Utilization of Spirituality and Spiritual Care in Nursing Practice in Public Hospitals in Kwazulu-natal, South Africa

This study explored the views of professional nurses in KwaZulu-Natal, South Africa regarding the role of spirituality and spiritual care in nursing practice and investigated whether professional nurses utilize spiritually based care in nursing practice. A cross-sectional descriptive design using multistage random sampling was utilized. Five hundred and fifty questionnaires were distributed to professional nurses between December 2012 and February 2013. A total of 385 participants completed the survey questionnaire, resulting in a 77% response rate. Data was analyzed using SSPS 0.20. The data revealed that nurses see spirituality and spiritual care as an important dimension of nursing practice but need greater preparedness. Nurses need to be effectively prepared to deal with the complexity of providing ethically based personalized spiritual care in an increasingly diverse society.


Introduction
There is a huge gap in South African nursing literature related to spirituality and spiritual care.Internationally, however, studies have grown focusing on the views of practitioners and faculty with regard to spirituality and spiritual care in nursing practice ( [1], p. 1758; [2], p. 1; [3]).Only one study on this topic was undertaken by Mahlungulu and Uys in South Africa.This, together with the growing empirical evidence abroad regarding the need to consider spirituality in nursing practice, led to the impetus for the current study ( [4], p. 15).
Myriad studies have documented the salience of spirituality and spiritual care to a range of issues such as HIV/AIDS, cancer, and heart disease ( [1], p. 1758).In light of the high prevalence of the HIV/AIDS pandemic in South Africa, the need for spiritual care becomes salient.It is postulated that the failure to incorporate spirituality and spiritual care into nursing is unethical, as spirituality is part of being human [5].Furthermore, the lack of sufficient preparedness on spirituality and spiritual care renders nurses unprepared to deliver holistic care ( [2], p. 1).
The purpose of this study was to explore the views of professional nurses at public hospitals in KwaZulu-Natal, South Africa regarding the role of spirituality and spiritual care in nursing practice and to investigate whether nurses utilize spiritually based care in practice.It is believed that, through the integration of spirituality and spiritual care, nurses will be more aware of patients' spirituality and spiritual needs, and be able to implement ethical spiritual care in practice.Furthermore, spiritually based care will also be considered as an important pillar alongside the physical and psychological dimensions in nursing care.Spiritual competence in nursing is critical to empowering nurses with adequate skill that will enable them to foster hope, purpose and meaning in the lives of those who are facing ill health or a possible loss of life [6].
Furthermore, the skill of nursing practice is not only task-orientated, but involves the establishment of a therapeutic interpersonal relationship that is based on caring, warmth, congruence, and empathy [7].This study is significant as it has the potential to help nurses in this study to recognize that patients are not only physical beings but spiritual beings as well.

The Conceptual Framework
The study utilized the Human-To-Human Relationship Model of Travelbee ( [8], p. 1).Travelbee declared that a nurse does not only seek to alleviate physical pain or render physical care, the nurse ministers to the whole person.Travelbee subsequently developed the Human-To-Human Relationship Model, which rests on the notion that nursing is fulfilled through a human-to-human relationship ( [8], p. 2).This model was based on Frankl's theory of Logotherapy [9].According to Logotherapy, nursing helps man to find meaning in the experience of illness and suffering [9].Puchalski ([10], p. 352) concurred, saying that one of the challenge that nurses face is to help people find meaning and acceptance in the midst of suffering and chronic illness.Spirituality therefore, as a guiding paradigm, forms the basis through which patients can find meaning through their illness and suffering.In addition, spiritual care when implemented can help patients to cope with health care problems and find meaning to such health issues [11].
Nurses in the context of this study can use the above framework as a guide by honoring each individual's subjective experience about health, health beliefs, illness, and death ( [12], p. 252).Since nurses are seen to be trustworthy, many patients turn to them to talk about their spiritual beliefs ( [13], p. 25).Spiritual needs are often more acute during illness ( [14], p. 350).This will include active and compassionate listening and companioning, where the nurse moves beyond notions of expert caregiver to a role which includes accompanying the dying person throughout their spiritual journey and allows patients to discuss meaning in their illness and suffering ( [14], p. 350).

Spirituality Defined
Amidst the development of spirituality in health care, spirituality in nursing remains highly contested due to its huge range, diversity and its association with religion ( [15], p. 226).Spirituality concerns our beliefs about our place in this world and seeks meaning and purpose in our lives [6].In addition, researchers ([2], p. 1; [16,17]) portrayed spirituality as referring to a universal concept of connection with a Supreme Being related to membership of and adherence to the practice of a particular faith, tradition or sect that does not necessarily require any religious belief.In contrast, several writers still posit that religion and spirituality are inseparable, and both constructs can be used interchangeably ( [18], p. 106; [19], p. 249; [20], p. 240; [21], p. 135).Following a similar trend Deal [22] and Barlow ([2], p. 1) commented that using spiritual or religious resources gives patients and families strength to cope during crisis.Nurses, however, are often unsure how to implement such a level of spiritual care ( [23], p. 25).Despite this limitation, several studies have revealed that nurses do have a positive attitude towards spirituality and spiritual care in nursing practice ( [23], p. 25).

Nurses Views on Spirituality and Spiritual
Chan [24] surveyed Hong Kong nurses (n = 110) to determine their attitudes regarding spirituality and spiritual care.Findings showed that the greater the nurse's spiritual care perception was, the more frequently spiritual care was included in that nurse's practices.In addition, the findings revealed that nurses can provide spiritual care by praying with or for the patient, reading holy books, playing music that lifts the patient's spirit, and calling in spiritual advisors to talk to the patient ( [25], p. 4).
In this vein, Deal and Grassley [26] agreed that nurses should use these spiritual resources to give patients and families strength to cope during illness and spiritual crises.Barlow ([2], p. 1) advocated the incorporation of spiritual activities such as listening, silence and touch.Khoshknab et al. [27] added that spiritual care also include respecting patients' religious and cultural beliefs, listening and talking with clients, being with the patient by caring, supporting, showing empathy, facilitating participation in religious rituals, promoting a sense of well-being, and referrals to chaplains.
Balducci [28] strongly emphasized that the best environment for spiritual care is when nurses acknowledge that it is a unique privilege to be trusted with a human life.Balducci [28] found that activities for spiritual care include plans by the nurse to take care of a person and not just manage a disease, an understanding of exactly what the patient wishes as an outcome of his/her disease, and being truthful and compassionate, which is the basis of mutual confidence in any relationship and an inclusion of prayer with the patient.Other strategies that nurses could use to meet patients spiritual needs are putting aside personal bias, recognizing patient's cues and verbal communication, making spiritual care resources such as a private space for prayer and meditation, being empathic, and including patient and family in health care decisions [29].

Spiritual Care Activities in Patient Care
Spiritual care as defined by student nurses from the Brigham Young University College of Nursing refers to: (1) establishing a trusting nurse-patient relationship; (2) providing and facilitating a supportive spiritual environment; (3) responding sensitively to the spiritual and cultural belief systems of patients and families; (4) acknowledging the importance of "presence" or therapeutic use of self; (5) demonstrating caring by practical nursing care; and (6) integrating spirituality into the care plan ( [30], p. 160).Nurses have to be willing to be with their patients spiritually by praying with them, being willing to talk to them, listen to their spiritual concerns and trying to relieve their suffering ( [31], p. 2).
A quantitative study with terminally ill French patients reflected on their needs as being an interpretation of life, search for meaning, a connection to the world and to loved ones, and a relationship with the transcendental ( [32], p. 18).Similarly, interviews with German chronically ill patients (n = 22) found that prayer, participation in religious ceremonies, reading spiritual books, turning to a higher presence, and the need for inner peace were an important part of their healing ( [32], p. 18).In addition, an American qualitative study of cancer patients (n = 28) found that patients identified kindness and respect, talking and listening, and prayer as the most important aspects of their spiritual care [33].

Prayer
The use of prayer is consistent with the recent study research of Shores [34] who found a high level of spirituality among nursing students.Callister et al. ( [30], p. 160) regarded prayer as the main method by which the spiritual needs of patients can be met.Dunn and Horgas ( [35], p. 337) agreed, adding that prayer was used as a coping strategy by 96% (n = 48) of participants (n = 50) aged 65-85 years.In a qualitative study of 100 pre-operative cardiac patients, Smith [29] found that 96 patients prayed the night before surgery.The metaphor of "men of prayer" was developed during a qualitative study of patients with prostate cancer [35].These patients identified prayer as most important in providing them with comfort and inner strength.Another survey of 292 cancer patients found that prayer was the highest coping strategy used by 64% (n = 187) of patients [36].
A cross-sectional American study of cancer patients (n = 70), oncology physicians (n = 206), and oncology nurses (n = 115) found prayer to be appropriate ( [32], p. 836).Balboni et al. ( [37], p. 836) agreed that prayer was viewed as appropriate by 64% (n = 45) of patients, 76% (n = 87) of nurses and 59% (n = 121) of physicians, respectively.A survey by The American Pain Society revealed that 76% of patients used prayer as the most common non-drug method of pain control ( [10], p. 353) Health and illness become part of the continuum of being, and prayer remains the salvation in both health and in sickness [38].Barber [39] agreed that prayer had positive effects on psychological and physical well-being.

Therapeutic Touch
The American Holistic Nurses Association [40] endorses the use of energy-based touch therapies by nurses as part of the scope and practice of holistic nursing.Therapeutic touch is an act of bringing a part of one's body, typically one's hand, into contact with someone.Touch practices are embedded in nursing's roots in holism with visionary guidance from Florence Nightingale, who alluded to the healing effects of the energetic environment on the human energy pattern [41].Touch communicates a message of support and bonding, whereby the patient feels that the nurse is close and committed ( [42], p. 180).Touch relates caring and compassion for the patient, brings comfort in times of illness and pain, and is welcome when patients are facing terminal illness or eminent death ([2], p. 1).Several authors felt that touch was a critical aspect of physical, emotional, and spiritual care ([2], p. 1; [43], p. 2; [44], p. 1).This connectedness is an important antecedent so that patients are able to view the nurse as honest, open, and concerned ( [45], p. 90).

Privacy for Self-Transcendental Reflection
A nurse should allow privacy and time for the patient to reflect on his condition.This will allow the patient time and space for self-transcendence.Self-transcendence is experienced as growth into one's unfulfilled potential.It is the process of extending oneself both inwardly in introspective activities and outwardly in relationships with others.Self-transcendence means to be able to reach out beyond one's self, to encounter a higher being or other human beings, and to fulfill meaning and purpose ( [45], p. 04).The benefits of self-transcendence are that it helps patients find meaning in suffering and allows for self-reflection.This can result in an acceptance of illness and a feeling of peace [46].

Empathic Listening and Being Present
Writing in a nursing context, researchers ([8], p. 2; [44], p. 1) found that there are three activities that underpin spiritual care.These include being with patients in their experiences of pain, suffering or need, and listening to patients express their emotions and anxieties such as depression, sorrow, fear or loneliness, which may hinder their wellness and touching patients to assure them physically, emotionally and spiritually.The act of being present results in a meaning exchange between a nurse and the patient [47].
Providing a committed presence implies one's own commitment to life and to the patient by being a physical and spiritual presence to the patient [42].Barlow ([2], p. 1) added that, while spiritual care might appear nebulous, merely being empathic, being present, actively listening, reading spiritual literature, touching, and providing referrals for religious support are all part of integrating spirituality into nursing care.To this end, O'Brien [43] agreed that spiritual care should be a natural part of the nursing process of assessment, diagnosis, planning, and intervention.

Design
This study utilized a quantitative descriptive research design to survey professional nurses at selected public hospitals.As it was impossible to survey all 25, 440 professional nurses due to time and financial constraints, multistage random sampling was adopted.This is the successive random sampling of units starting with the largest group and progressing to smaller units ( [48], p. 347; [49]).This ensured a total sample of 550 nurses, which then resulted in an approximate 77% return rate of 385.Since the norm for a response rate is 50% to 60% ( [48], p. 187), a selection of 385 participants has an acceptable error margin of five percent, as per consultation with the statistician.
A number of closed-ended questions, open ended questions, and Likert-type matrix questions were utilized.The following scales were used: "The Role of Religion and Spirituality in Social Work Practice" (RRSP) was readapted for nursing and permission to utilize the instrument granted by Professor M.Sheridan, who developed the scale."The Spiritual Care Rating Scale" (SSCRS) was developed and utilized by McSherry [50], McSherry [51], and McSherry, and Jamieson [1] was also included in the questionnaire after securing permission from Professor McSherry.

Validity and Reliability
A pilot study of the questionnaire was done to ensure validity.Reliability of "The Role of Religion and Spirituality in Social Work Practice" scale was tested in three different studies using Cronbach's alpha.The scale demonstrated high internal consistency across all these studies, with alpha scores greater than 0.82 [52].The SSCRS scale has also demonstrated consistent levels of reliability and validity with an original Cronbach's alpha coefficient of 0.64 [1].The SSCRS has been used effectively in over 42 different studies in 11 countries [53].
A descriptive cross-cultural survey of Persian nurses (n = 107) used a Persian version of the Spirituality and Spiritual Care Rating Scale (SSCRS) to assess the reliability and validity of the SSCRS scale.To assess content validity, the Persian questionnaire was given to 10 faculty members with relevant specialties.To assess face validity, the questionnaire was given to 13 psychiatry nurses to identify potential problems.The instrument was found to be clear, easy and understandable.To assess the reliability of the scale, test-retest was carried out.The findings were that the instrument was valid and reliable ( [27], p. 2939).
Similarly, Tiew, Drury and Creedy conducted a convenience sample of first-year student nurses (n = 745) by adapting segments of the SSCRS questionnaire to measure the validity and reliability of the SSCRS scale.Results showed that the SSCRS was a valid and reliable instrument for measuring the multifaceted perspectives of spirituality and spiritual care in practice by student nurses ( [54], p. 84).

Ethical Considerations
The study obtained full ethical clearance from The Institution Research Ethics committee of Durban University of Technology in October 2012 and received approval from the KwaZulu-Natal Provincial Health Research and Knowledge Management Committee in November 2012.The anonymity of the nurses was ensured, as the questionnaires did not require any identifying details.Participants also completed a consent form.

Data Collection and Analysis
Data collection was conducted between December 2012 and February 2013.The data was analyzed using the statistical software SPSS, version 20.0.Descriptive statistics and inferential statistics were applied to the data.Cronbach's alpha scoring, which measures reliability, was applied to all sections of the questionnaire.Alpha scores for all sections of the questionnaire were more than 0.70.An alpha score of more than 0.70 indicates a high level of reliability ( [55]; [56], p. 172).
Inferential statistics using Pearson's or Spearman's correlations at a significance level of 0.05 were also utilized.In-depth statistical analysis regarding spirituality and spiritual nursing care was correlated with health and well-being of patients.Sub-themes within the larger sections of the questionnaire were identified and explained.In addition, thematic analysis found common themes and variations among participants' responses.The Pearson's r-value indicates the strength of the relationship between the variables.Many positive correlations were noted in the study.

Demographic Data Was Related to Age, Gender, Race and Years of Experience
The age range for professional nurses surveyed varied between 20 and 60 years.A total of 40% (n = 152) of the participants were between the ages of 31-40 years.Only 15.1% (n = 58) of the sample was younger than 30 years.345 participants (the majority) were female (89.6%), compared to 40 males (10.4%).276 (most) were black (71.7%), 60 Asian (15.6%), 25 white (6.5%) and 23 Colored (6%).A small percentage was unspecified.A total of 39.2 (n = 151) of the participants reported having 10-20 years of nursing experience.A further 18.2% (70) had 21-30 years of nursing experience, while 7% (27) of participants had 31-40 years of experience.Only 34.5% (n = 133) of participants indicated having less than 10 years of experience.

Nurses Personal Spiritual/Religious Orientation
The majority of the participants (n = 335) (86.9%) belonged to the Christian faith.One percent (n = 4) were Buddhist, while 6.3% (n = 24) reported following the Hindu faith.A small percentage (n = 2) indicated being Agnostic (0.5%) and only 0.3% (n = 1) said he/she was Atheist.Despite the fact that a majority of the sample was Black, only 1.6% (n = 6) of the participants indicated following African Traditional faith.When asked whether participants felt that nursing was part of their spiritual life or path, 89.4% (n = 343) answered "yes."Ninety one percent (n = 350) of professional nurses stated that they have encountered patients with spiritual needs.

The Role of Spirituality and Spiritual Care in Nursing Practice
An average of 72.8% (n = 280) of participants agreed that spirituality and religion were within the scope of nursing practice and that the terms can be used interchangeably.In addition, 91.7% (n = 353) of participants agreed that knowledge of patients' spiritual beliefs is important for effective practice and 80% (n = 308) agreed that nursing practice with a spiritual component empowers the patient.Praying with the patient was seen as ethically acceptable by 83.1% (n = 312) of participants.An average of 89% (n = 343) of the sample indicated that respect for patients' dignity, respect for privacy and religious/spiritual beliefs, kindness, support and reassurance, listening to patients' fears, showing concern, personal friendships and relationships, a sense of peace; maintaining hope, forgiveness and finding meaning and purpose in illness, are all elements of spirituality and spiritual care.Participants were also asked if they participate in patient's spiritual rituals.Only 6.8% (n = 26) answered "often", 22.1% (n = 85) indicated "sometimes" while 71% (n = 273) stated "rarely" or "never".
More than 80% (n = 308) agreed that patients have their own personal spiritual beliefs.A total of 82.1% of participants (n = 318) agreed that spiritual participation helps protect patients against depression, while a further 80.5% (n = 310) of participants felt that religious beliefs provide guidelines for behaviors that are beneficial to patients.Three hundred and seventeen participants (82.3%) stated that life experience increases their spiritual maturity, and 81.3% of participants (n = 313) agreed that patients who were abused or neglected may especially benefit from spiritual beliefs or practices.A correlation between "nurses should help a patient develop spiritually as well as emotionally and socially" with "nurses should be able to assess the beneficial role of spiritual beliefs and practices in their patient's lives" was found to have a p-value of r = 238.
When asked whether participants felt that nursing was part of their spiritual life or path, 89.4% (n = 344) answered "yes."Further, a statistically significant relationship (p-value) of r = 0.001 with a p-value of r = 0.238 was found between the variables "indicate if you consider nursing to be a part of your spiritual life or path" and "I believe nurses can provide spiritual care by spending time with a patient, giving support, and reassurance in times of need.
A majority of the participants (82.9%) (n = 319) believed that the nurse, patient's family and friends, spiritual/religious leaders, and the patient themselves should be responsible for spirituality and spiritual care.Visits by spiritual/religious leaders, family, and friends were seen to be valuable for 91.9% (n = 353) of participants.However, only 20% (n = 77) of participants stated that they "often" encourage the patient's family to support any spiritual interest by the patient, pray privately for a patient, assess if the physical and social environment promotes the spiritual well-being of the patient, or assist a patient to talk about their personal spiritual needs.Reasons cited for not being able to provide spiritual care by 26.5% (n = 102) of participants were a lack of time, shortage of staff, language barriers between the nurse and the patient, and the uncertainty of how to provide spiritual care.

Discussion
A majority of the participants (n = 260) were between 31-50 years (67.5%), and 65% (n = 250) reported having more than 10 years of nursing experience, which reflects a sample characterized by extensive years of nursing knowledge and clinical experience.Furthermore, South African nurses begin their training after finishing school, as it is a profession that gives them a salary while working and studying.The ratio of males to females in this study was approximately 1:9.The predominance of females runs as a thread throughout the profession as a whole and are consistent with samples abroad where there is a strong dominance of females ([1], p. 759).The prevalence of 71.7% (n = 276) of black participants concurs with current South African legislation on affirmative action, which aims to correct the inequalities of apartheid [54].International samples in Europe and America differ and reflect that a majority of the nursing participants are white ([1], p. 759).

Role of Spirituality and Spiritual Care in Nursing Practice
There was a high level of acceptance of spirituality and spiritual care as part of nursing care practice.This could be attributed to the nurses' own personal spirituality.It can also be supported by the fact that 88% (n = 339) of the participants saw nursing as a calling, and 89.4% (n = 344) considered nursing as part of their spiritual path.This suggests that nurses who believed that nursing was a part of their spiritual path would be more inclined to provide spiritually based nursing care that is embedded in respect, kindness, compassionate listening, praying for patients, and referral to spiritual leaders.
Similar findings were made by Bailey, Moran and Graham, who interviewed Irish nurses' (n = 22) in order to understand their experiences of spiritual care ( [57], p. 43).A majority of the participants (77%) (n = 17) agreed that providing spiritual care was part of their role, and 75% of participants articulated (n = 16) that spirituality was a key attribute of nursing care.A further 55% (n = 12) of participants reported that making a personal connection was important for patients to be comfortable in expressing spiritual needs.Descriptions from their study that resonate with the data in the present study included: being there, being with the patient, giving hope, holding the patient's hand, and spending time with the patient.Eighty two percent of the sample (n = 18) described the importance of listening, and 93.2% (n = 20) believed that spiritual care can be provided by interventions such as listening and allowing patients to discuss their fears, anxieties and troubles.These findings suggest that spiritual care creates a more intimate relationship between patients and nurses, and that nurses should have spiritual resources to provide spiritually based care.

Salience of Spirituality and Spiritual Care to Patients
The current study also found that more than 80% (n = 308) of participants believed that spirituality was an important dimension in the lives of patients and that spiritual care interventions should be the collective responsibility of nurses, patients, family, friends, and spiritual leaders.This concurs with other studies in an international context ([58], p. 552).
Participants rarely participated in patients' spiritual rituals.This finding suggests that nurses are aware of the ethical constraints around providing spiritually based care.Although private prayer may be deemed acceptable, it is unethical for the nurse to participate in a patient's spiritual rituals since such a practice is not within the realm of nursing ethics ( [59], p. 34).The fact that the sample was aware of ethical constraints suggests an ability to ensure the maintenance of boundaries between professional care and those interventions that are not acceptable, despite them having high levels of personal religiosity and spirituality.
This awareness of professionalism in the milieu of personal spirituality (both nurses and patients) was noted in other studies, where 73% (n = 281) of nurses did not routinely provide spiritual care, but referred patients to the clergy, encouraged patients to pray privately and discussed spiritual topics with patients occasionally ( [58], p. 557).However, although nurses identified listening, touch, use of music, and caring as spiritual activities, such activities received similar support in the present study and fall within the context of professional practice ( [58], p. 557).
The issue around a lack of knowledge suggests the need to further strengthen training in this area given a patient population with strong spiritual needs.Despite such challenges, the spiritual needs of patients cannot be overlooked as part of a comprehensive approach to nursing care that may enhance well-being and recovery ( [59], pp.552-58).
About 80% (n = 308) of participants in this study indicated that nursing activities such as respect for patients' dignity, respect for privacy and religious/spiritual beliefs, kindness, support and reassurance, listening to patients' fears, showing concern, personal friendships and relationships, a sense of peace, maintaining hope, forgiveness, and finding meaning and purpose in illness underpin spiritually based care.This can be linked to the high levels of acceptance on the role of spirituality in nursing practice and concurs with findings made by McSherry and Jamieson ( [1], p. 1758) in the United Kingdom, where an average of 94.5% of nurses (n = 4054) agreed that nurses can provide spiritual care by having respect for privacy, dignity, and religious and cultural beliefs of patients.
Praying with or for the patient, spending time supporting and reassuring the patient, listening to patient verbalize his fears and anxieties, showing respect for dignity and spiritual/religious beliefs, showing kindness and concern, arranging spiritual/religious leaders visits, and offering hope are ethical activities that are reflected in Section 31(1) of the South African Nursing Act and have been supported in literature related to spirituality and spiritual care ( [59], pp.552-58).These activities can form the starting basis for beginner professional nurses to begin introducing spiritually based care into nursing practice in South Africa.

Conclusions
This study was salient, as it was one of the first surveys on spirituality in nursing that covered the entire Province of Kwa-Zulu Natal, South Africa.More importantly, as one of the first research studies on spirituality in nursing, this study not only filled a much-needed gap in the South African context, but also pointed important areas for future research.In general, the study found high levels of personal religiosity and spirituality among professional nurses; a trend which is evident in the overall South African population as well.This high level of spirituality among the sample, spilled over into their nursing role with a majority of the sample agreeing that spirituality spiritual care and were a crucial part of holistic nursing.
While this may be attributed to the participants' high level of personal spirituality, the fact that they encountered patients who brought the spiritual dimension into the nursing context may also have contributed to the high mean ratings on the RRSP scale.A majority of the sample concurred that patients expect spiritual care when faced with illness, psychological distress, and difficulties.Prior research in conjunction with data from present study supports the fact that spiritual care helps patients cope better with illness.Spirituality and spiritual care is seen as providing a sense of direction, hope and inner peace, allowing patients to accept and cope with problems, and thereby restoring their sense of well-being through faith.
This was a sample with significant nursing experience, which may reflect that spirituality has been a part of their nursing care for many years.While this and their own personal spirituality may have led to a level of comfort in providing spiritually based care, it must be emphasized that many are doing so despite having no formal training in spirituality and spiritual care interventions.Spirituality requires specialized knowledge and skill to discern between providing professional nursing care in a way that is ethical and meets the primary need of patient physical care and well-being.It is therefore concerning that many provide spiritual care interventions despite a lack of professional training.Given the large number of patients being encountered who require spiritual care interventions, it is important to prepare nurses to provide spiritually based intervention in an ethical way that benefits and supports patient recovery.
Nursing care practice should focus on nursing activities that enhance spirituality and spiritual care interventions.Responses emerging from the data include praying for the patient, spending time with the patient, supporting and reassuring the patient, listening to the patient, showing respect for spiritual/religious beliefs, showing kindness, assisting with visits to spiritual/religious leaders, offering hope and finding meaning in illness.Nurses need to be taught to provide relational spiritual care in the context of professional ethics.A majority of participants expressed that the barriers to providing spiritual care included a lack of time, uncertainty of how to provide spiritual care using spiritual care interventions, and a lack of knowledge regarding diverse religious faiths.These are areas warranting attention in clinical nursing practice and nursing education.
Despite these challenges, most participants agreed that, although spiritual care takes extra time, it has the potential to make a huge difference in patients' healing, cooperation, and satisfaction.Although most participants had received some information on spiritual care during their training, most nurses felt that such training was insufficient.Most agree on the need for workshops/courses/seminars on spiritual care for nurses.In order for this to happen, it is critical that there is a paradigm shift in nursing practice that will enable spirituality and spiritual care interventions to be seen as an important and integral part of spiritual care.Given the multitude of international research studies that have documented the role of spirituality in affecting healing, coping, and recovery in the midst of grave illness, it is pivotal that this paradigm shift occur in South Africa soon.

Figure 1 .
Figure 1.Spirituality and spiritual care interventions.

Figure 1 .
Figure 1.Spirituality and spiritual care interventions.