Spiritual comfort, spiritual support, and spiritual care: A simultaneous concept analysis. — TEI-tagged view

Ana Patrícia TavarespersName, Helga MartinspersName, Sara PintopersName, Sílvia CaldeirapersName, Patrícia Pontífice SousapersName, Beth RodgerspersName (2022date). “Spiritual comfort, spiritual support, and spiritual care: A simultaneous concept analysis..” Nursing Forumtitle·j.

Object of study — the concepts of spiritual comfortterm·dom, spiritual supportterm·dom and spiritual careterm·dom in nursing

Research question — what distinguishes spiritual careterm·dom, spiritual supportterm·dom and spiritual comfortterm·dom as singular concepts

Contribution — separate definitions of the three concepts and a validity matrixterm·key of their shared and distinguishing attributes

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Spiritual comfortterm·dom, spiritual supportterm·dom, and spiritual careterm·dom: A simultaneous concept analysisterm·key.

Abstract Spiritualityterm·dom is a dimension of life and the human being that should be included in holistic healthcare. One major barrier often described by nurses on implementing spiritualityterm·dom in practice relates to perceiving the concept of spiritualityterm·dom as subjective and sharing confounding similarities with other concepts. In this sense, the concepts of spiritual comfortterm·dom, spiritual careterm·dom, and spiritual supportterm·dom may require more distinct theoretical definitions aimed at clear and effective nursing interventionsterm·key within spiritual careterm·dom.

To provide a definition of spiritual comfortterm·dom, spiritual supportterm·dom, and spiritual careterm·dom.

Simultaneous concept analysisterm·key (SCAterm) of three concepts according to Haase et al., which is grounded on RodgerspersName' evolutionary view. The method was based on a literature review with the search of electronic databases on May 2020. Search and analysis have been blinded conducted by two reviewers.

One hundred thirty‐six studies were included in the SCAterm. Findings suggest that spiritual comfortterm·dom is an immediate state and an outcome. Spiritual supportterm·dom is related with an intimate and positive relationship with God. Spiritual careterm·dom is defined as a complex and interactive process. Both spiritual supportterm·dom and spiritual careterm·dom are grounded in a therapeutic context.

This SCAterm allowed the attributes of each concept to be identified and provides definitions that may facilitate the understanding of these concepts and promote the implementation of spiritualityterm·dom in nursing practice, but which has also led to future research on this topic.

BACKGROUND Spiritualityterm·dom is recognized as a fundamental dimension of life that can contribute positively to patients' health and well‐being and in dealing with illness and diseases. 1 Understanding spiritualityterm·dom in nursing may start with the recognition of this dimension as part of the global human being in a context of holistic nursingterm·key care. Spiritualityterm·dom represents a broad concept, often described as a subjective and multidimensional component of being human. 2 Spiritualityterm·dom is broader than religiosity, and has been defined in nursing as “(…) a way of being in the world in which a person feels a sense of connectedness to self, others, and/or a higher power or nature; a sense of meaning in life; and transcendenceterm·key beyond self, everyday living, and suffering.” 3 ,p.93 Despite being defined, the concept seems to be far from being integrated into practice and the barriers in the delivery of spiritual careterm·dom by nurses are already described in the literature. The main barriers are education and training on spiritual careterm·dom, lack of time, and clear guidelines regarding spiritual careterm·dom, and the difficulty of defining spiritualityterm·dom and spiritual concepts because of their subjectivity. 4 Due to the subjectivity of the concept often reported by nurses, discussing the boundaries between personal belief and professional practice is still a difficult task. 5 The subjectivity of the concept and considering other concepts as similar may affect the implementation of spiritual careterm·dom at the beginning of the process of being aware of the meaning of spiritualityterm·dom and related concepts. Concept development therefore seems to be essential in the process of clarifying concepts before being used in practice, but also for use in research.

In this regard, the concepts of spiritual comfortterm·dom, spiritual supportterm·dom, and spiritual careterm·dom are examples of the scope the subjectivity of spiritual dimension may have and of the gray areas among concepts, which may reflect on nursing care. Spiritual careterm·dom and spiritual supportterm·dom have been studied more frequently than spiritual comfortterm·dom, which remains poorly analyzed and defined.

Comfortterm·dom is a subjective concept and has been analyzed from different perspectives. Kolcaba, 6 in her theory about comfortterm·dom, defines the concept as an immediate state of being strengthened by the feelings of relief, tranquility, and transcendenceterm·key satisfied in four contexts (physical, psychospiritual, social, and environmental). Although the spiritual dimension of comfortterm·dom is explicit in this theory, the concept remains mainly associated with promoting physical care, such as hygiene care (and comfortterm·dom), pain relief or positioning, or by the absence of comfortterm·dom care in other dimensions that are perceived by patients as critical, specifically in nursing practice. 7 , 8 The physical domain of comfortterm·dom is related to the gaps and inconsistencies based on the difficulty of measuring the concept, and the association with physical emphasis of the concept persists mainly in daily care practice. Current scientific evidence also demonstrates this limitation. Further studies that develop the knowledge of comfortterm·dom in other dimensions, such as the spiritual dimension, are needed.

Spiritual careterm·dom as a concept is related to implementing spiritualityterm·dom and is grounded in the use of self of “being there” or of the presence of the healthcare provider which brings hope and peace to the patients and families. 9 Spiritual supportterm·dom is considered a nursing interventionterm·key and is included in the Nursing Interventionterm·key Classification; it is defined as “assisting the patient to feel balance and connection with a greater power.” 10 ,p.1199 These concepts share similar attributes not only in the spiritual dimension, but in the understanding of comforting, supporting and caring that are common to other areas. A conceptual clarification may facilitate the understanding and implementation in clinical practice, particularly in assessing and addressing patients' spiritual needs. There is missing in the literature a clear definition of spiritual comfortterm·dom, to make a clear distinction between the concepts. This clarification that this paper intends to give may help both theory and practice.

The simultaneous analysis of conceptsterm (SCAterm) procedure was developed by Haase et al., 11 and allows the clarification and development of related concepts in addition to the potential for strengthening the professional language. This method is based on RodgerspersName' evolutionary view of concept development. 12 SCAterm “is designed to analyze interrelationships and identify theoretical overlap, common themes, and distinguishing characteristics among similar or complementary concepts.” 11 ,p.227 Therefore, the aim of this study is to achieve a clear conceptual definition and a greater understanding of the individual meaning of spiritual careterm·dom, spiritual supportterm·dom, and spiritual comfortterm·dom as singular concepts, to provide exclusive theoretical definitions for each one, and to highlight their interrelationships and distinguish characteristics.

METHODS This is a SCAterm study, composed of the nine steps proposed by Haase et al., 11 which is grounded on RodgerspersName' evolutionary view. SCAterm model is based on the rationale that many concepts cannot be individually analyzed due to interconnections among concepts. They can, however, be understood by related comparison, since concepts are often similar enough that those closely associated need to be addressed. This is the situation with the concepts of spiritual careterm·dom, spiritual comfortterm·dom, and spiritual supportterm·dom.

Data sources Literature search was performed in May 2020, focused on spiritual careterm·dom, spiritual comfortterm·dom, and spiritual supportterm·dom on the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Academic Search Complete, Medical Literature Analysis and Retrieval System Online (MEDLINE), Scientific Electronic Library Online (SciELO), and Scopus. CINAHL and MEDLINE were chosen to explore nursing, medicine, and health related literature. SciELO and Scopus are scientific databases that encompass literature that goes beyond health literature and may provide some contributions to this concept analysisterm·key from other areas. The terms used in the databases were “Spiritual Careterm·dom,” “Spiritual Comfortterm·dom,” and “Spiritual Supportterm·dom,” and were searched to identify literature with those terms in the title. The search was conducted in each database and no time filter was used. This decision is related to the need to establish a conceptual foundation for each concept as complete as possible, retrieving the most information possible. Details of the search strategy and search results are presented in Table 1 .

Number of citations on the databases search and included articles Research papers written in English, Spanish, or Portuguese that discussed spiritual careterm·dom, spiritual comfortterm·dom, or spiritual supportterm·dom directly, including those that provided oblique definitions, antecedents, or attributes of each concept were included in this review.

A total of 3036 articles was identified specifically about spiritual careterm·dom, 317 about spiritual supportterm·dom, and 34 about spiritual comfortterm·dom. After the blinded screening, 4 articles specifically on spiritual comfortterm·dom, 28 articles on spiritual supportterm·dom, and 104 articles on spiritual careterm·dom were included in the SCAterm. PRISMA flow for each individual concept is available in Supporting Information: Appendix A .

Data analysis According to Haase et al., 11 the purpose of data analysis is not to develop a complete and finished definition of the concepts, but to provide an initial point for continued conceptual exploration in the discipline of nursing. Thematic analysis was performed as suggested by Haase et al. 11 and each article was read as often as necessary to determine the attributes, antecedents, and outcomes from each concept, that precedes the construction of the validity matrixterm·key. These aspects of three concepts were identified based on a rigorous analysis and the process of information collection was systematic, confirmable, and repeatable. In fact, attributes, antecedents, and outcomes of the three concepts were extracted from relevant articles and compared between and across disciplines before creating a validity matrixterm·key for comparison. In the next step, critical attributes, theoretical definitions, antecedents, and outcomes were derived for each concept independently.

RESULTS Spiritual comfortterm·dom Four papers were analyzed on spiritual comfortterm·dom. Despite no clear definition of the concept being found in that literature, spiritual needs were reported to have implications for patients' comfortterm·dom needs. Spiritual comfortterm·dom is described as a result of the perception of the patient, which means that it relates to inner consciousness of self. It is an immediate state and an outcome that establishes spiritual comfortterm·dom as a goal from nursing interventionsterm·key. As presented in the literature it becomes clear that providing spiritual comfortterm·dom requires effective communication. Regarding the attributes of the concept, we realized that spiritual comfortterm·dom is related to connection with self, others, environment, superior entity, God, or the transcendent. When a patient experiences spiritual comfortterm·dom, he/she obtains a sense of inner peace, well‐being, and feels supported by family and healthcare professionals. No enablers for the spiritual comfortterm·dom concept were identified in literature. The process model of spiritual comfortterm·dom is explained in Table 2 .

Process model: Spiritual comfortterm·dom Spiritual supportterm·dom Spiritual supportterm·dom was described in the literature reviewed as being potentially therapeutic in nature. In fact, spiritual supportterm·dom was discussed as based on a holistic approach of patients' needs, which is grounded in an affective relationship and communication between patient and staff. To achieve an effective communication, it is mandatory to establish a trustful relationship and empathic caring.

One of the attributes of spiritual supportterm·dom is the perceived positive influence of the concept by patients, also spiritual supportterm·dom is an intrapersonal concept. However, when we deeply analyze the several attributes of spiritual supportterm·dom, we can perceive that the concept is very focused and related to the intimate and affectionate relationship with a higher power or God, and closeness to the sacred or transcendent.

The results on spiritual supportterm·dom are displayed in Table 3 .

Process model: Spiritual supportterm·dom Spiritual careterm·dom According to the literature, spiritual careterm·dom represents a complex and multifaceted phenomenon with a therapeutic nature. The process of spiritual careterm·dom delivery is interactive and intentional and begins with the identification and assessment of spiritual needs of the patients. The relationship between patient and nurse must be based on trust and a multidisciplinary team approach, as this is vital for promoting patients' feelings of inner peace, gratitude, hope, comfortterm·dom, and spiritual well‐being. The literature emphasizes the role of nurses as key elements in the providing of spiritual careterm·dom. The intuitive sense, the spiritual/transcendent, and self‐awareness must be developed as well as moral skills.

The results are summarized in Table 4 .

Process model: Spiritual careterm·dom Validity matrixterm·key for critical attributes The construction of validity matrixterm·key 11 intends to explore interrelationships between concepts to identify and display commonalities across concepts. In this step, it is necessary to consider each element considering others, through constant comparisons and contrasts to identify inconsistencies and gaps. As shown in the validity matrixterm·key, spiritual careterm·dom, spiritual supportterm·dom, and spiritual comfortterm·dom are concepts with similarities but which also have significant differences (Table 5 ).

Validity matrixterm·key of critical attributes of spiritual careterm·dom, spiritual comfortterm·dom, and spiritual comfortterm·dom Spiritual comfortterm·dom is connected to an outcome that may result from nursing interventionsterm·key. Spiritual supportterm·dom and spiritual careterm·dom are grounded on a therapeutic nature, however spiritual supportterm·dom is related to an intrapersonal and transcendental dimension while spiritual careterm·dom is related to interpersonal nature. It means that spiritual supportterm·dom relates to an intimate and affectionate relationship with a higher power or God and spiritual careterm·dom relates to connection with self and others.

The detailed results including the studies of this SCAterm can be found in Supporting Information: Appendix B .

DISCUSSION This SCAterm was focused on three concepts related to spiritualityterm·dom that needed further analysis and clarification. This analysis is bringing the attributes, the antecedents, and the consequences of each concept and, in addition, disclosed the similarities and differences between the three concepts. Spiritual comfortterm·dom, spiritual supportterm·dom, and spiritual careterm·dom are interrelated concepts, and this is the main rationale of this review. Concept analysisterm·key is growing in some particular dimensions of nursing knowledge, and regardless of some criticism, some authors reinforce the need to conduct these studies to achieve an effective definition of a concept to promote nursing science and clinical care. 13 It is clear that the difficulty in defining the proposed concepts is not a contemporary problem, that is, it lies above all in the definition of the attributes of the process of caring, supporting and comforting, which are not yet clear in the literature, therefore, this difficulty is a current reality in different contexts.

In these findings, spiritual comfortterm·dom is defined as an immediate state and an outcome. However, this concept is still insufficiently developed for application and testing and only slightly operationally implemented in clinical practice, on this topic. PintopersName et al. 14 found it difficult to define and operationally implement comfortterm·dom, despite it being a fundamental need of human life and a vital concept in nursing care and philosophy. These authors underline that many definitions of comfortterm·dom do not include the spiritual dimension, and this can be a reductionist approach of the concept since comfortterm·dom needs to be embraced in a holistic perspective. 14 Considering this need, this study proposes a new definition of the concept that includes the spiritual dimension, which allows a broader concept perspective.

Spiritual supportterm·dom is more focused on an intimate and personal relationship with God and seems to be mainly related to the vertical dimension of spiritualityterm·dom. This connection with God or a superior being or entity is perceived as something positive. Several studies reinforce the positive relationship with God as a source of love, hope, coping with difficult times, and improves spiritual well‐being, much needed in times of illness and crisis. 15 , 16 , 17 The results concerning the analysis of the concept spiritual careterm·dom are similar to Ramezani et al. 18 In what concerns the attributes of the concept of spiritual careterm·dom, the intuitive sense, therapeutic nature, and the therapeutic use of self, have also been found to be critical attributes in this study. The therapeutic use of self is considered a core element in spiritual careterm·dom and contributes to effective holistic care. The use of self is a step forward in the way of “ being ” in the provision of spiritual careterm·dom by health professionals. 19 The antecedents of sensitivity and awareness regarding spiritual careterm·dom had already been referenced in previous analyses of the concept. It is essential for health professionals to be aware of their own spiritualityterm·dom to feel more comfortable talking to patients about this topic, which has a personal and intimate perspective.

The analysis of these three concepts found similarities and differences, that allows a differentiating framework to be established. The concept of spiritual comfortterm·dom is reported as an immediate state and an outcome, that is a consequence of a nursing interventionterm·key. We found that both the spiritual careterm·dom and spiritual supportterm·dom concepts have the comfortterm·dom dimension as a consequence, which is congruent with previous findings. It means that spiritual careterm·dom and spiritual supportterm·dom could be encompassed into the scope of interventions and spiritual comfortterm·dom into the outcomes. When we look into the antecedents it becomes clear that the identification and assessment of the spiritual needs of the patients is essential in the three concepts.

Spiritual comfortterm·dom, spiritual careterm·dom, and spiritual supportterm·dom are vital in the spiritual approach of patients, nevertheless the spiritual dimension is still neglected in nursing care and must have the same focus and importance as the other human dimensions. It refers to the holistic dimension of nursing care that should embrace the whole person and include the spiritual dimension, as we can find in the antecedents of the three concepts.

Spiritual comfortterm·dom is an immediate state and a result of the perception of the patient, that emerges from the connection with self, others, environment, and something superior or God. It is a positive feeling that brings a sense of inner peace, well‐being, and feelings of being supported. In the same way, both spiritual careterm·dom and spiritual supportterm·dom are seen as bringing well‐being and feelings of inner peace, love, and quality and satisfaction with life.

The differences between the concepts of spiritual supportterm·dom and spiritual careterm·dom, lies in the nature. Spiritual supportterm·dom has an intrapersonal nature, that refers to the intimate and affectionate relationship with a higher power or God, refers to an interconnectedness and a connection with God, others, and environment, but it also refers to an interpersonal phenomenon. It means that spiritual careterm·dom is an interactive and intentional process that includes, beyond the intimate and affectional connection with self, others, or God, the nursing interventionterm·key that is holistic and patient‐centered.

The validity matrixterm·key of critical attributes of spiritual careterm·dom, spiritual comfortterm·dom, and spiritual supportterm·dom outline that the ethical orientation is present in all three. CaldeirapersName and Timmins 20 emphasize that the provision of spiritual careterm·dom by nurses involves an ethical approach that is grounded on being respectful and truthful, maintaining confidentiality, and providing dignity while preserving care. In addition, all ethical principles must be present in spiritual careterm·dom, but beneficence is considered the most important when delivering spiritual careterm·dom. 21 This review brings into discussion the need of further research on these concepts, such as studies comprising patients' experiences and perspectives.

CONCLUSION This study enhances the conceptual understanding by clarifying the concepts of spiritual comfortterm·dom, spiritual supportterm·dom, and spiritual careterm·dom. Our finding shows that spiritual supportterm·dom and spiritual careterm·dom are grounded in a therapeutic nature in which one of the outcomes is the immediate state of spiritual comfortterm·dom. Spiritual supportterm·dom mainly encompasses the vertical dimension of the spiritual in which there is an intrapersonal and intimate relationship with God. The therapeutic nature of spiritual careterm·dom is a unique, multifaceted, interpersonal, and complex process, besides being broader and more widespread than spiritual supportterm·dom because it embraces the vertical and horizontal dimension of spiritualityterm·dom. Although this inquiry contributed to definitions of the concepts, there is the need to foster the development of this field and research regarding this topic with a goal of enhancing nursing science and care.

AUTHOR CONTRIBUTIONS Substantial contributions to conception, data collection, data analysis, and writing : Ana Patrícia TavarespersName, Helga MartinspersName, Sílvia CaldeirapersName, and Beth RodgerspersName. Drafting the article or revising it critically for important intellectual content : Ana Patrícia TavarespersName, Helga MartinspersName, Sílvia CaldeirapersName, Patrícia Pontífice SousapersName, Sara PintopersName, and Beth RodgerspersName.

CONFLICT OF INTEREST The authors declare no conflict of interest.

Supporting information Supplementary information.

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Supplementary information.

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Supplementary information.

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