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Objective: To investigate the definitions of spirituality in the healthcare field, identifying its main dimensions and proposing a framework that operationalizes the understanding of this concept.
Methods: This is a systematic review following the PRISMA guideline (PROSPERO: CRD42021262091), searching for spirituality definitions published in scientific journals. Searches were carried out in PubMed (all articles listed up to October 2020) and in the reference lists of the articles found in the database, followed by selection under specific eligibility criteria.
Results: From a total of 493 articles, 166 were included in the final analysis, showing that there is a large body of scientific literature proposing and analyzing spirituality definitions. In these articles, 24 spirituality dimensions were found, most commonly related to the connectedness and meaning of life. Spirituality was presented as a human and individual aspect. These findings led us to construct a framework that represents spirituality as a quantifiable construct.
Conclusions: Understanding spirituality is an important aspect for healthcare research and clinical practice. This proposed framework may help to better understand the complexity of this topic, where advances are desirable, given the relevance it has acquired for integral health care.
Keywords: spirituality, religion, religion and psychology, religion and medicine, healthcareSpirituality is a broad and complex concept which varies its understanding according to different cultural, religious and academic backgrounds (i.e., religious persons, scientists, or lay persons; Koenig, 2008; la Cour and Götke, 2012). In this context, there is a remarkable debate regarding the most accurate meaning, and regarding the possibility of having a single universal consensual definition for this concept (Peng-Keller, 2019). Some issues arise since the fact that spirituality is often linked and overlaps another important concepts, such as religion/religiosity and well-being/positive emotions (Hill et al., 2000).
Historically, the term spirituality was used to describe the practices of people who dedicated their lives into religious services or exemplify the teachings of their faith traditions (Koenig, 2008). Only in the last decades, spirituality has been detached from religiosity as a distinct construct, even though the scientific community still refers to this research field using the “dual” term religiosity/spirituality (R/S; Zinnbauer et al., 1997; Bauer and Johnson, 2019).
Research over the last decades has been growing substantially in the field of “Spirituality and Health,” showing a significant influence of spiritual and religious beliefs on both mental and physical health outcomes (Damiano et al., 2016), and approximately 30,000 articles have been published in this field of research from 1999 to 2013 in the PubMed database (Lucchetti and Lucchetti, 2014). In addition, the spiritual dimension has been proposed to be included in the multidimensional concept of “health,” as illustrated by discussions in the scope of the World Health Organization (WHO), which referred to the “inclusion of a non-material or spiritual health dimension, making the concept come to be regarded as a dynamic health state - physical, mental, spiritual and social behavior” (Grad, 2002; Dhar et al., 2011; Toniol, 2017).
This discussion is supported by a robust body of evidence suggesting a significant effect in physical, mental, and social health (Koenig, 2015; Zimmer et al., 2016; Mishra et al., 2017). Spirituality is generally related to diminished numbers of substance use, suicidal attempts and depression prevalence, less hospitalization, better coping with disease, better treatment adherence, and lower mortality rates (Moreira-Almeida et al., 2006; Guimarães and Avezum, 2007; Lucchetti et al., 2011). In addition to the clinical importance observed, patients want their doctors to address spirituality and most doctors and nurses consider important to integrate this aspect into their practice (Baetz et al., 2004). However, several barriers limit addressing R/S, including the lack of training by health professionals and the lack of clear defined concepts (Best et al., 2015; Menegatti-Chequini et al., 2019). In this context, the understanding of Spirituality becomes an important issue for research, clinical practice, and the training of health professionals (Lucchetti et al., 2012; Attard et al., 2019).
Despite the increasing use of the concept of spirituality among health researchers, there is no clear consensus about its definition (Chiu et al., 2004; Sessanna et al., 2007; Gall et al., 2011). This lack of standardized definition increases the potential for non-standardized constructs, creating pitfalls while comparing studies that use different criteria and instruments, especially in health-related researches. While for the social sciences there is no major concerns for the lack of an universal definition of spirituality, medical and health-related sciences need a structure and relative consensus, since most instruments attempt to quantify its intangible construct in order to evaluate its impact and propose health-related interventions (Macdonald and Friedman, 2002; Hill and Pargament, 2008).
Although a previous study has already used qualitative content analysis of the published literature (Elkins et al., 1988), in the last decades, the field of spirituality has considerably changed with a large number of publications and ongoing researches. Likewise, several articles were published with new definitions and concepts. Therefore, it is of urgent necessity to better clarify and disentangle the concepts of spirituality and religiosity, determining and understanding which dimensions of spirituality influence more positively health-related endpoints. In this sense, the present article aims to move forward on this discussion, presenting a systematic review of the spirituality concept for the healthcare field, identifying its main dimensions and proposing a framework that operationalizes the understanding of the term spirituality.
This is a systematic review based on the PRISMA statement for reporting systematic reviews and meta-analyses (Page et al., 2021). The protocol was registered in the PROSPERO international prospective registry of systematic reviews (registration number: CRD42021262091).
The following criteria were applied to include the studies in this review: articles that addressed the meaning, concept, or definition of spirituality (either new proposals of definitions in the healthcare area or operational definitions that analyzed pre-existent definitions in the literature). All articles (letters to the editor, editorials, opinion essays, observational studies) were included. No language or date restrictions were applied. The exclusion criteria were articles that were not available in full, articles not related to the definition of spirituality, and those that did not present a new concept or operational definition about spirituality.
The literature search was conducted using the PubMed database (all articles listed up to October 1, 2020), with the Boolean expression “spirituality [title] AND (concept OR definition)” and scanning reference lists of the included articles.
The selection of studies was conducted in three stages:
Stage 1: All references on the PubMed database were screened using the Boolean expression described above; additional records were identified through the list of references of the articles obtained. Duplicates were excluded using the Endnote software. Eligibility was determined based on title and/or abstract. Articles that brought a new proposal of spirituality definition or analysis of definitions already existing were considered and included. All included articles on stage 1 proceeded to stage 2.
Stage 2: The articles were read in full, focusing on the eligibility criteria and on evaluating the characteristics of the article (authors, year of publication, number of citations, language) and of the definition (discursive or in topics, newly proposed, operational definition or citation). Articles that only cited pre-existing definitions were excluded, but their lists of references were used as a secondary source.
Stage 3: All definitions of spirituality found were analyzed, seeking to identify the dimensions they presented.
All definitions of spirituality were analyzed looking for expressions or terms that could characterize a dimension. The conceptual dimensions were identified using expressions or terms that were repeated and/or carried a similar meaning among the different definitions, for example: the expressions “these dimensions of spirituality are applicable to all human beings” and “spirituality refers to a fundamental aspect of humanity” are part of different definitions of spirituality and have been classified as the “human dimension” simply (Anandarajah, 2008; Appleby et al., 2018). After identifying all dimensions, from all selected definitions, a second author looked up into each definition in order to confirm and unify all chosen dimensions. In this step, a score was established to quantify the use of a given term/expression, with each use corresponding to one point. The sum of the number of points was transformed into percentage, with 166 corresponding to 100%, since 166 was the total number of definitions analyzed. Terms that did not appear in at least 3 definitions were excluded, as they corresponded to less than 2% appearance in the definitions.
The results led us to construct a framework, organizing the correlated dimensions in horizontal axes, representing spirituality in a visual structure (see the “Discussion” section below).
We found 441 articles in the PubMed query and 54 additional records were identified in secondary sources. After excluding duplicates, a total of 493 articles remained for the first screening. From them, 277 were accepted for full text reading. After full text reading, 111 articles were excluded, leaving a total of 166 articles, most of which in English, that were included in final analysis concerning spirituality definitions. Figure 1 summarizes the steps of the systematic review. Tables 1 and and2 2 presents, respectively, the most cited articles and books on November 3, 2020, according to Web of Science and Google Scholar.