DISCURSIVE PAPER

Ethical issues of incorporating spiritual care into clinical practice

Rebecca L Polzer Casarez and Joan C Engebretson

Aims and objectives. The aim of this article was to analyse the scholarly discourse on the ethical issues of incorporating
spirituality and religion into clinical practice.
Background. Spirituality is an important aspect of health care, yet the secularisation of health care presents ethical concerns for
many health providers. Health providers may have conflicting views regarding if and how to offer spiritual care in the clinical
setting.
Design. Discursive paper.
Results. The discourse analysis uncovered four themes: ethical concerns of omission; ethical concerns of commission; conditions
under which health providers prefer to offer spiritual care; and strategies to integrate spiritual care. Ethical concerns of omission
of spiritual care include lack of beneficence for not offering holistic care. Ethical concerns of commission are coercion and
overstepping ones competence in offering spiritual care. Conditions under which providers are more likely to offer spiritual care
are if the patient has a terminal illness, and if the patient requests spiritual care. Strategies for appropriate spiritual care include
listening, and remaining neutral and sensitive to spiritual issues.
Conclusions. Health providers must be aware of both the concerns of omission and commission. Aristotles golden mean, an
element of virtue ethics, supports a more moderate approach that can be achieved by avoiding the imposition of ones own
personal beliefs of a religious persuasion or beliefs of extreme secularisation, and focusing on the beneficence to the patient.
Relevance to clinical practice. Key components for health providers in addressing spiritual concerns are self-reflection, provision
of individualised care, cultural competency and communication.

Key words: ethics, health provider, spiritual care

Accepted for publication: 26 February 2012

care into clinical practice in nursing, as well as in the medical

Introduction
Spirituality has been an important element of health and
healing since ancient times and in a variety of cultures
(Sawatzky & Pesut 2005, Sessanna et al. 2011). More
recently, with increasing scientific and technological empha-
sis, health care has become secularised. This has generated a
general discourse in the public and among health care
professionals. This discourse is also reflected in the scholarly
literature regarding the ethical issues of inclusion of spiritual
literature (Ellis et al. 1999, Monroe et al. 2003, Luckhaupt
et al. 2005).
These issues apply to all clinicians: however, the founda-
tional role of nursing is one of caring for the whole person
over the health-illness continuum. This positions nurses in a
somewhat different relationship with the patient than other
members of the health care team. Spiritual issues may be very
important to the patient during illness or other encounters
with the health care system. Nursing has been a leader in

Authors: Rebecca L Polzer Casarez, PhD, RN, Associate Professor -
Clinical, School of Nursing, University of Texas Health Science
Center at Houston; Joan C Engebretson, DrPH, RN, AHN-BC,
Professor, School of Nursing, University of Texas Health Science
Center at Houston, Houston, TX, USA
Correspondence: Rebecca L Casarez, Associate Professor - Clinical,
School of Nursing, University of Texas Health Science Center at
Houston, 6901 Bertner Ave. Room 782, Houston, TX 77030, USA.
Telephone: +1 713 500 2068.
E-mail: rebecca.l.casarez@uth.tmc.edu

2012 Blackwell Publishing Ltd

Journal of Clinical Nursing, 21, 20992107, doi: 10.1111/j.1365-2702.2012.04168.x 2099
RLP Casarez and JC Engebretson
recommending attention to the spiritual concerns of patients
as part of holistic health care (Burkhardt & Nagai-Jacobson
2009). Nurses are expected to use spiritual interventions, or
at least be knowledgeable and facilitate or actively apply
spiritual and religious worldviews to promote healthy
outcomes. This is confounded by the context in which nurses
practice. In addition to the secularisation of medicine on the
social level, Pesut and Thorne (2007) describe a liberal state
(p. 397) or culture in the United States which promotes
freedom, individualism, pluralism and tolerance and avoids
passing judgment on spiritual beliefs and practices. In some
cases, this is interpreted as avoiding any issues with spiritu-
ality as it is outside the secular realm of health care (Paley
2009). Nurses are often expected to be neutral observers.
However, they bring personal beliefs about spirituality to
their profession, and must try to negotiate societal, personal,
professional identities and ethical issues (Pesut & Thorne
2007). The aim of this article is to analyse the scholarly
discourse on the ethical issues of incorporating spirituality
and religion into clinical practice.
Background
Definitions of spirituality, religion and spiritual care
In the health care literature, the terms spirituality and religion
are often used interchangeably and are not differentiated
(Pike 2011). Examining the roots of the concepts of spiritu-
ality and religion, there is a distinction, although the two
concepts are often closely related. The root word spirit comes
from the Hebrew word Ruah which means breath, air, wind
and is associated with Nephesh, which means life or soul.
The Latin word Spiritus means breath of life (Reese 1980).
Spirit, in this sense, means the thing that separates a living
body from a corpse, and usually implies intelligence, con-
sciousness and sentience. In much of the literature, spirituality
is described as a dimension of a person that is a universal
concept and that involves meaning, purpose, transcendence,
connectedness and energy (Chiu et al. 2004, Pesut et al. 2008).
In contrast, religion, in Latin means to bind fast, which
refers to an institution with a recognised body of people who
gather together to worship, share a belief system and
participate in related rituals (Reese 1980). This group shares
a set of beliefs, values and behaviours of a group of people.
Religion is often distinguished as a subset of spirituality or
culture (Hollins 2005), and has been defined as an institu-
tional body of beliefs and practices (Chiu et al. 2004).
Despite these distinctions, in the health literature, the two
concepts are often not distinguished. This may explain why
there has been little consensus on the concept of spiritual
2100
care. According to Pesut (2006), spiritual care describes
nurses identifying the spiritual needs of their patients and
seeking to meet these needs. Carr (2008) discusses qualities of
spiritual nursing care which include being there for the
patient, developing caring relationships, fostering connec-
tions and promoting spiritual comfort and well-being.
Spiritual care may also include activities associated with
religious rituals and practices.
Historical perspective of Western health care
Historically and cross culturally, in the West, much of
medicine has been integrated with spiritual or religious
practices in which societies maintained a holistic approach
that united medicine, health and religion and spiritual beliefs.
Nursings earliest origins have documented women caring for
their families and later women who served as deaconesses
and matrons caring for neighbours and other members of
their communities. This involvement, primarily by women in
caring for the sick, continued through religious orders that
provided health care for the needy (Dolan et al. 1983).
In Western traditions, many hospitals were started by
religious groups, such as the Knights Hospitalers who started
hospitals for pilgrims on the Crusades. Nurses, both within
and external to monastic orders were very involved in caring
for the sick throughout the Middle Ages (Dolan et al. 1983).
Although some hospitals were founded for public health
reasons starting in the 18th century, a large number of
hospitals were founded by religious organisations, continuing
into the present time. Therefore, the integration of physical
health and spirituality has a lengthy history.
The secularisation of healthcare began with increasing
urbanisation and concomitant social concerns for public
health, along with the increasing scientific and technical base
for health care. Medicine separated from religion and became
grounded in the scientific method and political concerns.
Concurrently, the philosophy of dualism became more
pronounced in the academic sector. This philosophy was
applied to medicine in which the soma or body became
separated from the psyche. The soma, based in physical
empiricism was the foundation of medicine and the psyche,
the realm of thoughts and feelings (Churchland 1988,
Chalmers 1997). Religion initially was part of the psyche,
but as psychology strove to be more scientific, religion
became even more marginalised from medicine. These ideas
of dualism still persist, despite more recent scientific under-
standing in neuroscience of the unity of mind/spirit and body.
(Chalmers 1997, Damissio 2000). However, more recently,
Pargarment and Saunders (2007) also affirm that the concepts
of spirituality and religion are intertwined and have been
2012 Blackwell Publishing Ltd
Journal of Clinical Nursing, 21, 20992107
Discursive paper
associated with psychosocial health and development and
may be vital to mental health and well-being (Hill &
Pargament 2003).
Values and beliefs that underlie practices and behaviours
often associated with religious traditions are part of the
cultural ethos. The cultural diversity of the United States and
the recent communication technology and concurrent glob-
alisation have also raised many important issues regarding
the contemporary position of spirituality, religion and health
care. Spiritual or religious beliefs and practices are inherently
relevant to health care and health behaviours; yet the political
and philosophical secularisation of health care presents
ethical concerns for clinicians.
The present paper
Method
The ethics of appropriate integration of spirituality to clinical
practice has generated a lively discourse among health care
providers, particularly in nursing. Literature or written texts
can provide sources for analysis of issues in social discourse
(Lupton 1992, Gibson 2001, Ma et al. 2010). A thematic
analysis was used to examine the discourse from professional
literature which has been generated by and influences clinical
practice (Fairclough 1995, Dixon-Woods et al. 2005, Smith
2007, Thorne 2008, Ma et al. 2010). Six electronic databases
(Cumlative Index to Nursing and Allied Health Literature,
Nursing Reference Center, PsychINFO, PubMed, Scopus,
Sociological Abstracts) were searched for articles related to
ethics in spiritual care. Key search terms were ethics,
spirituality, spiritual care, religion, clinician, health provider.
Inclusion criteria were published articles between the years
19802011, in the English text, theoretical articles, clinical
articles and research studies. The articles could pertain to
health providers of any discipline. Clinical case studies or
articles that dealt with research participants under age 18
were excluded. This resulted in 21 research articles and 14
theoretical/discussion papers.
Thematic analysis of his literature involved the following
steps: (1) Both authors read and re-read the articles; (2)
categories were developed based on statements regarding the
ethics of integrating spirituality and religion into clinical care;
(3) themes were identified; and (4) consensus was established
on both categories and themes between the two authors.
Results
The analysis of the literature uncovered four themes which
are: ethical concerns of omission of spiritual care, ethical
2012 Blackwell Publishing Ltd
Journal of Clinical Nursing, 21, 20992107
Ethical issues in spiritual care
concerns of commission of spiritual care, situations under
which health providers prefer to offer spiritual care, and
strategies to integrate spiritual care into practice.
The first two themes of omission and commission can lead
to a polarisation of extremes in how health providers
approach spirituality in the health encounter. The second
two themes reveal pragmatic aspects of approaching spiritual
care in the clinical setting.
Ethical concerns of omission
Many authors have postulated that it is unethical for health
care providers to omit spiritual care. The primary reasoning
for this is a challenge to strict dualism and a belief that patients
are holistic human beings, including physical, psychological,
social and spiritual aspects of the self (Pesut & Thorne 2007,
Pembroke 2008, Koslander et al. 2009). Health care providers
have an ethical obligation to attend to all dimensions of a
person and provide holistic care (Cohen et al. 2001, Pesut
2006; Chattopadhyay 2007, Pesut & Thorne 2007).
Much of the writing on ethics and health are grounded in
four principles: beneficence, non-maleficence, autonomy and
justice (Beauchamp & Childress 2009). In nursing, justice is
often referred to as advocacy. The omission of spiritual care
can be seen as leading to violations of these principles
(Wright 1998). Beneficence, the duty to do what benefits the
patient, involves a nurses commitment to give of the self in
interaction with patients, as well as to respect patients
spiritual beliefs. Omitting spiritual care, because a nurse fears
personal discomfort in dealing with spiritual issues, resulting
in failing to address aspects of vital importance to a patient
would be an example of maleficence (the principle of non-
maleficence is restraint from harming another).
The next ethical principle, autonomy, is the right of patient
self-determination. The principle of autonomy requires that
nurses set aside their own personal beliefs and assess and
meet patient spiritual needs, from the perspective of what is
important to the patient (Wright 1998). Finally, by being a
patient advocate, nurses assist patients in achieving auton-
omy. Nurses can assist patients in finding meaning and hope,
and clarifying their spiritual beliefs and values. Therefore, if
spiritual care is omitted, patients may not have the oppor-
tunity to voice their spiritual needs and concerns and have
them addressed.
Buetow (2004) and Kuczewski (2007) note that under-
standing a patients religious and spiritual beliefs is a part of
providing culturally competent care. Knowledge about the
belief systems of patients is important in understanding their
motivations, respecting their rights and practicing individu-
alised patient care and the ethic of beneficience. The
2101
RLP Casarez and JC Engebretson
culturally competent health care provider would include the
patients religious beliefs in the process of making decisions
about health.
Barriers to spiritual care contributing to its omission
include different spiritual belief systems between the patient
and clinician resulting in lack of a common spiritual
language (Ellis et al. 2002). Another related barrier is
discrepancy about the importance of spirituality in health
care (Ellis & Campbell 2005). These differences often result
in the inability of patient and physician to share faith stories,
resulting in a more superficial patient/clinician relationship
(Ellis & Campbell 2005).
Health care professionals often report feeling incompetent
and are reluctant to approach spiritual issues because they do
not know how to provide spiritual care or speak about
spirituality (Wright 1998, Fletcher 2004, Holmes et al.
2006). Similarly, health professionals often remark that they
do not have sufficient training to provide such care (Ellis
et al. 1999, Olson et al. 2006). Some clinicians do not believe
it is part of their job (Holmes et al. 2006).
Situational barriers also exist. These include lack of time in
the clinical setting, (Wright 1998, Ellis et al. 1999, 2002,
Fletcher 2004, Holmes et al. 2006, Olson et al. 2006) an
ineffective setting (e.g. an exam room) (Ellis et al. 2002) and
management not perceiving spiritual care to be a priority
(Fletcher 2004).
Another situational barrier is related to ones employer.
For example in the US., governmental institutions must abide
by the first amendment requirement for separation of church
and state, yet also provide holistic health care. Warnock
(2009) reports an incident in the Veterans Administration in
which the Freedom from Religious Foundation (FFRF), a
national organisation of atheists and agnostics, recently
brought legal action against them for providing spiritual
care. The FFRF lost the lawsuit because the ruling was made
that spiritual care was permissible because it was voluntary.
It might also be argued that failure to address spiritual needs
is a violation of freedom of religion.
Finally, patients perceptions of barriers about discussing
spiritual care with their physician include that physicians are
not interested or too busy (Herbert et al. 2001, Holmes et al.
2006); have a fear of offending someone of a different faith,
lack sufficient training for a spiritual discussion (Herbert
et al. 2001); or do not have the time to discuss spiritual care.
(Holmes et al. 2006).
Ethical concerns of commission
Ethical concerns of commission include the inappropriate
application of spiritual care. Major concerns of commission
2102
are coercion and overstepping ones competence in offering
spiritual care. Pesut and Sawatzky (2006) identify two
approaches to spiritual care: descriptive or prescriptive. The
descriptive approach describes what the nurse does in
response to the spiritual needs of the patient. Examples are
using spiritual interventions, such as listening, respect,
establishing trust and supporting the wishes of patients.
Conversely, the prescriptive approach attempts to modify the
spirituality of the patient. This involves establishing a
spiritual goal (e.g. discovering meaning and purpose, finding
forgiveness, reframing beliefs about God, coming to salva-
tion), for the patient. Establishing such a goal for a patient,
particularly if it imposes the belief system of the nurse, can
lead to coercion.
Similarly, Cohen et al., (2001), and Pembroke (2008) note
that because of the social power the health care provider has
over the patient, the provider should not prescribe spiritual
activities for patients. Examples of such prescriptive activities
are initiating prayer with the patient and deliberately taking
spiritual assessments of patients to counsel them towards a
specific goal.
Pesut (2006) describes three approaches to spiritual care
that may be potentially coercive to patients. In the humanistic
approach, patients define what spirituality is for them. Nurses
then seek what is important to patients in terms of spirituality
to address any concerns. This is most often exemplified
through the nursing process in which nurses use structured
assessment guides, clinical diagnosis goals, interventions and
evaluation criteria to obtain this information. A potential
ethical issue associated with this approach is that it suggests
that there may be some objective reality (p. 131) by which a
nurse can make a judgment about a patients spiritual state
(e.g. purposeful behaviour). However, some patients may not
experience spiritual growth in such positive ways. Therefore,
this process may be intrusive and objectifying.
The second approach which is the theistic view, involves
the nurse applying theological concepts based on an under-
lying assumption that the origin of spirituality lies in God
(Pesut 2006). Humans must live in a relationship with God,
which includes health and well-being. Nursing is regarded as
a vocational service to human beings and to God. A potential
problematic ethical issue is that some nurses holding this view
feel that they have a responsibility to share their faith with
patients, even if this is not comfortable for patients. The
nurse may use vulnerable times to influence a patient towards
a specific spiritual belief system, which again may be
coercive. In the monistic view, nurses promote growth and
healing through attention to universal consciousness. The
emphasis is on the soul, as opposed to body work. Spiritual
care may transcend the physical restrictions of space and
2012 Blackwell Publishing Ltd
Journal of Clinical Nursing, 21, 20992107
Discursive paper
time, and may include energy-based forms of healing, such as
Therapeutic Touch, Healing Touch and Reiki Therapy. A
potentially ethical issue with the monistic approach is that
certain theistic traditions may consider energy-based thera-
pies to be incompatible with their religious beliefs. Some
nurses may not realise that by introducing these therapies
without making sure they are harmonious with the patient
belief system, they may be spiritually harmful to a patient,
and therefore unethical.
Another ethical concern of commission is clinician over-
stepping his or her level of competence. Based on the
argument on inadequate preparation, and increasing religious
diversity, Vandecreek (1999), discourages physicians from
discussing religious and spiritual issues with patients. Vande-
creek (1999) also emphasises that adequate preparation in
offering spiritual care is vital. Therefore, patients should be
referred to appropriately trained clergy, as physicians do not
have the proper training to address spiritual issues. Discuss-
ing spiritual issues with patients may evolve into complex
personal and theological dilemmas for which physicians are
not prepared. Similarly, Pesut (2006) remarks that if nurses
are to claim an ethical responsibility to spiritual care, they
must clearly describe the nature of this care, and receive the
appropriate education to perform this care competently.
Conditions for spiritual care
There are conditions under which health providers are more
likely to offer spiritual care. The most common scenarios are
if the patient requested or brought up spirituality (Monroe
et al. 2003, Curlin et al. 2006, Olson et al. 2006), or the
patient was terminally ill (Daaleman & Frey 1998, Ehman
et al. 1999, Ellis et al. 2002, Monroe et al. 2003, McCord
et al. 2004, Olson et al. 2006). Other situations are related to
specific illnesses, such as the patient having a severe medical
illness (heart disease, cancer, depression, anxiety), pregnancy,
miscarriage, traumatic illness in the family (Ellis et al. 2002)
or undergoing major surgery (Cohen et al., 2001). Condi-
tions also include marital and family counselling (Daaleman
& Frey 1998), loss of loved ones (McCord et al. 2004); the
presence of symptoms without an explanation, role change
within the family, ICU admission, treatment failures and
patient dissatisfaction with progress of treatment (Ellis et al.
2002).
Physicians are more likely to offer spiritual care if they
identify themselves as religious or spiritual (Ellis et al. 2002,
Luckhaupt et al. 2005, Olson et al. 2006) or have a high level
of religiosity (Luckhaupt et al. 2005, Curlin et al. 2007).
Other factors include the physician being Protestant (Olive
1995, Curlin et al. 2006), female (Holmes et al. 2006), in
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Journal of Clinical Nursing, 21, 20992107
Ethical issues in spiritual care
practice longer than 15 years (Daaleman & Frey 1998) and
having the belief that religion had health relevance (Chibnall
& Brooks 2001).
Many patients wish to receive spiritual care, but they are
more likely to want spiritual care under certain scenarios. The
most common scenario is if the patient has a life-threatening
illness (MacLean et al. 2003). Others are if the patient is in
poor health or has a serious medical condition (Mansfield
et al. 2002, McCord et al. 2004); or the patient recently lost a
loved one (McCord et al. 2004). Patients are also more likely
to want spiritual care if they are female (Mansfield et al. 2002)
or African American (MacLean et al. 2003).
Strategies to integrate spiritual care into clinical practice
Several authors agree that the general approach towards
offering spiritual care should be descriptive, rather than
prescriptive (Pesut & Sawatzky 2006, Winslow & Wehtje-
Winslow 2007). In general, the recommendations for health
providers are to follow patients wishes regarding spiritual
care, rather than prescribing or encouraging patients to
relinquish spiritual practices (Winslow & Wehtje-Winslow
2007). Health professionals should be supportive resources
for patients through establishing trust, listening, being
respectful (Pesut & Sawatzky 2006) and being neutral and
sensitive towards spiritual issues (Fletcher 2004). It is also
important for providers to empower patients to express their
own values (Winslow & Wehtje-Winslow 2007).
A variety of specific spiritual strategies are discussed in the
literature. Cohen et al. (2001) suggest that the physician
should first develop rapport with patients before asking about
religion or spirituality. They also recommend that, at
minimum, patients are asked whether they have spiritual or
religious beliefs that are of significance to them, the impor-
tance of these beliefs, and how these beliefs might affect their
choices about medical care, and/or affect treatment choices.
Other strategies include allowing spiritual discussion to
evolve from the psychosocial history, e.g. asking what would
help with stress (Herbert et al. 2001), reinforcing the impor-
tance of spiritual coping mechanisms, asking spiritual ques-
tions at onset of the relationship and again during crises, and
assessing and affirming patients spiritual resources (Ellis
et al. 2002). Pembroke (2008) advocates that physicians take
a spiritual history, not to engage in the complexity of spiritual
issues, but as an expression of holism, and to acknowledge
spirituality as an important aspect of the patients life, in the
context of illness and care.
Specific recommendations have been proposed for working
in restricted environments, such as governmental institutions.
Fletcher (2004) reinforces the idea of nurses as advocates by
2103
RLP Casarez and JC Engebretson
offering spiritual care for individual patients and their
families. Suggested strategies include allowing for large
numbers of family and friends in patients rooms for healing
ceremonies, allowing for expression of spirituality through
music, or through religious practices that may be unfamiliar
to the clinician, and giving comfort to family members.
Designing a room for patients and family members which
include educational material on spiritually related issues,
such as forgiveness, end-of-life issues and dealing with loss
was also suggested. Warnock (2009), in relation to the FFRF
lawsuit, recommends using spiritual care policies and proce-
dures that are consistent across programs, allowing patients
to define religion and spirituality themselves using culture
and religiously neutral terminology and providing informed
consent to patients upon utilisation of their spiritual assess-
ment questionnaire and for the provision of subsequent
spiritual care.
Much of the literature is in agreement that it is ethical for
health providers to pray publicly with patients, if the patient
initiates the request and the health provider is comfortable in
this situation (Cohen et al., 2001; Curlin et al. 2006, Win-
slow & Wehtje-Winslow 2007, Pembroke 2008). Pembroke
(2008) also notes that if health providers are uncomfortable
in accepting a patients request for prayer, they can demon-
strate respect by recommending colleagues or chaplains who
would be willing to share in prayer with the patient.
Curlin et al. (2005) discuss physician recommendations on
ways to address conflicts in care between the patients and
health providers due to different spiritual belief systems. The
recommendations for clinicians are as follows: first, try to
remain open-minded and make every effort to understand the
patients point of view. In cases where the provider feels the
patient would suffer harm from not accepting treatment,
encourage the patient to incorporate religious ideas and
practices as adjuncts to treatment, rather than as substitutes.
Providers might also reason from the patients religious view
that the medical therapy is not only compatible, but possibly
encouraged by the patients belief system. If either of the
above fails, ask for assistance from the patients family or
religious community, and in the case of an impasse, refer the
patient to another provider.
Discussion
There is extensive discussion in the literature about the
conditions under which spiritual issues are important in
health care. Despite these discussions, there is considerable
discourse about how or if clinicians, of any discipline, should
address spirituality in practice. This discourse reflects a
dichotomised or polarised debate at the extremes of omission
2104
and commission: the evangelistic mission of incorporating
spiritual elements into patient care that can provide a
spiritual conversion at an important and vulnerable point in
the persons life or a complete secularisation of health care
with strict adherence to scientific regimens. There are good
arguments against both areas of extremes. Both of these
extremes can propagate ethical maleficence of commission or
omission. It is vital to any ethical clinical practice to clearly
understand that the patient is in a vulnerable position: 1)
related to the social position of the clinician (physician or
nurse) as authority by virtue of knowledge that the patient
doesnt have and 2) by the fact that the patient is either ill or
worried about becoming ill.
In addition to the bioethical principles, one can evoke
Aristotles (trans. 1999) caution against the vices of excess
and deficiency from his discourse on the ethics of virtue to
begin to ground the discussion on the appropriate position
for clinicians. As most of the egregious ethical problems seem
to come from the two extreme ends of the continuum, the
best course is in the more intermediate area or as the moral
virtue as a mean between two vices.
On the extreme evangelistic side, the clinician is coercing a
vulnerable patient to convert to the providers religious
perspectives (excess). This can violate patient autonomy and
may put into question the first amendment of separation of
church and state. On the totally secular side (deficiency) again
the provider is imposing his views of religion (that of denial
or atheism), often evoking the first amendment. It is
important to note that the first amendment to the US
constitution advocating for separation of church and state,
provides for freedom of religion, not freedom from religion.
One could argue that this rigid stance also violates the
patients freedom and autonomy. Aristotle (trans. 1999)
discussed at length the importance in many situations of
seeking the intermediate path (virtue), and avoiding the two
extremes of excess and deficiency (vices). The issue of
incorporating spirituality in clinical care seems to be a very
appropriate situation to apply this rendering of the celebrated
golden mean or moderation in most things. This position
also allows for the actions to be flexible but also to be guided
by the principles of autonomy, beneficence and non-malfi-
cence (Beauchamp & Childress 2009).
Culture, defined as shared values, beliefs and related
behaviours (Atkinson 1995) has relevance in incorporating
spirituality and religion in health care. Religious beliefs and
practices have been the focus of many ethnographic studies in
health care (Malefijit 1989). As basic values and beliefs are
often rooted in religious beliefs and practices, they are often
very pervasive and guide the behaviour of both the patient
and clinician. One of the major concerns in incorporating
2012 Blackwell Publishing Ltd
Journal of Clinical Nursing, 21, 20992107
Discursive paper Ethical issues in spiritual care

spiritual or religious issues into clinical practice is the
increasing cultural diversity with its concomitant diversity
of spiritual and religious beliefs and practices.
Using an approach of cultural competency may provide
clinicians with an awareness of their beliefs and allow them a
position to better understand the beliefs of the patient. A well
published rubric is the cultural competency continuum (Cross
et al. 1989) which posits harmful discrimination or destruc-
tiveness at one end and cultural competency and proficiency
at the other. It is noteworthy that cultural blindness (treating
all cultures alike while not differentiating among cultural
differences) is at the lower end of the scale just above
destructiveness and incapacity. Above this are precompe-
tence, competence and finally proficiency at the high end. At
higher levels of competency, the concept of individualised
patient centred care is paramount (Engebretson et al. 2007).
Accommodating individual patients values, beliefs and
circumstances is also an essential part of implementing
evidence based practice (Strauss et al. 2005).
Paasche-Orlow (2004), writing on ethics and cultural
competency, advocates that culturally competent care is a
moral good that emerges from an ethical value and commit-
ment to patient autonomy and justice (p 349). He identified
the ethical principle of cultural competence as the following:
(1) acknowledgment of the importance of culture in peoples
lives, (2) respect for cultural differences and (3) minimising of
any negative consequences of cultural differences (pg 347).
These principles exhort the clinician to appreciate that a
narrow biomedical vision of disease is insufficient. This does
not imply a thorough knowledge of all cultures or religions,
but rather good communication skills and openness to
learning about this individual patients beliefs, values and
practices. The profession of nursing has long advocated for
patient autonomy and advocacy, which is reflected in many of
the codes for practice, so a respect for cultural and religious
differences is a logical aspect of this stance.
commission. These concerns have reflected a polarisation of
extremes in how health providers deal with spirituality in the
clinical encounter, with an ethic of avoiding either extreme.
The discourse also revealed pragmatic strategies to integrate
spiritual care into clinical practice.
Relevance to clinical practice
In clinical application, the ethical principle of beneficence is
paramount. The first step is self-awareness. The clinician
begins by reflecting on personal values and beliefs regarding
spirituality and religion. If the nurse has views that spiritu-
ality is extremely important or extremely unimportant, which
are at the polar ends of the continuum, then self awareness of
this is a call for caution in imposing those beliefs on patient
care. If the nurse is very uncomfortable in dealing with
spiritual issues, there are often other members of the health
care team to whom the nurse can consult or refer. It is
paramount to remember that spiritual or religious issues may
be essential to good patient care and to culturally competent
care.
The next step is to use good communication skills to better
understand the patients beliefs, values and spiritual concerns.
This sets the basis for providing the best care that is
individualised and addresses the specific spiritual needs of
that patient.
Zinnbauer and Pargament (2000) have also identified a
number of specific approaches and applications in incorpo-
rating spirituality or religion in clinical care. These include
careful examination of ones model of treatment and
assumptions the model makes about religion and spirituality,
appraisal of the patients religion or spirituality upon initial
assessment, training in multicultural counselling and acquir-
ing knowledge about specific religious traditions frequently
encountered in ones clinical practice.

Contributions
Conclusion
Study design: RC, JE; data analysis: RC, JE and manuscript
The discourse analysis uncovered two concerns related to preparation: RC, JE.
spiritual care in the clinical setting: concerns of omission and

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