Implementing spiritual care into nursing practice requires nurses to develop knowledge of spirituality, and acquire the necessary skills and attitudes to meet patients’ needs. This descriptive exploratory study conducted in Malta sought to identify the nurses’ characteristics for delivering spiritual care. The Transpersonal Caring-Healing Framework guided the study. All participants were Roman Catholics except a patient who was affiliated with Islam religion. Data were collected by audiorecorded face to face interviews or focus groups from seven groups of participants: patients with myocardial infarction, cancer; institutionalized older persons; hospital and community chaplains; and nurses and health care professionals. Data analysis was guided by the Content Thematic Analysis Framework. The findings identified one central theme which is ‘being in doing’ incorporating personal spirituality which can be applied therapeutically to meet patients’ spiritual needs. The six sub-themes which explain the nurses’ characteristics form the acronym MERVIC namely: role Modeling in spiritual care in the clinical environment to sustain theoretical knowledge; Education on spiritual care in undergraduate and post-graduate programmes; Reflection in and on action as a means of evaluation of spiritual care; Vocation: responding to a personal call to uptake the nursing career; Take Initiative to be present actively to patients; and Commitment to deliver spiritual care. Although Malta is a religious country and the majority of participants were Catholic Christians with the exception of one Muslim, the findings are limited to nurses affiliated with mono-theistic religions. Limitations were acknowledged and recommendations were set for integration of spirituality into the nursing curricula; further research to develop a framework of competences in spiritual care; and trans-cultural longitudinal research to explore further these characteristics, the complex concepts of ‘being in doing’, and therapeutic use of self in spiritual care

Spiritual care, Nurse, Characteristics, Presence, Reflection, Commitment, Watson’s transpersonal caring-healing framework, Burnard’s content thematic analysis

Baldacchino D (2016) ‘Being in Doing’: ‘MERVIC’ Characteristics for Nurses’ Delivery of Spiritual Care. Ann Nurs Pract 3(4): 1053.

Care is a central concept in nursing which evolves through personal life experiences including clinical experiences [1-4]. Addressing the complex and subjective spiritual dimension in care is a challenge to nurses which requires specialized education for the nurses to obtain the necessary skills, knowledge and competence in delivery of spiritual care [5-7]. However, recently, the Nursing and Midwifery Council Code [8] excluded the role of the nurse to address the spiritual needs in contrast to the set of guidelines which still includes the nurses’ competence to address patients’ spiritual needs [9]. Research in USA, Europe and Asia identified various factors including those related to the nurse, which may contribute towards the effectiveness of spiritual care such as, age, gender, upbringing, culture, spiritual involvement, personal life experiences and nursing education [10-13]. Nursing codes of ethics, guidelines, and policies give directives towards what is expected of the nurse to include the spiritual dimension of holistic care [14-18].

Spiritual care involves an environment in which the values, customs and spiritual beliefs of the individual are respected [19]. The spiritual aspects of patient care are those dimensions of human life which form part of personal experiences that transcend sensory phenomena. Although people may express their spirituality through their own religiosity, the spiritual aspect may be different from the religious experiences. Spirituality encompasses the bio-psychosocial aspects of human life; finding meaning and purpose in life, and associated with beliefs and values [20]. Thus, ‘spiritual care permeates and integrates all aspects of care provision, just as spirituality integrates and unifies all dimensions of the individual’ [21].

Research suggests various nursing interventions in spiritual care identified by nurses, health care providers and patients such as, actual presence, active listening, empathy [6,22,23]; facilitating clients’ religious and existential coping strategies [24,25]; helping in the process of acceptance of illness, instilling hope in patients’ life [26]; and referring to chaplains or other professionals [27]. To implement spiritual care, the nursing process is proposed namely assessment, diagnosis, planning, implementation and evaluation [28]. However, emphasis is being put on what nurses ‘claim to do’ rather than on what nurses are ‘observed to do’ [29]. This is because spiritual care incorporates two dimensions namely: ‘being’ and ‘doing’ [10] whereby nurses implement care subjectively, according to their own philosophy of life [30,31].

Research indicates that the nurse’s own spirituality and attitudes in care are predictors of spiritual care [12,32, 33]. Integration of nurse’s own spirituality in the delivery of spiritual care demonstrated by positive attitudes and respect to patients, while experiencing giving to and receiving from the patient [34,35]. Thus, nurses’ own spirituality may enhance spiritual care in an attempt to address patients’ spiritual needs while experiencing spiritual growth [33,36]. Thus, therapeutic spiritual care, that is, spirit-to-spirit care [37] tends to go beyond the immediate physical needs, so that it incorporates not only the immediate physical needs but also the psycho-social and spiritual needs. By being with, the patient is helped to rise above the material perspective of life. Eventually, a sense of inner peace is promoted which may sustain the patient even during deterioration of the physical body [35]. Hence, spiritual care involves also the personal spirituality of the nurse which may be transformational for both the patient and the nurse [33,37].

Nursing has been criticized for underestimating the spiritual dimension in care, claiming that care is not being delivered holistically [38-40]. This creates impairment in care as the patient needs to be considered as a balance between mind, body and spirit [41,42]. Several factors explain this limitation such as, lack of nurses’ awareness of its importance and lack of preparedness to deliver spiritual care; misinterpretation of the term spirituality which is synonymously considered as religiosity, and thus considering spiritual care within the chaplain’s role; unwillingness to deliver spiritual care, possibly due to feelings of incompetence; and several ethical issues associated with the delivery of spiritual care such as, confidentiality, privacy, documentation, patients’ consent to receive spiritual care [43].

Research to date, on nurses’ characteristics to deliver spiritual care is scarce [7,10]. Thus, research studies on nurses, health care professionals, patients with acute, chronic illness, institutionalized older persons, and life threatening illness were conducted in Malta [10] in order to explore a set of requisites for nurses’ delivery of spiritual care as perceived by patients and health care professionals.

Aim

Identify the nurse’s characteristics for delivering spiritual care derived from qualitative data from chaplains, nurses, health care professionals and patients with myocardial infarction, patients with cancer receiving hospice care, and Maltese institutionalized older persons in Malta and Australia.

Cultural aspects of care in Malta

Malta is a small archipelago of five islands in the Mediterranean with a population of 425,799 consisting of 50.4% females and 49.6% males [44]. The two major islands are Malta (27km by 14km) and Gozo (14km by 7km) [45]. The small geography of Malta contributes towards family connectedness and support, especially in times of distress. The majority of the population (95%) is affiliated with the Roman Catholic religion [46], which is reflected in the recruited samples of participants. The global phenomenon of immigrants in Malta is increasing the diversity in religions during hospitalisation, of which the main two religions are Islam and various sects of Christianity. A list of multi-denominational pastors is available in hospitals to address the respective religious needs of patients. This indicates the importance of knowledge, skills and attitudes of the health care professionals to integrate spirituality/religiosity in care [5].

Watson’s Transpersonal Caring-Healing Framework [47]

This theory which guided this study emphasizes the caregiver’s conscious intention to care which may enhance the healing effect of medical interventions, with an impact of wholeness in the delivery of care. This is because, additional to addressing the disease and the relative medical treatment, the nurse adopts other sources of inner healing based on spirituality, which goes beyond the diagnosed illness and its medical cure. This includes the therapeutic use of self, derived from nurse’s own spirituality. This process involves a transpersonal relationship between the nurse and the patient which aims to safeguard the dignity, humanity, inner harmony and wholeness of both the nurse and the recipient of care.

This transpersonal relationship will eventually influence the attitudes of both the nurse and the patient. Transformation may occur in both the nurse and the patient whereby both may learn from each other and relate professionally with dignity [10]. On reflection, caring may be found as a source of influence on the nurse’s life such as, appreciating health and life better and setting priorities in life, which may eventually make an impact on delivery of care. This is synonymous with spiritual care which is defined as being and not simply doing [48-51] which may yield therapeutic and holistic impact. Being refers to the nurse’s personal spirituality which may be transformational for both the client and the nurse [52].

Research Design

This study forms part of a larger descriptive study with mixed-method approach, conducted between 2006 and 2010 on Maltese samples of patients, chaplains, nurses and health care professionals [7,10,48,53-57]. The perceived nurses’ characteristics for delivery of spiritual care were deduced from the qualitative data derived from the audio-recorded face to face interviews and focus groups according to the respective sample.

Samples

Purposive sampling technique was adopted to recruit Maltese patients, hospital and community chaplains, nurses, and health care professionals working in medical wards, older persons’ residences; patients receiving hospice care and others with first myocardial infarction. All the samples were Maltese who were recruited from Malta, except a Maltese group of older persons who was recruited from a residence in Melbourne Australia (Table 1).

Table 1: Demographic data of all samples.

Group	Samples and Demographic data
1	A purposive sample of 10 nurses (5 females & 5 males) working in an older persons’ institution; aged 20-49 years; all Catholics; minimum of 5 years clinical experience.
2	A purposive sample of 12 health care professionals working with patients with dementia (9 females; 3 males);  nurses (n=5); physiotherapists (n=2); medical doctor (n=1); occupational therapists (n=3); podiatrist (n=1);  aged 21-40 years; all Catholics; minimum of 5 years clinical experience.
3	A purposive sample of 8 nurses (7 females; 1 male);  aged 20-59 years; all Catholics; minimum of 5 years clinical experience
4	A purposive sample of 14 nurses (7 males; 7 females);  aged 22-47 years; all Catholics; minimum of 5 years clinical experience in a medical ward nursing patients recovering from acute  myocardial infarction.
5	Three stratified samples:  14 nurses (7 males;7 females); aged 22-47 years;  15 chaplains (7 hospital and 8 community chaplains); aged 37-65 years; minimum pastoral/clinical experience of five years;  15 patients with acute myocardial infarction (7males; 8 females); aged 40-75 years; all Catholics.
6	Three Purposive samples:  23 Maltese older persons institutionalized in a private residence in Melbourne Australia (n=6); private residence in Malta (n=7); and  state residence in Malta (n=10);  aged (65-94 years); all Catholics; institutionalized for a minimum of 12 months
7	A purposive sample:  10 patients receiving hospice care (4 males; 6 females);  aged 50 – 80 years; all aware of their diagnosis. Religious affiliation: 9 Christians and 1 Muslim.

MERVIC characteristics for nurses’ delivery of spiritual.

Research Instruments and Data Collection

The Demographic questionnaire was developed for the purpose of the study to collect data on personal characteristics such as gender, age, clinical / pastoral years of experience, and religious affiliation. In-depth data were collected by audio-taped face to face interviews from four samples of nurses and health care professionals; and by focus groups from patients with myocardial infarction, patients with cancer, institutionalized older persons and chaplains/ health care professionals (Table 2).

Table 2: Process of generation of findings guided by the Content Thematic Analysis Framework (Burnard 1991).

No	Samples & Method  of data collection	Categories	Sub-themes	Central Theme
Gr 1	10 nurses  Face to face interview	Active presence in care; Giving care and receiving in return; Setting a good example to junior nurses; Reflecting on their nursing actions.	1. Role Modelling in the clinical  environment; 2. Education on spiritual care  integrated within nursing  programmes; 3. Reflection in and on action to  evaluate spiritual care; 4. Vocation responding to a  personal call to uptake the  nursing career; 5. Initiative to be present  actively to patients; 6. Commitment to deliver  spiritual care.	Being in Doing
Gr 2	12 health care  professionals  Face to face interview	Personal spirituality enabling therapeutic care; Putting oneself in the position of the recipients; Dedicated to their work; Taking initiative to upgrade their knowledge on holistic care.
Gr 3	8 nurses  Face to face interview	Behaviour in care coherent with personal spirituality; Giving priority to learning holistic care; Being committed to holistic care; Respecting diversity in religious affiliations.
Gr 4	14 nurses  Face to face interview	Presence of mind and soul at work; Ability to do to others what they would like to be done to them; Being a role model to students; Reflection and evaluation of care.
Gr 5a	14 nurses  Focus Group	Nursing actions coherent with patients’ spiritual beliefs; Being with the patients;  Giving priority to the person and overcoming technological  distractions; Incorporating spirituality education in undergraduate courses.
Gr 5b	15 chaplains Focus Group	Ability to identifying the suffering of Christ in care; Responding to God’s call; Teaching spirituality to juniors by their spiritual care; Reflection on coherence between nurses’ actions and patients’  spirituality.
Gr 5c	15 patients Focus Group	Personal spirituality in nursing practice; Presence of soul in care; Vocation to their nursing career; Integrating spirituality into education
Gr 6a	6 older persons in a  private residence in  Melbourne Focus Group	Seeing Christ crucified in the vulnerable; Quality time with individual residents;  Nursing care is a vocation rather than just a salary
Gr 6b	7 older persons in a  private residence in  Malta Focus Group	One to one availability with clients; Giving priority to religious issues in care; Being a resource of courage.
Gr 6c	10 older persons in  a state residence in  Malta Focus Group	Assistance in individual religious rituals; Initiative to be educated on meeting religious/spiritual needs; Awareness of patients’ spiritual needs.
Gr 7	10 patients receiving  hospice care Focus Group	Mindfulness at giving care; Role modeling to students; Commitment to their consistent holistic care; Considering the uniqueness of each client.

The main question asked was: What are the requirements for nurses to deliver spiritual care? Please give examples through your own and/or clinical experience. Probing questions were based on the literature review on nurses’ role in spiritual care.

Research Ethics

Institutional permissions were granted by the respective hospital/church authorities and the University Research Ethics Committee. Measures were taken to abide by the research ethics principles such as, autonomy, privacy, safety, and confidentiality.

Data Collection

A pilot study was performed by the main author on two face to face interviews and the first 20 minutes of each focus group, which served as an evaluation to the moderator and the respective co-researcher. Both types of pilot studies indicated the need to observe and record the non-verbal cues and to enhance time management to allow enough time for participants to explain their opinions. The 45-60 minute audio-recorded interviews were carried out privately as agreed with the respective participants. Similarly the focus groups were conducted in a quiet seminar room. The interviews were conducted in Maltese for better comprehension and expression of perceptions.

Data Analysis

The qualitative data were transcribed verbatim in Maltese, and 30 out of the 44 interviews were validated by the interviewees. The focus group transcripts were validated by the main author who moderated the three focus groups. Data underwent content thematic analysis, guided by Burnard’s Framework [58]. Quotations were used from the seven samples and compared across the different groups which generated six sub-themes and were then collapsed into one central theme: ‘being in doing’ associated with personal spirituality in relation to nurses’ attitudes towards spiritual care. The quotations were translated into English and verified by a professional linguistic person. A random sample of 10 interview transcripts and one focus group transcript were analyzed by another Maltese nurse researcher, which yielded a high overall agreement.

Central theme: Being in doing

Sub-theme 1: Role modelling in the clinical environment;

ub-theme 2: Education on spiritual care integrated within nursing programmes; Sub-theme

3: Reflection in and on action to evaluate spiritual care;

Sub-theme 4: Vocation responding to a personal call in the nursing career;

Sub-theme 5: Initiative to be present actively to patients;

Sub-theme 6: Commitment to deliver spiritual care.

For clarity purposes the findings and the discussion were merged together in the following section.

Process of generation of findings guided by Burnard’s Content Thematic Analysis Framework [58]

The nurses’ characteristics for delivery of spiritual care were derived from the qualitative findings derived from 44 face to face interviews and three focus groups (Table 3).

Table 3: The central theme: ‘Being in Doing’: MERVIC characteristics for nurses’ delivery of spiritual care (Figure 1). The central theme: ‘Being in Doing’

Being in doing’: Therapeutic use of personal spirituality in nursing care
Diagram: Lighting  the  lamp	The light is the spiritual dimension of nursing care (Bradshaw 1994). Spirituality in care incorporates both the patient’s and the caregiver’s personal spirituality. Self-awareness of one’s personal  spirituality may be achieved by finding meaning and purpose in the individual’s life and nursing career; and by selfassessment on the extent to which one is living harmoniously with the inner self, others, nature and God/higher power. No  one can give from what he/she does not possess (Baldacchino 2003 p.25).
	i	Awareness of the importance of the spiritual dimension in care is enhanced by the nurse’s initiative to become  aware of one’s own spirituality which may be transformational for both the patient and the nurse.
	n	The named patient: Spiritual care views the patient as a unique holistic person with a name and human dignity  unlike the medical model which dehumanizes the patient and considers him/her as a number and a physical being.
	h	Holistic care: Liaising with the multidisciplinary team including the hospital chaplain to assess and address spiritual  needs. Thus, spirituality may integrate the bio-psycho-social and cultural perspectives of the individual patient.
Spiritual care is considered as a form of being which enables therapeutic doing (Baldacchino 2010a).

The central theme is ‘being in doing’ composed of personal spirituality which may influence nurses’ attitudes while delivering spiritual care which contributes towards therapeutic holistic care. The six subthemes summarized in the acronym MERVIC (Figure 1)

Figure 1 ‘Being in Doing’: MERVIC Characteristics for nurses’ delivery of spiritual care Adapted from: Baldacchino (2010a) Spiritual Care: Being in Doing (p.iv) Permission granted from Preca Library, Malta.

explain the nurses’ characteristics for delivery of spiritual care namely, role modeling to junior caregivers; education on spirituality to be integrated in undergraduate and post-graduate course programmes; reflection in and on action; vocation: responding to a spiritual call; taking initiative for active presence in care; and commitment towards delivery of spiritual care.

Central Theme: Being in doing’

The central theme derived from the qualitative data was found as ‘Being in doing’ which encompasses self awareness of personal spirituality which may generate therapeutic spiritual care and holistic care. This entails the development of a therapeutic nursepatient relationship with the intention of addressing the holistic needs of the individual patient, including the spiritual dimension in care (Figure 1).

‘Spiritual care enables delivery of holistic care……. Through experience I can say that the more the caregiver is aware of his/her spiritual beliefs, the more likely will the occupational therapist (OT) become sensitive to patients’ spiritual beliefs, problems and needs. One’s spirituality tends to help the caregiver to respect the holistic individuality of the patient and overcome the mistake of seeing and treating only the specific illness of the patient’ (OT 2).

Since spirituality is a complex concept, nurses need to update themselves to become and maintain their competence in the delivery of spiritual care [6,58]. Education is an ongoing process which needs to be supported by the education sector and the multidisciplinary team, including the chaplain/pastoral caregiver, especially in the presence of theological beliefs and conflicts which need pastoral expertise [59]. The nurses’ quick referral of patients to chaplains to address spiritual needs has been criticized. This infers that nurses may be incompetent to address spiritual needs and they do not consider spiritual issues as part of their role [48]. Nurses are recommended to take an active role in meeting the spiritual needs of patients in collaboration with the chaplain [5,10,60,61].

‘Looking back to my years of nursing care, I believe that I attempted to deliver spiritual care to patients as part of holistic care. On reflection, I can say that attending to the religious needs of patients helped me to experience personal growth. My attempt to help patients explore further their own purpose of life helped me to appreciate my health as a blessing!’ (Nurse 8)

This therapeutic nurse-patient relationship may include also the therapeutic use of self in care [62] which may enhance compassionate presence and self-growth which enables finding meaning and purpose in nursing and life [63]. Originally, few theories addressed the spiritual dimension in care such as, [64- 66]. Following the exploration of spirituality in research and critique about the omission of the spiritual dimension in care [48], some theories were reviewed such as, [67] and others were newly developed [63,68]. Holistic care by the health care professionals is based on patient centred-care model which includes patients’ beliefs and values; the bio-psycho-socialspiritual model of care emphasising the holistic approach to care; and the altruistic compassionate model of care which requests the health caregivers to be actively present with the patient during suffering [63].

‘The nurses tend to encounter difficult situations in patient care. Many times, illness itself may be meaningless because suffering is difficult to be understood. Therefore, I end up giving and receiving as I also undergoes a spiritual experience’. Also differences in personal beliefs and and religious beliefs between the caregiver and the patient pose a challenge to holistic care’. (Nurse 3).

This is the reason why diversity in culture and religious beliefs; the influence of spirituality in the therapeutic caring relationship; and the spiritual needs of the caregivers were also incorporated in the whole-person-patient model of care [68]. Collaboration is emphasised by the development of the Interprofessional spiritual care model [5] which focuses on spiritual assessment; models of care and care plans; inter-professional team training, quality improvement, and personal/professional development to enhance the quality of spiritual care.

Sub Theme 1. Role Modelling in the clinical environment

The nurse’s role is to promote ‘an environment in which the human rights, values, customs and spiritual beliefs of the individual, family and community are respected’ [14]. This is supported by various Nursing Associations such as, the North American Nursing Diagnosis Association [69] which incorporates the spiritual dimension as part of the nursing assessment. The environment includes the nurse and the health care professionals who are consistently assisting patients in their holistic needs [70].

Students can learn a lot from Hospice care as they deal also with our religious and spiritual problems. For example, I couldn’t find any answer to my illness (crying)….. Why has this happened to me? Also why not me? I know it’s difficult…..! However, the way nurses and the priest dealt with me gave me a lesson which I will treasure for life. So caregivers are in a good position to teach patients and students by their way of addressing such complicated issues of spirituality. (Patient Focus Group)

Thus, the same clinical environment could also be a resource of learning by the presence of role models in spiritual care. It is argued that spirituality is caught rather than taught [71]. This emphasises the need of role models in patient care whereby the nurses’ are in doing may relieve patients’ suffering and serve as a resource of learning. However, it implies that there is no need to integrate teaching on spirituality and spiritual care within the curricula.

Literature has criticised this notion because the complexity of spirituality and spiritual care renders it difficult to find role modelling in the clinical practice [21,58]. Therefore, if spirituality were only to be ‘caught’ in practice, spiritual awareness and the development of the necessary skills necessary for delivery of spiritual care might not occur. Additionally, when ‘role modelling’ of delivery of spiritual care practices is inappropriate or absent, addressing spiritual needs will be constantly inappropriate or omitted. Thus, role modelling needs to be supported by taught programmes on spiritual care [7,58].

Sub Theme 2. Education on spiritual care integrated within nursing programmes

Lack of preparedness of nurses to deliver spiritual care generated feelings of incompetence to deliver spiritual care [70]. Research supports theoretical teaching on spiritual care as a single study unit or threaded across the undergraduate course programme [58,72], supported by clinical role-models and mentors [73]. Theoretical learning was considered beneficial for the nurse learners, both for their spiritual self-development and also to transfer theory into their clinical practice in order to address patients’ spiritual needs [70,74].

‘When the group of doctors left the room, I became aware of the seriousness of my heart attack. I was scared! So I preferred to have some quiet time to pray for God’s help. This is as important as the medical treatment. So caregivers need to be taught in their course programmes about attending the spiritual aspect of patients’. (Patient Focus Group). Hence, nurses need to equip themselves with formal organised educational programmes to become competent in spiritual care. The adoption of a model of teaching spiritual care such as the ASSET model for Auctioning Spirituality and Spiritual care Education and Training in nursing [75] provides a holistic and systematic mode of learning while including the cultural perspective of the individual patients. The nurses’ own initiative for further education, through self directed learning and supported by CPD educational courses will help them to maintain their competence in the delivery of spiritual care. Thus, education will clarify the complexity of the concepts of spirituality; enhance awareness of personal spirituality, facilitate delivery of spiritual care; and adopt the appropriate attitude of ‘being in doing’ for the ultimate purpose of meeting patients’ needs holistically [10].

Sub Theme 3. Reflection in and on action to evaluate spiritual care

Through reflection in and on delivery of spiritual care [76,77], the caregiver may evaluate the appropriateness of the care given and the possible influence of that care on the nurse’s life.

‘Before entering the hospital gate, I tend to separate my role of a nurse from my other roles in life to enable me to concentrate on the individual client. Thus, I check on myself to focus more on what I’m doing and what I have done to patients. This helps me to communicate actively with each patient whole heartedly……I try to listen to the patient’s physical problems while opening up myself to psychological or spiritual cues which may need further referral to a more competent person such as, a psychologist or a hospital chaplain…..’ (Nurse 5)

Research demonstrates that reflective exercises, by the use of quiet time and reflective diaries, may enable individuals to communicate with their inner-self and enhance their understanding of their personal self, perceptions, attitudes, actions and professional practice [78,79]. Reflection, education, and learning through role-modeling may influence the caring attitudes and perceptions of holistic care [1,80]. Reflective clinical experience helps nurses to become in touch with their inner-self, their own values and beliefs and eventually increase understanding of their own life and that of others [81]. Thus, self-reflection may increase self-awareness about personal spirituality which may be accompanied by spiritual growth, more attention to their personal spirituality, and higher priority to spirituality in patient care [82]. Thus, the outcome of selfreflection and self-awareness may strengthen the therapeutic nurse-patient relationship with two-way impact on both the nurse and the patient [47].

Sub Theme 4. Vocation: Responding to a personal call in the nursing career

Since the majority of respondents were Christians, the essence of the purpose for becoming a nurse was based on a personal call/a vocation rather than simply having a job, a career.

‘The work of a nurse should be looked upon primarily, as a vocation, a call with a very specific mission to fulfill. The patient expects nurses to be healing agents or at least to help in easing his/her sufferings, both physical, psychological and even spiritual ailments. Their care, gentleness, humane approach and constant concern will help the patient recover fully and quickly. Building a trustful relationship between both sides will facilitate the healing process’ (Community Chaplain 4).

Responding to a personal call originates from the Old Testament in the Bible whereby several prophets and leaders such as Moses, were called by God for a mission, and they felt supported by God’s helpful accompaniment [83]. An example is found in the miracle at the Cana wedding in the Galilee. Compassion and empathy were shown by the mother of Jesus who was invited together with Jesus and his disciples. Although not part of the family, the current problem was identified by Jesus’ mother, ‘They have no wine’ [84]. Eventually, a problem solving approach was undertaken in order to meet the needs of the newly-wed couple and their family. This infers that active presence may yield therapeutic use of self which is much needed in spiritual care [6,21].

‘Old age consists of a lot of sufferings….. Although we are old, not much of worth in today’s life, we deserve to be respected. To help you in your nursing care, I beg nurses to see the suffering Jesus in the vulnerable person under their care. This might encourage nurses to care for us with dignity’. (Melbourne Focus Group)

Understanding the noble call/vocation to become an active nurse in spiritual care may generate inner peace, therapeutic nurse-patient relationship and development of the right aptitude towards holistic care [38,85] and spiritual care [86]. Since no research was traced to date on the nurses’ experiences of why they wanted to become a nurse, comparison with research was limited. Narrations collected on a website ‘Nurse Together’ demonstrate the nurses’ awareness of their ‘call’ to nursing which is associated with compassion and professional care. Few considered other influencing factors such as, hospitalization experiences or mere luck to be the reasons for becoming a nurse [87]. However, this anecdotal assumption merits further comparative research between nurses from diverse cultures and religious affiliations.

Sub Theme 5. Initiative to be present actively to patients

Taking initiative to be actively present in patient care may be associated with awareness of personal spirituality and holistic healing [90-94].

‘Instead of just giving care as a task, it is important to be present with the patient and not be overloaded with personal problems or giving more attention to the technical aspect of patient cares. When patients realize that the nurse is giving care attentively, and offering presence to patients, they tend to confide their problems with the caregiver especially during the silence of a night duty. Then, the nurse may sustain the patient spiritually even during feelings of helplessness. This flourishes nurses’ satisfaction with the positive impact on the nurse herself and a healing presence on patients’ life.’ (Nurses’ Focus Group)

The nurses’ light of their own personal spirituality (Figure 1) may generate active humane presence to the holistic needs of patients, including the spiritual needs, which is the goal of spiritual care. Therefore, being aware of the need to give attention to one’s own spirituality by finding meaning in the nursing career and purpose in life, the nurse may consider the importance of including spirituality in care. Eventually, the nurse may take initiative to be present actively during delivery of patient care in order to address patients’ spiritual needs. The nurses’ reflection and self-assessment on their connectedness with the innerself, others, nature and God/higher power may help them to become aware of their personal spirituality and enhance their harmonious relationships [72], which may eventually enrich the therapeutic use of self in spiritual care by being in doing [10].

Finding altruistic meaning in their nursing career may enrich their purpose in life with generation of inner peace [48]. Peacefulness may generate positive attitudes towards the sacred dimension of each patient, irrespective of their religious affiliation or absence of religion. Thus, personal spirituality may help nurses to give priority to patients’ holistic needs [12], and may be transformational to both the patient and the nurse [35].

While giving spiritual care, nurses may experience spiritual growth through reflection in and on care [76,77]. Education and self-assessment may help nurses to nurture the power within the self which motivates them to find and sustain meaning, purpose and fulfillment in their nursing career and help them remain committed to deliver holistic care spiritually [95].

Sub Theme 6. Commitment to deliver spiritual care

The goal of the nurse is to be oriented consistently towards their commitment of being in doing throughout the delivery of nursing actions with the aim of having a transformational therapeutic relationship, which is beneficial for both the individual patient and the nurse. In the simplest intervention in nursing care, the therapeutic use of self may humanize patient centered-care with dignity and combat the hidden task-centered care [7,72] which threatens spiritual care and holistic care [6,22].

‘The home sister and the nurses are very caring. They not only take good care of our various needs, but they also convey a message of encouragement through their dedication and love. They help us believe that ‘courage aids healing’. (Melbourne Older Persons’ Focus Group)

This is in contrast with the medical model which is mainly oriented towards the physical medical care with the consequence of depersonalization of the person and fragmented care [10,96].

‘On getting old, I confirmed the need of prayer in my life. At home I used to go to church daily. Some nurses help us to go to the chapel but others might think that it’s not their job! Yes it is of course. Thus, students and nurses need to be educated to understand our need of assistance in such a religious activity’. (Malta Older Persons’ Focus Group)

Research demonstrates misinterpretation of spirituality as it may be considered to be synonymous with religiosity. Thus, attention to religious needs might not be considered as part of their nursing role. This may be due to lack of educational preparedness with feelings of incompetence to deliver spiritual care with the consequence of referring patients to hospital chaplains [6,70]. Thus, nurses are to show commitment to holistic care by taking initiative to further their knowledge on spiritual care and consider it as part of their nursing role in liaison with the multidisciplinary team, including the hospital chaplain.

Data were collected only once from all the seven groups of participants which might have missed changes in responses across time. However, the in-depth data enabled exploration of the characteristics for nurses’ delivery of spiritual care. Although a heterogeneous sample was recruited composed of seven groups, the Catholic affiliation of the majority of the participants renders the findings applicable to a Judeo-Christian population. Research on the characteristics of the nurses to deliver spiritual care is scarce. Thus, these findings were compared to the limited research on spiritual care and other research available on the concept of caring which impairs the external validity of the findings.

The ‘MERVIC’ characteristics for nurses’ delivery of spiritual care may guide nurses to take initiative to learn further on spiritual care to understand better its complexity. Further education may help nurses to become more aware of their personal spirituality, and the sacred origin of their vocation in their respective nursing career. Eventually, nurses may increase their knowledge of how patients’ spiritual and religious needs may be addressed and be committed to enhance the quality of delivery of spiritual care [82,96].

MERVIC characteristics model sheds light on the importance of ‘being in doing’ and therapeutic use of self. Eventually, personal spirituality, knowledge, skills and attitudes are applied therapeutically to meet patients’ spiritual needs. Further education may help nurses to become role models to teach spiritual care in practice while attending to the respective spiritual needs with respect and dignity. Thus, further longitudinal trans-cultural research is recommended on patients, nurses and healthcare professionals with different religious affiliations on pre-requisites for the caregiver to deliver spiritual care and exploration of the complex concept of ‘being in doing’ in care. Further trans-cultural comparative research is suggested to explore the possible reasons of coming into nursing and the possible impact on patient spiritual care. Spirituality and spiritual care need to be integrated within the nursing curricula in order to enhance nurses’ competence in spiritual care which may eventually be applied in patient care and provide role-modeling for junior nurses and students in the clinical environment. While considering the complexity of spiritual care, development of a list of competences by the Delphi method approach is recommended to guide the learners and educators on the acquisition of competence in spiritual care.

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