T H E WA Y F O R WA R D doi: 10.1111/j.1365-2702.2006.01648.

The principal components model: a model for advancing spirituality

and spiritual care within nursing and health care practice
Wilfred McSherry BSc, MPhil, PhD, RGN
Senior Lecturer, Department of Nursing and Midwifery, Faculty of Health and Social Care, University of Hull, Hull, UK

Submitted for publication: 22 November 2005

Accepted for publication: 22 February 2006

Correspondence: McSHERRY W (2006) Journal of Clinical Nursing 15, 905–917

Wilfred McSherry The principal components model: a model for advancing spirituality and spiritual
Department of Nursing and Midwifery care within nursing and health care practice
Faculty of Health and Social Care
Aim. The aim of this study was to generate a deeper understanding of the factors
Foss Building
and forces that may inhibit or advance the concepts of spirituality and spiritual care
West Campus
University of Hull within both nursing and health care.
Cottingham Road Background. This manuscript presents a model that emerged from a qualitative
Hull study using grounded theory. Implementation and use of this model may assist all
HU6 7RX health care practitioners and organizations to advance the concepts of spirituality
E-mail: w.mcsherry@hull.ac.uk and spiritual care within their own sphere of practice. The model has been termed
the principal components model because participants identified six components as
being crucial to the advancement of spiritual health care.
Design. Grounded theory was used meaning that there was concurrent data col-
lection and analysis. Theoretical sampling was used to develop the emerging theory.
These processes, along with data analysis, open, axial and theoretical coding led to
the identification of a core category and the construction of the principal compo-
nents model.
Methods. Fifty-three participants (24 men and 29 women) were recruited and all
consented to be interviewed. The sample included nurses (n ¼ 24), chaplains
(n ¼ 7), a social worker (n ¼ 1), an occupational therapist (n ¼ 1), physiotherapists
(n ¼ 2), patients (n ¼ 14) and the public (n ¼ 4). The investigation was conducted
in three phases to substantiate the emerging theory and the development of the
model.
Results. The principal components model contained six components: individuality,
inclusivity, integrated, inter/intra-disciplinary, innate and institution.
Conclusion. A great deal has been written on the concepts of spirituality and spir-
itual care. However, rhetoric alone will not remove some of the intrinsic and
extrinsic barriers that are inhibiting the advancement of the spiritual dimension in
terms of theory and practice.
Relevance to clinical practice. An awareness of and adherence to the principal
components model may assist nurses and health care professionals to engage with
and overcome some of the structural, organizational, political and social variables
that are impacting upon spiritual care.

Key words: health care, nurses, nursing, qualitative research grounded theory,
spiritual care, spirituality

2006 Blackwell Publishing Ltd 905

W McSherry
Introduction
Within health care there seems to be a consensus that the
term spirituality is deeply subjective because it has many
interpretations (Byrne 2002). During the last decade, the
concept has come under considerable scrutiny, by a range of
health care professions including nurses, chaplains, physi-
cians, social workers and, more recently, occupational
therapists.
Despite the academic and theoretical enquiry, much of the
debate has lacked criticality resulting in the perpetuation of
definitions neither based on nor tested through empirical
study (e.g. Murray & Zentner 1989, Tanyi 2002 and, more
recently, Cook 2004). However, these definitions are useful
because they provide nursing and health care with a
descriptive and tangible grasp on what may constitute
spirituality. Having stated this within the contemporary
literature there is a noticeable shift as commentators start to
challenge and refine some of the theoretical and conceptual
constructs associated with spirituality (Draper & McSherry
2002, Swinton & Narayanasamy 2002, Henery 2003, Tilley
& Ryan 2003, Bash 2004, MacLaren 2004, Narayanasamy
2004, Whitehead 2006). This deeper level of deliberation is
welcome because it will undoubtedly help refine and advance
the spirituality agenda.
In addition, there is an urgent need for nursing and, indeed,
health care at all levels: organizational, managerial, practice
and educational to move beyond the theoretical. Considera-
tion needs to be given to issues such as transferring theory
into practice (Oldnall 1995, 1996) and ensuring that the
theory reflects the cultural, religious and ethnic diversity
existing within contemporary societies.
This paper provides a model or framework termed prin-
cipal components model that arose out of an empirical study
(Fig. 1). It raises awareness of some of the structural,
organizational, cultural and personal concerns that may
prevent the advancement of spirituality within health care.
Contextualization
Literature review
A search of the electronic databases CINHAL and MEDLINE
from 1991 to 2003 using key words: spirituality and spiritual
care in combination with qualitative, quantitative and groun-
ded theory, led to the identification of 36 original research
papers. A general search using just the word spirituality
resulted in over 2000 papers being identified. To restrict the
number of papers limiters were applied: the papers were
written in English, contained an abstract with the research
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2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 905–917
Individuality
I
n
n
a Integrated Inclusivity
t
e
Inter/intra
disciplinary
Institution
Figure 1 Principal components model. For The advancement of
spirituality and spiritual care.
design clearly stated. The literature review focused upon
identifying central themes and empirical research studies.
However, this section addresses only how grounded theory
studies have been used to investigate the spiritual dimension.
Outline of the studies using grounded theory methodology
The literature review revealed that 23 international studies
had been conducted using qualitative methods, for example,
phenomenology (Carroll 2001) ethnography (Shirahama and
Inoue 2001) and grounded theory (Walton 1999 and Caven-
dish et al. 2000). Eight grounded theory investigations were
identified exploring diverse aspects of spirituality, six inter-
national and two conducted in the United Kingdom (UK).
The significant properties of each of the studies (Hungelmann
et al. 1985, Burkhardt 1991, 1994, Harrison & Burnard
1993, 1999, Thomas & Retsas 1999, Cavendish et al. 2000,
Walton & St Clair 2000, S. Kearney, University of Hull, Hull,
unpublished dissertation, J. Walton, University of Missouri-
Kansas City, unpublished doctoral dissertation) are summar-
ized in Table 1.
The review established that grounded theory has been the
most frequently used qualitative methodology in the explo-
ration of the spiritual dimension. One reason for this may be
that grounded theory (as do other qualitative methods)
allows the researcher to discover attitudes, meanings and
characteristics. In addition, this method allows the researcher
to explore a phenomenon that is not readily visible. More
importantly, grounded theory enables the researcher to
construct and test existing theory.
The way forward
Table 1 Summary of grounded theory investigation
Author (year)
Hungelmann et al. (1985)
Burkhardt (1991, 1994)
Harrison and Burnard (1993)
Kearney University of Hull,
Hull, unpublished
dissertation
Walton (University of
Missouri-Kansas
City, unpublished
doctoral dissertation, 1999)
Thomas and Retsas (1999)
Cavendish et al. (2000)
Walton and St Clair (2000)

2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 905–917
Purpose
Determine defining characteristics of
spiritual well-being
Identify and describe how women in
Appalachia view their spirituality
and to describe characteristics of
spirituality as understood by these
women
Explore trained nurses perceptions of
spirituality both personally and
professionally in order to highlight
their knowledge and understanding
Investigate the role of spirituality as a
coping mechanism in multiple
sclerosis viewed from the patients
perspective
Discover what spirituality means fro
patients with an acute myocardial
infarction and to identify patient’s
perceptions of how spirituality
influences their recovery
Construct a grounded theory
explaining how the spirituality of
people with terminal cancer develops
Explicate the opportunities that occur
in life that either support or enhance
spirituality in adult
Identify what spirituality means to
heart transplant patients and to
identify perceptions of how
spirituality influences illness and
recovery
A model for advancing spirituality and spiritual care
Number of
participants Theory developed
n ¼ 31 no break Basic social process of harmonious
down by gender interconnectedness was discovered with two
provided major themes that applied to all categories
harmony and connection
n ¼ 12 Females Common understanding of spirituality that
was identified – a unifying force that shapes
and gives meaning to the pattern of one’s
Self becoming and connecting
n ¼ 10 no break Three higher order headings; The concept of
down by gender spirituality; Spirituality and nursing
provided practice, and the spirituality of nurses.
General categories identified were –
definitions of spirituality, relevance and
importance to the nurses role,
manifestations of patients’ spiritual needs,
nurses’ beliefs relating to the ‘why’ of
suffering, nurses’ beliefs relating to
mortality nurses sources of hope and
strength
n ¼ 11 Spirituality was viewed as an effective
Six females strategy helping patients cope with chronic
Five males illness, discover meaning in illness and
suffering, combat loneliness and isolation,
satisfy the human desire to give and receive
love, redress the balance between lack of
locus of control due to chronic illness,
encourage hope and a positive outlook
n ¼ 13 Core category ‘receiving presence had four
Four females sub categories divine presence, presence of
Nine males friends, family, or community; presence of
health care providers. ‘Receiving presence
also permeated three subcategories
developing faith, discovering meaning and
purpose and giving the gift of self
n ¼ 19 Identification of one single unifying core
12 females category labelled ‘transacting self
Seven males preservation’. This process is dependent
upon three behaviours ‘talking it all in’,
getting on with things’ and putting it all
together
n ¼ 12 Two overall domains emerged as significant
Eight females to participants’ physical domain,
Four men metaphysical domain. Seven themes
emerged from domains – connectedness,
beliefs, inner motivating factors, divine
providence, understanding the mystery,
walking through and life events
n ¼ 11 Two core categories were identified
Four females – enduring illness and Sustaining hope
Seven males
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W McSherry
Study design
To gain access to the perceptions of spirituality held by health
care professionals, patients and the general-public and also to
gain information regarding the extent to which they expect
either to provide or receive spiritual care, qualitative research
was conducted using a grounded theory method of inquiry
(Glaser & Strauss 1967). Strauss and Corbin (1998, pp. 158–
159) tell us that ‘Grounded Theory is a general methodology
for developing theory that is grounded in data systematically
gathered and analysed’.
Aim and objective
The investigation had one broad research aim and three
objectives (see W. McSherry, Leeds Metropolitan University,
Leeds, unpublished PhD thesis, pp. 122–123):
The purpose of this investigation is to explore the subjective nature of
spirituality and spiritual care by using existing theory to reflect upon
the way in which health care professionals, patients and public
perceive the concept from within diverse care settings and with
differing religious/world views.
Objective three is concerned directly with this paper:
To produce a model of spirituality in order to generate a deeper under-
standing of the concept for use within nursing and the wider health
care community in order to shape future practice and education.
Recruitment
A small recruitment questionnaire was constructed and
piloted during phase 1. This obtained information about an
individual’s perceptions of spirituality and assisted in iden-
tifying who would be willing to be interviewed. The areas
addressed in the questionnaire are detailed in Box 1. Ques-
tion 4 asked respondents to select one statement that best
reflects their understanding of the word spirituality. The
statements were:
Box 1 Areas addressed in recruitment questionnaire
Q1 Gender
Q2 Age
Q 3 a, b, c Length qualified, Type of work, Grade
(health care professionals only)
Q3 Length of stay in hospital or hospice (patient)
Q4 Statement about spirituality
Q5 Religion
Q6 Practising religion
Final section Willingness to participate in an interview
and contact details.
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2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 905–917
• Spirituality involves only religion;
• Spirituality is concerned with finding meaning, purpose
and fulfilment in life;
• Spirituality applies to all people even those who are unsure
or do not believe in any God;
• I do not know what is meant by the term spirituality.
These statements reflected the main classifications of
spirituality as detailed in health care definitions (Murray &
Zentner 1989, Tanyi 2002). The recruitment questionnaire
was distributed to staff and patients by charge nurses
(W. McSherry, Leeds Metropolitan University, Leeds, unpub-
lished PhD thesis). This approach to recruitment was adopted
in all phases of the research. Completed questionnaires
were examined, the information collated and a database
of potential participants created. This database was very
helpful for theoretical sampling because of the potential to
identify participants to advance the emerging theory.
Participants
Fifty-three participants (24 men and 29 women) age range
18–80þ were recruited and consented to be interviewed. The
sample included nurses (n ¼ 24), chaplains (n ¼ 7), a social
worker (n ¼ 1), an occupational therapist (n ¼ 1), physio-
therapists (n ¼ 2), patients (n ¼ 14) and the public (n ¼ 4).
Although the major world religions were represented the
majority of participants were from Christian denominations.
Participants were recruited from three areas: area I (A
hospice); area II (A large Acute National Health Service
Trust) and area III (A large Acute National Health Service
Trust). Areas I and III were in the same city in the North of
England. Area II was in another city in the same geographical
region. Using two different regions allowed capture of ethnic
and religious diversity. Area II was specifically selected as the
most recent National Census (Office for National Statistics
2001) identified it as a region that contains a greater diversity
of ethnic groups than areas I and III.
Sampling methods
Two forms of sampling were used. At the outset of data
collection, purposeful or open sampling allowed a broad
range of nurses and patients to be recruited into the study in
an attempt to capture the diversity of belief, professional
experience, religious affiliation and understandings about
spirituality.
As interview transcripts were analysed and themes began
to emerge, the sampling thus became more focused. At this
stage theoretical sampling was applied meaning that individ-
uals were recruited with the specific aim of advancing or
checking out an emerging theme or idea within the data. For
The way forward
example, in phase 3 a number of chaplains, health care
professionals and people with a specific religious belief were
recruited to clarify the notion of teamwork with regard to
spiritual care.
All participants who agreed to be interviewed were
contacted by telephone to arrange a suitable date. For
patients and the general public this contact was supported
by a letter containing an information leaflet providing
essential information about the study.
Ethical approval/issues
Ethical approval was gained from the relevant Local
Research Ethics Committees. Institutional permission and
access were negotiated with Service Managers once Research
Governance Committees had also approved the investigation.
Verbal and written consent were obtained prior to all
interviews. All transcripts and information pertaining to
participants were kept in a locked filing cabinet. Participants
were given a code to ensure anonymity and confidentiality.
After interview, participants also had the opportunity to
access counselling.
Data collection/analysis
In line with grounded theory, there was concurrent data
collection and analysis. Semi-structured interviews were
conducted. All interviews were recorded and transcribed in
full during phases 1 and 2. Partial or selective transcribing was
undertaken during phase 3. Interview transcripts were ana-
lysed and coded. Codes were used to form categories, proper-
ties and central themes. In grounded theory, the theory emerges
from the data as opposed to a set of preconceived ideas being
imposed on the data by the researcher. Tape recordings were
repeatedly listened to, analysed, coded and recoded to make
sense of the data and develop the emerging theory. Theoretical
notes and memo writing aided theory development.
Coding
Three levels of coding were used to break down and manage
the data. Initially level I – or substantive (open) coding in-
volved analysis of every word, line and paragraph of each
interview transcript. This process led to the identification of
concepts, properties and dimensions within participants’
transcripts, for example, how participants understood and
defined spirituality.
Level II – axial (theoretical) coding: a technique introduced
by Strauss and Corbin (1998). This type of coding is about
relating and making links between and across categories,
subcategories and participant groups. For example several

2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 905–917
A model for advancing spirituality and spiritual care
patients felt spirituality to be concerned with supernatural
forces whilst the majority of nurses felt spirituality is
associated with inner self. This type of analysis led to the
formation of a category called ‘definitions of spirituality’ with
the subcategories labelled ‘supernatural forces’ and ‘essence
and core’. By constantly asking questions of the data the
emerging theory was refined.
Level III (Selective) coding assisted in the identification of a
core or overarching category that was able to clarify the
emerging theory. This type of coding led to the identification
of a core category termed ‘Assumption vs. expectation’
and the construction of the principal components model
(W. McSherry, Leeds Metropolitan University, Leeds,
unpublished PhD thesis).
The three levels of coding were not necessarily discrete or
sequential in nature, meaning they could be performed
simultaneously. Concurrent data collection and analysis
meant that the study had three interconnecting phases. Each
of the phases advanced the emerging theory.
Phases of the study
Phase 1 acted as pilot study and explored participants’ un-
derstandings of the terms ‘spirituality’. It was conducted
principally with patients and nurses from the hospice. Phase 2
was carried out with nurses and patients in the two acute
NHS Trusts. In this phase, several questions were asked to
determine whether patients and nurses would recognize the
constituents of spirituality as expressed in the health care
literature (Box 2). In phase 3, the findings from phases 1 and
2 were explored with a number of health care professionals: a
social worker, physiotherapists and chaplains, who were
recruited from areas I and III. This phase allowed verification
of the theory with a range of participant groups.
Findings and discussion
This section presents and discusses some of the findings
generated in this study. For a more detailed explanation and
account of the overall findings (see W. McSherry, Leeds
Metropolitan University, Leeds, unpublished PhD thesis).
Excerpts of transcript have been used to illustrate and
substantiate some of the findings.
Origin of the principal components
The term Principal Components is derived from the quantita-
tive, scientific paradigm and used in Factor Analysis. However,
the term has been used as it has relevance and significance to the
findings of this study. A principal component in this context
refers to a key component that was perceived by the partici-
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W McSherry

Box 2 Selection of probe questions used during phase 2

People seem to have different ideas about spiritual things. What do you think of as spiritual matters/things?
What do you think people’s needs in this area might be?
During your stay in hospital have you had any spiritual concerns? Or during your life have you ever experienced any spiritual
concerns? Can you describe these?
Do you think that spiritual things are only about going to church or place of worship for the religiously inclined or is it more
than that?
What are your thoughts or ideas about a belief or faith in a God or Supreme Being?
Would this be important to your understanding of spiritual things or not?
What are your thoughts concerning the need to forgive and a need to be forgiven in life?
Do you think of forgiveness as a spiritual matter or not?
Would you say that there is a need to finding meaning in the good and bad events of life?
What gives your life meaning? Do you think of this as a spiritual matter or not?
Have you any thoughts or opinions around nurses enabling patients to find meaning and purpose in their illness?

pants to be fundamental to their understanding of spirituality
and spiritual care. The principal components identified were,
Individuality, Inclusivity, Integrated, and Inter/Intra disciplin-
ary in addition to the terms Innate and Institution. It is
suggested that failure to address these key elements within
health care practice and education will result in the spiritual
needs of all (providers and consumers) being only partially met.
The principal components were identified throughout the
data analysis. With the use of the constant comparative
method it was established that the principal components were
recurrent and cross-cutting themes featuring explicitly or
implicitly within participants’ transcripts within all three
phases of the investigation. For example, the word individual
was used by many patients and health care professionals to
describe the personal nature of spirituality as reflected in the
following excerpt:
P: Spirituality, I think it is personal, it depends on what the individual
believes… (p. 23, patient II).
P: I think we do give a good standard of what we call care to
people and spiritual care is encompassed within that care (p. 1,
nurse I).
Therefore, spiritual care was not perceived as something
separate to the caring process but integral. In addition,
concern was expressed by some health care professionals
that there was a danger of fragmenting spirituality, seeing
it as another dimension to be addressed. Almost all of the
health care professionals articulated that inter/intra disci-
plinary collaboration were central for the delivery of
spiritual care:
R: Who do you feel should be responsible for providing spiritual
care?
P: All of us everybody we have to work together as a team.
Obviously, I think it is the responsibility of everybody, erm, not just
the chaplain, the team, not just the social workers, I think nurses as
well (p. 10, nurse, I).

Likewise, there was a realization by participants, especially In summary the principal components were central and
among health care professionals, that the language surround- fundamental themes that participants considered central to
ing spirituality needed to be inclusive in that it should have their understanding of spirituality and the nature of spiritual
meaning for all people not just those with a religious belief: care.

P: …I think it is wider than that, yes, people that do not believe in a

God can still have spiritual needs or beliefs, or may believe in
something else (p. 26, nurse III).
Regarding the provision of spiritual care, there was aware-
ness by patients and health care professionals that spiritual
care was not something separate to the caring process. On the
contrary, some patients and health care professionals implied
that spiritual care was often hidden, provided subconsciously
during the performance of seemingly routine interactions and
everyday dealings with patients. The belief that spiritual care
is integrated is echoed in the following:
Individual components explained
Individuality. The findings of this investigation imply that
each person had his/her unique perceptions of spirituality
shaped by several factors, culture, socialization, life experi-
ences, religious beliefs and institutions (Cawley 1997).
Therefore, any attempt to define spirituality, while helpful
in that it can elucidate the phenomenon, must take into
account that a definitive or authoritative definition is perhaps
idealistic and unrealistic given the diversity of perceptions
(Narayanasamy 2001). It would appear that the participants
involved in this inquiry had unique, individual perceptions of

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2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 905–917
The way forward
spirituality. The findings also reveal that, for some individ-
uals, the concept of ‘spirituality’ in the manner in which it has
been paraded in health care may be totally alien and have no
significance or meaning to them. For example one patient
stated:
P: I have not a clue. I really don’t know what it means. To me it is just
about religion. I don’t know how you describe it quite honestly.
That’s why when you rung up I thought to my self, I do not know
what I am going to say to you, because I do not know what it means
(p. 22, patient, surgical, III).
Therefore, language, metaphor and symbolism and under-
standing of spirituality will ultimately be individually deter-
mined by cultural, institutional and societal forces.
Stanworth (1997, p. 22) captures this, stating:
It is language which, in our increasing sophistication, we need to
remember rather than learn, for it endows and characterizes the very
essence of humanity.
This quotation also has significance and poignancy, especially
in relation to multi-cultural, inter-cultural and cross-cultural
encounters, because assumptions cannot be made regarding
an individual’s perceptions of spirituality. For one partici-
pant, a Christian chaplain, they had a threefold understand-
ing of the concept:
P: My current understanding is that it is threefold! The meaning
purpose aspect which is most often talked about, is only part of
spirituality and I would say that equally at least relationships and I
still struggle to find the right word, a sense of transcendence awe,
wonder, mystery are also important parts of spirituality and spiritual
care (p. 42, chaplain I).
Conversely, a Hindu participant viewed spirituality purely
within a religious context:
P: Yes spirituality is pertaining to religion and its principles (p. 17,
Hindu male, II).
This finding suggests that there is not a single homogenous
understanding of spirituality. This point can be extended to
include inter- and intra- professional interactions because,
whilst the findings suggest that the majority of health care
professionals interviewed have a shared understanding of
spirituality, a small number was unfamiliar and uncomfort-
able with the concept. For example:
P: Yeah I think in OT’s they might use a similar word because em the
OT’s looking at all the aspects of the person so, that is one aspect
they would probably look at! If someone has got spirituality! But em
I expect on a day-to-day bases it is not a word that is in common
usage! (p. 21, occupational therapist).

2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 905–917
A model for advancing spirituality and spiritual care
The net effect of this finding is that health care professionals
must be guided by the individual patient with his/her
individual spiritual needs whether directly or indirectly
expressed. The danger is that health care is creating a
professional discourse which makes generalization and
assumptions regarding people’s understandings of spirituality
and their expectation in terms of receiving spiritual care
(Rumbold 2002, McSherry et al. 2004).
Moreover, individuality must not be mistaken or confused
with the notion of individualism. The findings revealed that,
while understandings of spirituality are diverse and individu-
ally determined, many participants viewed spirituality not as
an egocentric concept concerning self. On the contrary, many
of the participants felt that their spirituality was shaped and
gained expression through their association with a wider
community or found meaning in the wider service to others.
This was especially apparent with participants from some of
the Eastern faith traditions, for example, in Islam:
P: All of a sudden, you have got the extended family, the immediate
family, the extended family and the community coming to see this
person!…It is a religious duty amongst Muslims within the commu-
nity to visit! (p. 15, Muslim, male II).
Therefore, it would appear that individualism for some
participants does not fit comfortably with their perception of
spirituality.
Inclusivity. Inclusivity, in this context, refers to the need to
capture and reflect the perceptions and concerns of all
stakeholders involved in the delivery of health care. This
insight should also reflect the understandings of the wider
community. The findings caution all health care professionals
to pay specific attention to the language and discourses that
have been constructed otherwise there is a grave risk of
spiritual discrimination. The definitions constructed in health
care may unknowingly alienate some religious and ethnic
groups especially for individuals whose spirituality is based
on unorthodox or perceived morally deviant practices such as
Satanism or the Occult. Some nurse interviewed indicated
that they would support patients from such unorthodox
traditions but indicated that they would have to refer to the
code of professional practice (NMC 2004):
P: Now I would say because somebody’s erm somebody’s spiritual
needs as such that may not be morally right to me! But may be that I
am C of E may be totally disgust them? But I think what you would
have to do is there’d have to be explanations and may be this is just
like a fall back really and you’d have to fall back on the restrictions of
your registration etc and what you are doing and because of the fact
that there are other patients… (p. 6, nurse I).
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W McSherry
An appraisal of some of the definitions of spirituality used in
health care suggests that spirituality is concerned with the
notion of goodness, morals and behaviours that are socially
acceptable (Tanyi 2002). Therefore, we may judge an
individual’s spirituality in terms of a right and wrong against
our own cultural standards and expectations. This approach
is rather restrictive and exclusive and is problematic in that
not all communities, cultures and societies will start from the
same perspective in terms of what is morally right, wrong or
socially acceptable.
Presently, the approach adopted in health care, rather than
being deemed inclusive, could be viewed to be exclusive
reflecting the views of the majority population and, therefore,
it has been perceived as predominantly Judeo-Christian, and
Anglo-American. What Markham (1998, p. 74) refers to as a
secular form of ‘a Christian understanding of spirituality’. It
is my belief that this is not a deliberate attempt to exclude
other ethnic and religious groups from the debate. On the
contrary, as interest in spirituality within health care has
grown, the debate is now reflecting the international, cultural
and religious differences that exist (Conco 1995, Rassool
2000, Chiu 2001, Shirahama & Inoue 2001, Fawcett &
Noble 2004).
Cautionary note
Caution is required since an inherent danger is that, if we
focus solely upon the beliefs and needs of the minority ethnic
and religious groups, we can inadvertently alienate, or even
minimize the beliefs of the majority population.
What we are witnessing at present within the nursing
literature could be construed as anti-religious because there
seems to be some diffidence towards religion and spirituality
(Hollins 2005). There seems to be a desire to move away
from or even eradicate the religious element of spirituality
within definitions (Dyson et al. 1997). Wright (2005) suggests
a cultural shift in terms of how formal religious practice is
viewed. Heelas and Woodhead (2005) term this the ‘spiritual
revolution’.
By redressing the above omissions in terms of reflecting
the diversity of language and understanding this will ensure
the creation of an inclusive definition, or as Hay and Hunt
(2000, p. 42) term ‘reconstruction of a common spiritual
language’.
Inclusivity means that all people working within health
care institutions, whether these are primary, secondary or
tertiary care, be involved in the construction of the concep-
tual and theoretical knowledge. The literature review reveals
that there is under representation of some professional groups
contributing to the conceptual and theoretical debates. Yet,
the findings of this investigation corroborate that the majority
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2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 905–917
of health care professionals feel that attending to the spiritual
dimension of their clients is of paramount importance.
Responsibility for providing spiritual care
A further aspect of inclusivity is the notion of who has
responsibility for providing spiritual care. It could be argued
that, through default, this is best managed by the nursing
profession (Stoter 1995, McSherry 2001, Speck 2005).
However the findings support the proposition that all indi-
viduals including the ward house keeper, the volunteer or the
medical director, have a collective responsibility. This inclu-
sive model will only work if it is instituted with the principles
of equality and equity, meaning that all stakeholders have an
equal share and vested interest. These principles are import-
ant because some patients may undertake a spiritual audit of
all staff to identify a spiritual resource person. Therefore, all
health care staff have the potential to be selected. The idea of
patients undertaking a spiritual audit is evident in the fol-
lowing transcript in which the patient is distinguishing be-
tween a ‘hard’ nurse, concerned with the condition and a
nurse who focuses more on the individual:
P: Facial, attitude, body language, erm, her initial few sentences, gives
her away. You can tell, whether she’s concerned about you as
individual and not as a patient. She will probably ask you ‘oh what
did you do before you came here then?’ As an introduction and you will
give her a few answers and she can work on them, you see spread the
tree out before getting to your complaint. She has established herself!
Where as, the hard nurse will come in ‘what’s all this about pain in your
chest we’ll sort you out?’ You know made the point! (p. 14, patient I).
Therefore, all health care professionals must be informed of
the importance of spirituality and spiritual care for some
patients.
Inter-intra-disciplinary. The literature review confirms that
neither nurses nor, indeed, any of the health care professions
feel that they have a monopoly with regards to spiritual care
(Stoter 1995, Narayanasamy 2001, Taylor 2002, Mowat &
Swinton 2005, W. McSherry, University of Hull, Hull,
unpublished MPhil dissertation). The vast majority of the
nurses and health care professionals interviewed articulated
that the key to success was to be found in inter- and intra-
disciplinary collaboration and working. The terms ‘inter’ and
‘intra’ in this context are defined as ‘inter’ working with other
professional groups and ‘intra’ working within the same
professional group. Stoter (1995, p. 138) highlights the benefits
of ‘team working’ in relation to the provision of spiritual care:
Good teamwork will undoubtedly enhance the quality of spiritual
care available for patients, clients and relatives. It will also bring
The way forward
added strength to the members involved as they learn from each other
finding opportunities for self-development and support, sharing
experiences and skills in the process.
There was an acute awareness among all the health care
professional participants and, indeed, some of the patients, of
the support that can be derived from collaborating and
referring to individuals with more expertise such as chap-
lains, social workers and counsellors.
Taylor (2002) suggests that nurses are the ‘generalists’ in
spiritual care because they do not possess any formal or
advanced training in spiritual matters. Taylor (2002) affirms
that chaplains, social workers and, from the non-western
religions, Shamans and folk healers, may be considered the
‘specialists’ in spiritual care because they may have received
some formal education in spiritual care, pastoral counselling
and psychology.
However, I think it would be more helpful to talk in terms
of partners with shared and collective responsibility rather
than making such arbitrary distinctions which have conno-
tations of inter-professional rivalry. In addition, it might be
more helpful to talk in terms of the generalists and the
specialists having a symbiotic relationship since each are
dependant upon the other with the desired goal of meeting
the patients’ spiritual needs.
Regarding intra-professional working, many nurses spoke
in terms of employing the support and skills of a nurse(s)
whom they felt to be more competent in managing spiritual
issues. Having interviewed such individuals it became appar-
ent that their interest in spirituality stemmed from a strong
religious belief or they developed their knowledge in this area
either informally through personal reading, and reflection or,
more formally, by attending workshops or conferences.
While many nurses implied that this process worked well it
could still be construed as ‘passing the buck’. Besides, there is
also the question of with whom the patient feels comfortable
in addressing spiritual issues. These spiritual resource nurses
may not be the first choice of the patient. A further
consideration is the emotional burden placed upon such
individuals in terms of depleting their own spiritual resources
(Walter 2002).
Avoidance of spiritual issues
It was commented by some nurses that it was very demanding
dealing with patients’ spiritual needs and, because of the
emotional implications, some stated that they would avoid
dealing with patients’ spiritual issues. The notion of avoid-
ance was evident in one nurse’s transcript:
…not having the answers that patients want to hear, so rather than
dealing with that you don’t do it!…Using avoidance rather than, you

2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 905–917
A model for advancing spirituality and spiritual care
know, I think, yeah, possibly using avoidance rather than actually
dealing with it (p. 3, nurse I).
However, many nurses indicated that if they felt that they had
insufficient knowledge or competence to support a patient
then they would refer the matter on to a colleague, chaplain
or a member of the psychosocial team. This mechanism of
referral suggests that practitioners were recognising limita-
tions within their own competence but that they felt
comfortable and reassured that patients’ needs could be met
within the wider team. This practice underlines the theory
that central to the provision of spiritual care is the notion of
inter and intra-disciplinary collaboration.
Integrated. The dilemma all have with a vested interest in the
provision of spiritual care is that we must guard against
‘fragmentation’. Spirituality should not simply be seen as
another box to be filled in on an assessment/admission form.
Bradshaw (1997) implies that, if nursing is truly concerned
with ‘holism’, then the spiritual cannot be divorced from the
physical and material, supporting the idea of integrated care.
A key finding of this investigation is that nurses and some
health care professionals working within diverse care settings
are already providing spiritual care, supporting patients with
their spiritual needs. These professionals are providing
effective spiritual care unaware that they are doing this.
The notion of integrated care is reflected in this excerpt:
R: Would you say that they satisfactorily help you to maintain your
spiritual needs?
P: Yes to a large extent but they do not know they are doing it?
R: So they would not articulate it?
P: No, it is through the care and concern (p. 14, patient I).
I believe that a model of integrated care is central to the
future delivery of spiritual health care.
Innate and institution. Data analysis revealed that two
further ‘I’s’ may be critical in the advancement of spiritual
care, namely the innate nature of spirituality and the
institution. The hypothesis that spirituality is innate within
all individuals is not new. Narayanasamy (1999), reviewing
the work of Hardy (1979) and others, for example, Hay
(1994), reveals that there is growing body of evidence to
support the biological basis or origin for spirituality. This
biological basis founded on the evolutionary principle of
‘biological survival value’.
The idea of all humans possessing a conscious or uncons-
cious awareness of spirituality was articulated by some
participants supporting the theory of a biological basis. This
finding supports the principle of spirituality being universally
913
W McSherry
espoused in health care literature. Universality means that all
individuals possess the potential to experience spirituality. As
one patient commented: ‘we all have spirituality but at very
low levels’.
‘Consciously aware’ was articulated and viewed as a
central part of one’s being and make up. Words like ‘sparkle’,
‘essence’, ‘inner’ and phrases such as ‘it’s what makes you,
you!’ were used to describe and locate spirituality at the core
of the human condition.
‘Unconscious awareness’ was evidenced when individuals
were asked to comment upon, or provide their understanding
of, the term ‘spirituality’. Several individuals felt that they did
not know what was meant by the word. Interestingly, as the
conversation progressed, they began to talk about experien-
ces and philosophies, beliefs they held that had guided their
life that would fall under the umbrella term of spirituality. If
this hypothesis is correct then, technically, all individuals in
need of health care will require some form of spiritual care.
However, this is not an edict to make generalizations.
Institutions
The findings of this investigation suggest that spirituality is
perceived by some patients and health care professionals as a
powerful resource in times of illness and hospitalization. This
supports the findings of earlier studies that attending to the
spiritual needs of patients may enhance one’s sense of well-
being (Hungelmann et al. 1985, Walton 1999, D. Baldac-
chino, University of Hull, Hull, unpublished PhD thesis).
However, if this resource is to be harnessed and the quality of
the patients’ life enhanced then sufficient resources should be
made available by organization and institutions to enable
health care professionals to achieve this goal.
The findings of this investigation suggest that management
within the hospice setting was very much aware of ensuring
that sufficient resources were available in terms of staff being
on duty, not only to meet the physical but also the spiritual
needs of patients. In stark contrast, the acute trusts were
plagued with staff shortages and underinvestment in terms of
staff having time and capacity.
The introduction of spiritual care guidelines (SEHD 2002,
DH 2003, NICE 2004) may once again raise the profile of the
spiritual dimension by placing responsibility for spiritual care
provision at the feet of Chief Executives and Service
Managers. However, such provision should be much wider
than merely addressing what Keighley (1997, p. 49) terms
‘second order outcomes’ that focus upon the structure and
process of service delivery. It is acknowledged that it will be
difficult to provide outcome measures in terms of assessing
the changes in the spiritual state of an individual. However,
the danger is, because of the subjectivity surrounding
914
2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 905–917
spirituality, that guidelines overemphasize policy and stra-
tegic measures, such as calculating sessions for chaplains
instead of engaging with practical issues such as how best to
prepare and support staff in dealing with spiritual matters.
Application of the model to practice
Having explored the individual components there needs to be
some explanation of how the model can be operationalized
and applied within health care practice. First, I will provide a
commentary on the schematic diagram (Fig. 1) explaining the
relationship and dynamics of each component and their
potential impact upon practice.
Axes explained
The model is supported by the two solid lines or axes, the
vertical representing the innate nature of spirituality. The
direction of the arrow implies that individuals will have
varying levels of spiritual awareness ranging from a subcon-
scious spiritual awareness at the base to those who will posses
a profound conscious awareness. Furthermore, the vertical
direction infers that spiritual awareness may fluctuate either
increasing or decreasing because it is not static but dynamic
across a life span (Carson 1989).
This axis allows application of spirituality to all patients and
client groups, for example individuals with learning disabilities
or other organic brain diseases such as dementia. Although
such individuals may not be consciously aware of a spiritual
dimension, the model accommodates this via the theory of
innate (universality) suggesting that spirituality resides in all
people. In essence, the model is anti-discriminatory because it
applies to all individuals, irrespective of a functioning intellect.
Horizontal axis
The horizontal axis represents the institution referring to the
context of care and the organizational structures that are
responsible for providing and supporting spiritual care. Again
the direction of the arrow implies the degree of importance
that an organization may attach to the spiritual dimension
ranging, from little or no importance to viewing it has high
priority and of great importance. The more an organization
moves towards the right of the axis, the more it should cor-
relate with improvements in service provision in this area
which will ultimately influence the quality of spiritual care in
terms of strategy, structure and process.
Illustrative example
If spirituality has a prominent feature within an organization
then there will be investment in staff and resources, which
in turn, will lead to improvements or better standards of
The way forward
spiritual care. In addition, these organizations may recognize
a need for continuing professional development and research
in the area to evaluate and advance practice.
Application of the four principal components
The four principal components are represented not by solid
lines but by broken lines demonstrating an interdependence
and interconnectedness with each other. If any of the com-
ponents are overlooked then the model may become inef-
fective. All the principal components must be addressed
because they are central to understanding spirituality and in
providing spiritual care.
Service providers, educators and academics must focus on
the individual, recognising that spirituality is uniquely
defined. It must be borne in mind that language, symbolism
may be diverse since it will have been shaped by many
variables such as community, culture and socialization. By
focusing upon individuality and inclusivity the model should
ensure that a language of spirituality is created that is
culturally sensitive in that it allows for ethnic, cultural and
religious variation.
The principal of inclusivity draws attention to language
and terminology used to define spirituality. By adopting this
principle the proposition of a professional and public
discourse can be explored and deficits remedied (McSherry
et al. 2004). Inclusivity will ensure that definitions of
spirituality are shaped by all in health care and the wider
community so that they have meaning and significance for
them. Adhering to the principle of inclusivity will ensure that
all involved in the delivery of health care have a shared and
collective responsibility in determining policy and strategy in
terms of meeting spiritual needs.
The concept of a shared responsibility underpins the idea
of inter-and-intra professional collaboration. Without colla-
boration spiritual care provision will be only partially
effective. The findings indicate that spiritual care is very
much dependent upon a synergy between all health care
professionals, patients and their significant others. This
synergistic relationship ensures that all parties feel supported
and affirmed in their desire to provide effective spiritual care.
Therefore, any attempt to advance insight and practice in this
area must ensure that all health care professionals are
consulted. Consultation will create a sense of ownership
and prevent the perpetuation of spiritual care being perceived
as being bureaucratically and managerially enforced
(McSherry et al. 2004).
The essential principle in the model is the theory of
integration. Spiritual care is not to be seen as an additional
dimension fragmented out and set apart from the essential care
that health care professionals provide. Spiritual care permeates

2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 905–917
A model for advancing spirituality and spiritual care
and integrates all aspects of care provision, just as spirituality
integrates and unifies all dimensions of the individual. The
result is spiritual care is often a hidden and unarticulated and
mysterious concept because it is fused and caught up in
everyday practices, rituals and interactions with service users
(Byrne 2002, Taylor 2003). Therefore, any attempt to isolate
totally spiritual care as a discrete area for attention, such as
spiritual assessment, must be carefully planned and tested.
Limitations/recommendations
Because of the small number of participants in some of the
sample groups results may not be generalized. In addition, the
idea of self-selection may mean that individuals who opted to
participate in the study may not reflect the views of the
general population. Therefore, while the results of this
investigation are interesting in that they offer valuable insight
they may not be totally representative. Similar investigations
need to be undertaken with larger samples that capture the
rich, religious and ethnic diversity that exists within health
care and societies.
Conclusion
By focusing upon these principal components a deeper
meaning of spirituality and spiritual care will be achieved.
Attending to the principal components could help to capture
a language and discourse of spirituality that has significance
and relevance for all working in a contemporary health care
system and living in a pluralistic society. These components
will provide a framework, a set of guiding principles, for
educating and preparing staff at all levels of organizations to
meet the spiritual needs of diverse communities. The Princi-
pal components model provides a structure around which
spiritual care services can be formulated. It is envisaged that
the Principal components model will have relevance for all
helping to advance spirituality and spiritual care in terms of
theory, practice and education.
Acknowledgements
I would like to thank Professor Keith Cash, Professor Alan
White and Dr Linda Ross for all their support and research
supervision during the completion of my PhD thesis from
which this paper is derived. A special thanks to Dr Rebecca
Hill for her constructive feedback on the revised manuscript.
Contributions
Study design: WMcS; data collection and analysis: WMcS;
manuscript preparation: WMcS.
915
W McSherry
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