel, and van Leeuwen 2019 ; Zhang et al. 2023 ); (2) spiritual well‐beingterm·dom (Azarsa et al. 2015 ; Bangcola 2022 ; Jafari and Fallahi‐Khoshknab 2021 ; Özakar Akça, Gülnar, and Özveren 2022 ; Ross et al. 2016 , 2018 , 2014 ); (3) spiritual knowledge and skillsterm·dom (Babamohamadi et al. 2022 ; Connors, Good, and Gollery 2017 ; Ebrahimi et al. 2017 ; Guo et al. 2023 ; Heidari, Afzoon, and Heidari 2022 ; Hellman, Williams, and Hurley 2015 ; Irmak and Sagkal Midilli 2021 ; Kalkim, Sagkal Midilli, and Daghan 2018 ; Kang et al. 2021 ; Karaman and Sagkal Midilli 2022 ; Özakar Akça, Gülnar, and Özveren 2022 ; Petersen et al. 2017 ; Petersen and Schiltz 2020 ; Wang et al. 2022 ; Zhang et al. 2023 ); (4) spiritual‐care self‐efficacyterm·dom (Azarsa et al. 2015 ; Cheng et al. 2021 ; Guo et al. 2021 ; Heidari, Afzoon, and Heidari 2022 ; Kalkim, Sagkal Midilli, and Daghan 2018 ; Petersen et al. 2017 ; Sezer and Ozturk Eyimaya 2022 ; Shamsi, Khoshnood, and Farokhzadian 2022 ; Southard et al. 2020 ; Wang et al. 2022 ; Zhang‐Yi et al. 2021 ; Zhang et al. 2023 ) and (5) dynamismterm·dom (Babamohamadi et al. 2022 ; Kalkim, Sagkal Midilli, and Daghan 2018 ; Kang et al. 2021 ; Petersen and Schiltz 2020 ; Ross et al. 2022 ; Vogel and Schep‐Akkerman 2018 ). In summary, we propose that spiritual competenceterm·dom in nursingterm·key is a dynamic process that nurses must initiate by cultivating their own spiritual awarenessterm·dom. Once cultivated, this awareness can enable nurses to acquire spiritual well‐beingterm·dom for themselves as well as the knowledge, skills and sense of self‐efficacy that are critical in their provision of spiritual careterm·key. The way in which this process unfolds is unique for each nurse.

Spiritual awarenessterm·dom is required to initiate the dynamic process of spiritual competenceterm·dom. Spiritual awarenessterm·dom related to nursingterm·key typically evolves in the context of nurses' professional experiences (Ross et al. 2016 ; Sezer and Ozturk Eyimaya 2022 ; van der Vis‐Sietsma, de Man‐van Ginkel, and van Leeuwen 2019 ; Zhang et al. 2023 ). Spiritual awarenessterm·dom is a critical initiating factor because it enables nurses to understand, accept and respect their own spiritual beliefs, the spiritual beliefs of others and the differences among them. By appreciating these differences, nurses can begin to holistically assess patients' spiritual needs (Ahmadi et al. 2021 ; Baldacchino 2006 ; Damsma‐Bakker and van Leeuwen 2021 ; Guo et al. 2023 ). Researchers have found that spiritualityterm·dom‐related assignments in nursingterm·key‐education programs can improve students' spiritual awarenessterm·dom and help them view patients from a more holistic perspective (van der Vis‐Sietsma, de Man‐van Ginkel, and van Leeuwen 2019 ).

Nurses who possess spiritual well‐beingterm·dom experience satisfaction (Azarsa et al. 2015 ; Jafari and Fallahi‐Khoshknab 2021 ; Ross et al. 2016 , 2018 ) are in a better position to recognise and meet the spiritual‐care needs of patients (Bangcola 2022 ; Özakar Akça, Gülnar, and Özveren 2022 ; Ross et al. 2014 ). Jafari and Fallahi‐Khoshknab ( 2021 ) found that nurses with higher levels of spiritual well‐beingterm·dom exhibit higher levels of spiritual competenceterm·dom. Similarly, Azarsa et al. ( 2015 ) found that nurses' spiritual well‐beingterm·dom bolsters their spiritual awarenessterm·dom and professional experience in ways that improve the nurses' ability to recognise patients' spiritual careterm·key needs.

Nurses acquire the ‘spiritual knowledge and skillsterm·dom’ required for spiritual competenceterm·dom through education and clinical training that address spiritualityterm·dom and spiritual careterm·key (Irmak and Sagkal Midilli 2021 ; Kang et al. 2021 ; Özakar Akça, Gülnar, and Özveren 2022 ; Petersen and Schiltz 2020 ; Zhang et al. 2023 ). When equipped with spiritual knowledge and skillsterm·dom, nurses can effectively harness their spiritual awarenessterm·dom and well‐being to provide spiritual careterm·key tailored to patients' spiritual needs (Babamohamadi et al. 2022 ; Heidari, Afzoon, and Heidari 2022 ; Hellman, Williams, and Hurley 2015 ; Kalkim, Sagkal Midilli, and Daghan 2018 ; Wang et al. 2022 ). Connors, Good, and Gollery ( 2017 ) found that innovative teaching strategies such as spiritual assessment and spiritual careterm·key simulation can improve nursingterm·key students' knowledge and skills necessary for listening to patients, assessing their spiritual needs and providing quality spiritual careterm·key.

Spiritual‐care self‐efficacyterm·dom refers to nurses' belief that they are competent providers of spiritual careterm·key (Shamsi, Khoshnood, and Farokhzadian 2022 ; Southard et al. 2020 ; Wang et al. 2022 ; Zhang‐Yi et al. 2021 ). This belief can be thought of as confidence in providing spiritual careterm·key and has been found to be positively associated with trust between nurses and patients (Kalkim, Sagkal Midilli, and Daghan 2018 ; Petersen et al. 2017 ; Sezer and Ozturk Eyimaya 2022 ; Zhang et al. 2023 ). The more nurses believe in their ability to provide spiritual careterm·key, the more they practice it, which further improves their ability to provide spiritual careterm·key (Azarsa et al. 2015 ; Cheng et al. 2021 ; Guo et al. 2021 ; Heidari, Afzoon, and Heidari 2022 ). Nursingterm·key students who are more confident in their ability to provide spiritual careterm·key are better able to provide it and connect with patients (Ross et al. 2014 ).

Spiritual competenceterm·dom in nursingterm·key is a dynamic process even though only one of the reviewed studies supports this characterisation (Ross et al. 2022 ). Evidence of dynamismterm·dom is demonstrated through the cumulative findings of all the studies reviewed for this analysis. Reviewed studies consistently report that nurses' spiritual competenceterm·dom evolves over time. It has neither a defined endpoint nor a universally applied path. Rather, the development and evolution of the attributes of spiritual competenceterm·dom in nursingterm·key follow the highly indeterminate fluctuations of nurses' professional careers and the contexts in which their careers play out.

Antecedentsterm·mth Antecedentsterm·mth are events that occur before a concept and contribute to the occurrence of the concept (Tofthagen and Fagerstrøm 2010 ). We identified the following three antecedentsterm·mth of spiritual competenceterm·dom in nursingterm·key: (1) nurses' willingness to learn about spiritualityterm·dom (Guo et al. 2023 ; Kalkim, Sagkal Midilli, and Daghan 2018 ; Karaman and Sagkal Midilli 2022 ; Li et al. 2022 ; Sezer and Ozturk Eyimaya 2022 ); (2) nurses' engagement in spiritual education (Connors, Good, and Gollery 2017 ; Damsma‐Bakker and van Leeuwen 2021 ; Petersen et al. 2017 ; Petersen and Schiltz 2020 ; Ross et al. 2022 ; Shamsi, Khoshnood, and Farokhzadian 2022 ; Southard et al. 2020 ; van der Vis‐Sietsma, de Man‐van Ginkel, and van Leeuwen 2019 ; van Leeuwen et al. 2008 ) and (3) nurses' engagement in spiritual‐care training (Damsma‐Bakker and van Leeuwen 2021 ; Petersen et al. 2017 ; Shamsi, Khoshnood, and Farokhzadian 2022 ; van der Vis‐Sietsma, de Man‐van Ginkel, and van Leeuwen 2019 ). The three antecedentsterm·mth occur sequentially: willingness precedes and promotes engagement in spiritual education, which itself precedes and promotes engagement in spiritual‐care training.

Willingness to learn about spiritualityterm·dom precedes and promotes nurses' spiritual competenceterm·dom (Guo et al. 2023 ; Kalkim, Sagkal Midilli, and Daghan 2018 ). For instance, the more open a nurse is to receiving education and training related to spiritualityterm·dom and spiritual careterm·key, the more spiritually competent the nurse tends to be (Karaman and Sagkal Midilli 2022 ). The more enthusiasm or desire there is in a nurse's willingness to learn about spiritualityterm·dom and spiritual careterm·key, the better able the nurse will be to grasp relevant complex concepts (Li et al. 2022 ; Sezer and Ozturk Eyimaya 2022 ). Willingness to learn about spiritualityterm·dom may nurture positive attitudes toward spiritual careterm·key, contributing to nurses' spiritual competenceterm·dom (Guo et al. 2023 ; Karaman and Sagkal Midilli 2022 ).

Multiple studies have examined how spiritual education can shape spiritual competenceterm·dom in nursingterm·key (Petersen and Schiltz 2020 ; Ross et al. 2022 ; Shamsi, Khoshnood, and Farokhzadian 2022 ; Southard et al. 2020 ; van der Vis‐Sietsma, de Man‐van Ginkel, and van Leeuwen 2019 ; van Leeuwen et al. 2008 ). Spiritual education for nurses can strengthen their theoretical understanding of both spiritualityterm·dom (Petersen et al. 2017 ; Ross et al. 2022 ; Southard et al. 2020 ; van Leeuwen et al. 2008 ) and spiritual careterm·key (Petersen et al. 2017 ; Ross et al. 2022 ; Shamsi, Khoshnood, and Farokhzadian 2022 ; van der Vis‐Sietsma, de Man‐van Ginkel, and van Leeuwen 2019 ). Innovative teaching methodsterm·dom can be used to improve nursingterm·key students' spiritual competenceterm·dom. For instance, Connors, Good, and Gollery ( 2017 ) found that students' exposure to a spiritual education may significantly improve the confidence with which they view their spiritual‐care abilities. In another study, Damsma‐Bakker and van Leeuwen ( 2021 ) implemented an online spiritual‐care competency tool for nursingterm·key students that enhanced their awareness of the importance of spiritual careterm·key in nursingterm·key.

Spiritual‐care training, which nursingterm·key students or nurses receive in clinical settings after they have completed some form of spiritual education, focuses on the practical skills that these individuals will need if they are to provide high‐quality spiritual careterm·key (Petersen et al. 2017 ; Shamsi, Khoshnood, and Farokhzadian 2022 ). Nursingterm·key students and nurses who receive spiritual‐care training can move beyond any fear they might have regarding their ability to provide quality spiritual careterm·key (Damsma‐Bakker and van Leeuwen 2021 ; van der Vis‐Sietsma, de Man‐van Ginkel, and van Leeuwen 2019 ). Spiritual‐care training can help career nurses develop spiritual competency (Shamsi, Khoshnood, and Farokhzadian 2022 ). For example, a nursingterm·key‐education program that balances the theoretical component of spiritual learning with supervised training activities involving a real patient alerted nursingterm·key students to the benefits of spiritual careterm·key and improved their spiritual competenceterm·dom, which included the ability to communicate with patients about spiritual matters (van der Vis‐Sietsma, de Man‐van Ginkel, and van Leeuwen 2019 ).

Consequencesterm·mth Consequencesterm·mth are events that can occur as a result or outcome of a concept (Tofthagen and Fagerstrøm 2010 ). The consequencesterm·mth of spiritual competenceterm·dom in nursingterm·key can be personal or professional. Personal consequencesterm·mth include enhanced well‐being, spiritual health, satisfaction and personal growth (Babamohamadi et al. 2022 ; Bangcola 2022 ; Chen et al. 2020 ; Damsma‐Bakker and van Leeuwen 2021 ; Guo et al. 2021 , 2023 ; Li et al. 2022 ; Machul et al. 2022 ; Petersen and Schiltz 2020 ; van der Vis‐Sietsma, de Man‐van Ginkel, and van Leeuwen 2019 ), while professional consequencesterm·mth include an improved ability to provide holistic care, patient‐centred care and improved patient‐health outcomes (Abell, Garrett‐Wright, and Abell 2018 ; Abu‐Snieneh and Abdelaziz 2022 ; Adib‐Hajbaghery, Zehtabchi, and Fini 2017 ; Ahmadi et al. 2021 ; Baldacchino 2006 ; Chen et al. 2020 ; Cheng et al. 2021 ; Damsma‐Bakker and van Leeuwen 2021 ; Guo et al. 2021 , 2023 ; Heidari, Afzoon, and Heidari 2022 ; Hsieh et al. 2020 ; Jafari and Fallahi‐Khoshknab 2021 ; Kang et al. 2021 ; Li et al. 2021 ; Machul et al. 2022 ; Petersen et al. 2017 ; Petersen and Schiltz 2020 ; Ross et al. 2016 ; Semerci et al. 2021 ; Southard et al. 2020 ; van der Vis‐Sietsma, de Man‐van Ginkel, and van Leeuwen 2019 ; van Leeuwen et al. 2008 ; Zhang‐Yi et al. 2021 ; Zhang et al. 2023 ).

From a personal perspective, acquiring spiritual competenceterm·dom enhances nurses' spiritual well‐beingterm·dom and confidence in providing spiritual careterm·key, two outcomes that reduce feelings of frustration that nurses might experience while providing spiritual careterm·key (Babamohamadi et al. 2022 ; Damsma‐Bakker and van Leeuwen 2021 ; Guo et al. 2021 ; Heidari, Afzoon, and Heidari 2022 ). Because spiritual well‐beingterm·dom in nurses can take the form of emotional peace or low work‐related stress, spiritual well‐beingterm·dom improves their ability to address patients' spiritual needs (Heidari, Afzoon, and Heidari 2022 ; Zhang‐Yi et al. 2021 ). Spiritually competent nurses are relatively satisfied with their performance of nursingterm·key duties, including spiritual nursingterm·key duties, and are in a good position to experience personal growth, to endure life stressors and to provide high‐quality nursingterm·key care (Bangcola 2022 ; Chen et al. 2020 ; Machul et al. 2022 ; van der Vis‐Sietsma, de Man‐van Ginkel, and van Leeuwen 2019 ).

Spiritually competent nurses are likely to provide holistic focused care by addressing patients' spiritual needs, in addition to their physical and psychosocial needs (Abell, Garrett‐Wright, and Abell 2018 ; Ahmadi et al. 2021 ; Baldacchino 2006 ; Chen et al. 2020 ; Jafari and Fallahi‐Khoshknab 2021 ). The spiritual‐focused care provided by spiritually competent nurses is likely to be tailored to patients' unique needs in all stages of illness, a patient‐centred approach that improves health outcomes (Baldacchino 2006 ; Damsma‐Bakker and van Leeuwen 2021 ; Guo et al. 2023 ; Machul et al. 2022 ; Ross et al. 2016 ). In general, spiritual careterm·key provided by spiritually competent nurses can improve patients' quality of life by decreasing their suffering, increasing their hope and fostering their acceptance of life circumstances (Abu‐Snieneh and Abdelaziz 2022 ; Adib‐Hajbaghery, Zehtabchi, and Fini 2017 ; Guo et al. 2021 ; Heidari, Afzoon, and Heidari 2022 ; Kang et al. 2021 ; Li et al. 2021 ; Petersen et al. 2017 ; Petersen and Schiltz 2020 ).

Proposed Conceptual Definition Based on the above definitions and findings regarding spiritual competenceterm·dom in nursingterm·key, we define the concept as a dynamic process that, once initiated by nurses' spiritual awarenessterm·dom, promotes their spiritual well‐beingterm·dom, their spiritual knowledge and skillsterm·dom, and their sense of spiritual‐care self‐efficacyterm·dom .

Discussion Our concept analysis clarified attributes, antecedentsterm·mth and consequencesterm·mth of spiritual competenceterm·dom in nursingterm·key and supported the development of a clear definition of the concept that should strengthen research on the topic and actual practice in the field. We identified five attributes of spiritual competenceterm·dom in nursingterm·key: spiritual awarenessterm·dom, spiritual well‐beingterm·dom, spiritual knowledge and skillsterm·dom, spiritual‐care self‐efficacyterm·dom and dynamismterm·dom. Although only one of the reviewed studies explicitly included dynamismterm·dom, findings from almost all of the reviewed studies implicitly indicate the dynamic evolution of spiritual competenceterm·dom.

In analysing the literature, we identified three antecedentsterm·mth of spiritual competenceterm·dom in nursingterm·key: nurses' willingness to learn about spiritualityterm·dom, nurses' engagement in spiritual education and nurses' engagement in spiritual‐care training. These antecedentsterm·mth may be influenced by nurses' spiritual, religious or philosophical beliefs. This may be more common in non‐religious contexts (i.e., countries without a state religion), where culture, values and philosophical beliefs may provide a foundation for enhancing spiritual competenceterm·dom for some nurses. To become spiritually competent, nurses should receive some form of education and training in the delivery of spiritually focused nursingterm·key care. However, mandating that nurses participate in competency development may be counterproductive, as willingness to receive an education and to participate in training are positively associated with the degree of spiritual competenceterm·dom. Thus, efforts should be made to provide spiritual education and training to nursingterm·key students and practicing nurses who are willing to engage in these development programs. The consequencesterm·mth of spiritual competenceterm·dom in nursingterm·key can be broken down into personal and professional consequencesterm·mth. Among the most frequently cited personal consequencesterm·mth are enhanced well‐being, satisfaction and personal growth, while the most important professional consequenceterm·mth is improved patient health outcomes. These consequencesterm·mth reflect the positive components of spiritualityterm·dom, such as acquiring meaning and purpose in life and promoting transcendence and connectedness with the self, community and the sacred.

Sociodemographic and professional factors associated with spiritual competenceterm·dom in nursingterm·key include age, gender, marital status, religion, educational level, nursingterm·key work‐related experience and frequency of spiritual practices (Adib‐Hajbaghery, Zehtabchi, and Fini 2017 ; Alshehry 2018 ; Babamohamadi et al. 2022 ; Chen et al. 2020 ; Guo et al. 2021 ; Hsieh et al. 2020 ). Participants in the selected studies covered a wide age range, and multiple studies suggest that nurses between 20 and 50 years of age are more likely than nurses over the age of 50 to be spiritually competent (Adib‐Hajbaghery, Zehtabchi, and Fini 2017 ; Guo et al. 2021 ; Hsieh et al. 2020 ; Irmak and Sagkal Midilli 2021 ; Kang et al. 2021 ). Although most participant‐based studies included primarily female participants, which precluded an examination of possible differences between males and females, one study found evidence that female nurses are significantly more spiritually competent than male nurses (Babamohamadi et al. 2022 ). Studies had inconsistent findings regarding marital status, with Guo et al. ( 2021 ) and Kang et al. ( 2021 ) proposing that married nurses are more spiritually competent than single nurses, while Babamohamadi et al. ( 2022 ) found that single nurses are more spiritually competent than married nurses. Although most participants in the relevant studies identified as religious, only two studies found that these participants were significantly more spiritually competent than participants who did not identify as religious (Hsieh et al. 2020 ; Machul et al. 2022 ). Regarding educational levels, those with higher educational levels are more spiritually competent. For example, Chen et al. ( 2020 ) and Guo et al. ( 2021 ) presented evidence that nurses with a bachelor's degree are more competent than those with an associate degree, while Kang et al. ( 2021 ) reported that nurses with a master's degree are more spiritually competent than those with a bachelor's or an associate degree. Nursingterm·key experience is also associated with spiritual competenceterm·dom: nursingterm·key experience has been positively and significantly associated with spiritual competenceterm·dom (Adib‐Hajbaghery, Zehtabchi, and Fini 2017 ; Guo et al. 2021 ; Hsieh et al. 2020 ; Kang et al. 2021 ). Experience with spiritual activities (e.g., reading books on the subject, meditating and practicing mindfulness) was found to enhance nurses' spiritual competenceterm·dom (Chen et al. 2020 ; Hsieh et al. 2020 ). While these findings provide preliminary evidence that sociodemographic and professional factors may affect nurses' spiritual competenceterm·dom, additional research is needed to better understand the unique contributions that these factors make to spiritual competenceterm·dom in nursingterm·key.

Findings from this analysis should be interpreted in the context of the specific nursingterm·key role. Of all the studies, 69% recruited practicing nurses (i.e., nurses who were working directly with patients); the remaining 31% recruited nursingterm·key students. Although the aim of this study was to provide a comprehensive understanding of the concept of spiritual competenceterm·dom in nursingterm·key, we may have overlooked factors specific to being a nurse (e.g., salary level) or being a nursingterm·key student (e.g., grade point average) that might shape development of spiritual competenceterm·dom. In addition, most of the selected studies enrolled practicing nurses from multiple departments; only a few studies enrolled nurses from specific specialty departments, such as hospice (Kang et al. 2021 ); oncology (Damsma‐Bakker and van Leeuwen 2021 ); intensive care (Abu‐Snieneh and Abdelaziz 2022 ) and psychiatry (Irmak and Sagkal Midilli 2021 ). Thus, further research is needed to explore whether department‐specific factors influence the spiritual competenceterm·dom of nurses caring for specific populations.

Ability and opportunity to provide spiritual careterm·key are essential to the process of developing spiritual competenceterm·dom in nursingterm·key. Thus, impediments to these factors can undermine nurses' spiritual competenceterm·dom. In the studies analysed, the impediments that were cited include onerous workloads, fear of overstepping patients' values, lack of confidence in providing spiritual careterm·key and insufficient knowledge about spiritualityterm·dom and the provision of spiritual careterm·key. In education and training programs for nurses, an emphasis on spiritualityterm·dom may help these individuals overcome some of the above impediments.

Attention should be paid to the conceptual models that underpin educational and training programs devoted to nurses' spiritual competenceterm·dom, as they can affect the development, implementation and outcomes of this competenceterm·key. Our analysis of the selected studies led us to identify three conceptual models of spiritual competenceterm·dom that could facilitate the development of such programs. The Spiritual Competenceterm·dom Model for Psychiatric care (Campinha‐Bacote 1995 ) includes three critical attributes of spiritual competenceterm·dom in nursingterm·key: spiritual awarenessterm·dom and spiritual knowledge and spiritual skills. Although the model was initially developed for psychiatric nurses, its use in general nursingterm·key gives every indication of being valid. The model could be used to help develop spiritualityterm·dom‐oriented educational and training programs, including those related to the development of spiritual assessments and spiritual careterm·key in nursingterm·key. Another model—the Spiritual Careterm·key Competency Framework—consists of seven domains: (1) knowledge in spiritual careterm·key; (2) self‐awareness in spiritual careterm·key; (3) interpersonal relationships and communication; (4) ethical and legal issues in spiritual careterm·key; (5) assessment and implementation of spiritual careterm·key; (6) quality assurance in spiritual careterm·key and (7) informatics in spiritual careterm·key (Attard, Ross, and Weeks 2019 ). This framework can facilitate the design and delivery of educational and training programs targeting spiritual careterm·key competency. Finally, Cao et al. ( 2020 ) developed the Spiritual Care Competenceterm·dom Conceptual Framework to help educators develop a program for teaching spiritual careterm·key to practicing nurses in China: the framework focuses on (1) nurses' awareness, understanding and application of spiritualityterm·dom; (2) the intrapersonal, interpersonal and transpersonal levels of spiritualityterm·dom in nurses and (3) the worldview, connectedness and transcendence levels of spiritualityterm·dom in nurses. This framework can guide the design of clinical training programs for the spiritual‐care competenceterm·dom of nurses. Further research on these models can determine the extent to which they can effectively guide the education and training of diverse populations of nursingterm·key students and practicing nurses in the realm of spiritual competenceterm·dom.

Limitations The studies selected for this concept analysis each had limitations, which imposed important limitations on our findings. Most of the selected studies used the SCCS to operationalise care‐focused spiritual competenceterm·dom. However, because the SCCS measures skills, it is unlikely to measure all five attributes of spiritual competenceterm·dom identified in our analysis. As recommended by van Leeuwen et al. ( 2009 ), researchers seeking to measure our broader range of attributes should consider combining the SCCS with other scales (particularly those that measure spiritual awarenessterm·dom and spiritual attitudes). In addition, most studies measured only the ‘levels’ of spiritual competenceterm·dom, a pattern that left unaddressed other aspects of spiritual competenceterm·dom, especially its consequencesterm·mth.

The cultural and religious contexts of the selected studies could also have affected our analysis. Most of these studies were conducted in countries where (1) many people consider religion an essential element of one's identity; (2) many people treat religion and spiritualityterm·dom interchangeably and (3) the majority of participants identified as religious. Studies conducted in these countries found evidence that religion significantly affects nurses' spiritual competenceterm·dom, but generally left unanswered the question of how non‐religious nurses and nursingterm·key students perceive and respond to issues involving spiritual competenceterm·dom. Another limitation of our study is that all of our selected studies were in English, and this fact may have led us to exclude important research published in other languages. Finally, we analysed only those studies addressing the nursingterm·key discipline. This decision limits the generalizability of our findings, as practitioners in other disciplines may hold views of spiritual competenceterm·dom quite different from those of nurses.

Implications for Nursingterm·key Spiritual competenceterm·dom in nursingterm·key is essential to nurses' personal and professional development and to providing holistic patient‐centred care. Integrating spiritualityterm·dom into nursingterm·key education may serve as a foundation for clinical practice and research, where nurses demonstrate their spiritual competenceterm·dom. Thus, we highlight the significant implications of spiritual competenceterm·dom for nursingterm·key education and training, nursingterm·key assessment and management and nursingterm·key research.

Nursingterm·key Education and Training As mentioned above, spiritual careterm·key is a required nursingterm·key competency in nursingterm·key education (American Association of Colleges of Nursingterm·key 2021 ) and in providing holistic patient‐centred care (American Holistic Nurses Association 2016 ; Hospice and Palliative Nurses Association 2022 ). However, most US undergraduate nursingterm·key programs and textbooks do not address spiritualityterm·dom as part of formal nursingterm·key education. To address this, nursingterm·key courses and curricula should include formal instruction on fundamental aspects of spiritualityterm·dom (e.g., spiritual awarenessterm·dom and spiritual careterm·key in nursingterm·key) for all stages of spiritual development across the lifespan. Integrating spiritualityterm·dom in nursingterm·key educational programs will allow nursingterm·key students to develop their spiritual awarenessterm·dom, making them better equipped to provide holistic patient‐centred care.

There is a need to integrate spiritualityterm·dom into clinical training programs to enhance nurses' spiritual competency post‐graduation. This may be most effective when training and education on spiritualityterm·dom are implemented in care settings or contexts that require spiritual careterm·key, such as long‐term care facilities (Chen et al. 2020 ), critical care units (Abu‐Snieneh and Abdelaziz 2022 ; Azarsa et al. 2015 ), psychiatry units (Irmak and Sagkal Midilli 2021 ) and units providing hospice or end‐of‐life care (Kang et al. 2021 ). The formal inclusion of spiritualityterm·dom into nursingterm·key instruction and clinical training programs can be guided by one of the conceptual models identified earlier, such as the Spiritual Careterm·key Competency Framework (Attard, Ross, and Weeks 2019 ). Holistic nursingterm·key clinical training programs that promote nurses' spiritual competenceterm·dom may assist nurses in navigating patients' needs and care.

Nursingterm·key Assessment and Management A comprehensive assessment of patients' spiritual needs is essential to providing spiritual careterm·key. Integrating comprehensive standard spiritual assessments into clinical nursingterm·key practice will facilitate nurses' provision of spiritual careterm·key and equip nurses with the skills to collaborate with and refer patients to chaplains and other religious and spiritual professionals as needed (Campbell, Robison, and Godsey 2023 ). Yet, institutional guidance pertaining to spiritual assessment for nurses is often lacking (Balboni et al. 2022 ). The lack of institutional guidance with the current implementation of spiritual careterm·key provides opportunities for nurse leaders to define who should assess patients' spiritual needs, how often assessment should occur and what types of care or interventions can be offered to meet identified spiritual needs. Nurse leaders and policymakers should ensure that spiritual careterm·key policies reflect evidence‐based recommendations.

Nursingterm·key Research The findings of this concept analysis highlighted limitations in the analysed studies that serve as areas for future research. For example, it was not clear whether nurses' sociodemographic characteristics significantly influence their spiritual competenceterm·dom, particularly within nurses' cultural and religious contexts. Thus, further targeted research is needed to explore the potential role of nurses' sociodemographic characteristics in more diverse samples (e.g., for nurses who do not identify as religious). Additionally, further research is needed to explore nurses' spiritual competenceterm·dom in specialty areas (e.g., oncology) to understand patterns of patients' spiritual needs in these units. Lastly, further research is needed to examine the feasibility of spiritual assessment tools before their implementation into clinical practice.

In conclusion, findings from our concept analysis help clarify the concept and related practices of spiritual competenceterm·dom in nursingterm·key. We have shown that spiritual competenceterm·dom is a dynamic process initiated by spiritual awarenessterm·dom and promotive of ever‐evolving spiritual well‐beingterm·dom, spiritual knowledge and skillsterm·dom, and spiritual‐care self‐efficacyterm·dom in the lives of nursingterm·key students and practicing nurses. Our concept analysis provides a foundation for future research aimed at helping nurses develop spiritual competenceterm·dom and provide quality spiritual careterm·key.

Author Contributions This manuscript was written by N.S.A. with a critical review from A.L.E. and K.E.M. N.S.A. and A.L.E. contributed to the study's conception and design. Data collection and analysis were performed by K.E.M. and N.S.A. All authors commented on previous revisions and provided approval for the final version for publication.

Conflicts of Interest The authors declare no conflicts of interest.

Acknowledgements The authors have nothing to report.

Data Availability Statement Data sharing is not applicable to this article as no new data were created or analyzed in this study.

References Associated Data Data Availability Statement Data sharing is not applicable to this article as no new data were created or analyzed in this study.