Spirituality in Nursing: an Analysis of the Concept

There is scientific evidence that the spiritual well being of a person can affect quality of life and the response to illness, pain, suffering and even death. In spite of this evidence, spirituality in nursing has not been examined within a South African context. The purpose of this study was to describe the phenomenon of spirituality from the perspective of nurses and patients/clients with the aim of generating a middle range theory of spiritual care in nursing. A qualitative mode of inquiry using a grounded theory method was applied. A sample of 56 participants com­ posed of 40 nurses, 14 patients and 2 relatives of pa­ tients was recruited by theoretical sampling procedure from one public hospital, one private hospital and one hospice setting. Focus group interviews and one on one in depth interviews were conducted. An audio tape recorder was used to record the interviews. Field notes and memos were also kept. Data were collected and analyzed simultaneously. Non-numerical Data Qualification Solutions NUDIST soft­ ware was used to code data into different levels of codes. The results were rich descriptions of the concept of spirituality. This concept was described as a unique individual quest for establishing and, or, maintaining a dynamic transcendent relationship with self, others and with God/supernatural being as understood by the per­ son. Faith, trust and religious belief were reported as antecedents of spirituality, while hope, inner peace and meaningful life were reported to be consequences of spirituality.


Introduction
Over the past two decades there has been a growing in crease in discussions about the concepts of human spiritu ality and spiritual care in relationship to holistic caring (Oldnall, 1996: 138).This recent upsurge of interest in mat ters of spirituality is not only in the nursing profession, but also in politics, education, Theology and in other health related professions (Carr, 1996: 159;Louw, 1995:47).Carr (1996: 159) argues that this recent attention to matters of spirituality can only be associated with the urgent need for a rigorous philosophical analysis in a realm where the bulk of the talk is notoriously fast and loose.Indeed, by far the most pressing problem concerning the construction of a plausible account of spirituality relates precisely to the looseness with which every day language is used to de scribe spirituality (Carr, 1996: 159).Research suggests that spirituality can influence a person's health, and the quality of life lived (Ross 1995:457).It was for this reason that the researchers decided to conduct this study.

The purpose of the study
The purpose of this study was to analyse the concept of spirituality from the perspectives of both patients/clients and nurses in South Africa, with the aim of uncovering distinctive and shared meanings of this phenomenon.There are no research studies that have been reported in South Africa on human spirituality in nursing, therefore there is a need to investigate this phenomenon in order to incorpo rate it into nursing care.

Background of the study
Nurses describe their professional uniqueness in patient care as embedded in the concept of holistic caring in which a person is viewed as a unique bio-psycho-social, moral, and spiritual being (Oldnall, 1996: 138).The central tenet of holism is unity of all aspects that make a human being.Holism is based upon the premise that the whole is greater than the sum of its parts (Goddard, 1995: 808).The oppo site of holism found in nursing practice is the fragmenta tion of a person into a body in bed, a case for surgery, a disease for pathological investigations (Salladay and McDonnell, 1989:543).In response to the challenge of car ing for the person as a whole, the International Council of Nurses' (ICON) code of ethics (1973) incorporated spiritual care as part of the nurses' responsibilities.
Defining human spirituality is not an easy task.Nursing literature reveals that there is a plethora of definitions which include a need for meaning and purpose in life, a need for hope, trust, faith in self, others and in a power beyond self, a need for forgiveness, a need to establish and maintain a dynamic relationship with self, others and the Ultimate Other (Carson, 1989:5;Goddard, 1995: 809;Golberg, 1998: 837;Sardana, 1990:31;Shelly & Fish, 1988:37;).There is scien tific evidence from North American and British studies and literature that the spiritual well being of a person can influ ence the quality of life lived and the general response to the crisis of illness, suffering, pain and even death (Ross, 1994a: 439).The manner in which spirituality is conceptual ised and defined will have significant implications for pro fessional nursing practice, nursing education and further development of the ontology and the epistemology of nurs ing (Goddard, 1995: 811).In spite of this interest in spiritu ality, there are no studies that have been recorded in South Africa on spirituality as it relates to patient care.

Statement of a problem
The problem that was identified in this study was the ab sence of an explicit description of the concepts of spiritual ity within a South African context.Concept clarification is imperative if South African nurses and patients/clients are to recognize spirituality within a broader context of holism.The implicit nature of spirituality needed to be explicated from the perspective of those giving and receiving nursing care.The identification of the essential constitutive ele ments of the phenomenon of spirituality will be helpful to nurses providing care.

Research questions
The research questions that this study endeavoured to answer were; 1.
What were the descriptions given by nurses, pa tients /clients and patients' relatives to the concepts of spirituality?2.
How did spirituality influence nurses, patients/cli ents' responses to illness, pain suffering and death?3.
What were variances, complexities and diversities inherent in the descriptions of spirituality?

Significance of the study
Although there is an increasing recognition of the spiritual dimension of a person and a need for spirituality to be incorporated in patient care, there is still obvious concep tual disparity, vagueness and ambiguity in the descriptions given by different authors (Goddard, 1995: 808).Several factors have been identified as the cause of this ambiguity and vagueness in descriptions of the concept of spiritual ity.Piles (1990: 37) found that spiritual needs were often confused with psychosocial needs.Goddard (1995: 809) also argues that the inability to distinguish between the psychosocial and spiritual needs and spirituality and re ligiosity have potential results of either neglect or inappro priate response to the patients' spiritual needs.
Although the scientific attention of nurses in the Western world is on issues of spirituality, no studies have been reported in South Africa on the topic of spirituality.Nurses like McConnochie (1994: 36) purport that the reality of spir ituality is more of a challenge to nurses dealing with pa tients suffering from terminal illnesses such as acquired immune deficiency syndrome (AIDS).Often these patients feel that they have let their families, friends and God down and that they have not lived up to the standard of their own cherished values.

Literature review
The literature review that was conducted initially covered the philosophical background about human nature and human spirituality; religious perspectives on human na ture and human spirituality and finally human spirituality and spiritual care as part of total patient care.The nature of the human being was the starting point for philosophical inquiry.The origin, the purpose and the human destination have always been a cause for concern to those who love wisdom (Stumpf, 1966 : 1).The philosophical arguments that were included in this literature review are Rationalism, Empiricism, Marxism, and Existentialism (Conforth, 1954:2;Descartes, 1911 a: 21;Kiergaard, 1941: 10, Locke, Berkeley, Hume & Reid, 1953:12).
What could be deduced from the literature is that a human being needs power beyond himself or herself to cope with the daily demands of life (Kalumba & English, 1996:5).This power is found in the person's spirituality (Goddard, 1995: 815).It was also reported that every human being has a natural inclination or desire to maintain a relationship with a higher being (Rasi, 1994: 225).This desire to maintain a relationship with the higher being is increased by life threat ening situations (Reed, 1987: 336).This is what makes the study of human spirituality such a vital component of nurs ing science and essential to total patient care.

Research Design
The research design used in this study was a qualitative grounded theory design.Qualitative grounded theory de sign is a mode of scientific inquiry oriented towards under standing human beings and the nature of their interactions in their natural setting (Brink & Wood, 1989: 161).The quali tative method of inquiry examines phenomena outside the context of the existing gestalt or sedimented views (Burns & Grove, 1987: 85).The purpose of a grounded theory method is to form a new gestalt in order to generate new theories.Bums & Grove (1987: 85) argue that the researcher needs to step out of the sedimented views and be open to a new gestalt that will emerge from the data and from the researchers' abstract thinking.
To conceptualise spirituality from the perspective of pa tients/clients and nurses within a South African context required an approach that could allow the researchers to step out of the existing gestalt about this phenomenon.
The grounded theory method explores the social psycho logical process that is found within human interaction (Streubert & Carpenter, 1995: 145).Grounded theory ex plores the richness, complexity and diversity of human ex periences and contributes to the development of middle range theories or substantive theories (Streubert and Car penter, 1995: 146).
Grounded theory method is appropriate when studying ar eas in which very little or no research has been done and when new viewpoints or gestalt are needed to describe phenomena that are not clearly understood (Cheniz & Swanson, 1985: 7).The phenomenon of spirituality fits the criteria.There is very little research that has been done on this topic and not in South Africa.Even the research done outside South Africa showed some ambiguity in the use of this concept (Golberg, 1998: 836).

Setting description
The settings found to be appropriate for this study were hospitals and hospice settings.The hospitals selected in cluded one public, one private and one hospice.These settings were chosen because the researchers believed that they would be more likely to access a variety of patients and nurses who could provide data that were rich, complex and diverse in describing the phenomena of interest.These settings allowed the researchers to collect data that were context bound.Context accounted for the setting as well as the events impinging on a particular setting (Chenitz & Swanson, 1985: 102).

Sampling procedure
A purposive theoretical sampling procedure was followed.
Purposive sampling refers to the process of selecting par ticipants who are rich in information needed by the re searcher (Morse, 1994: 91).Theoretical sampling on the other hand refers to the method of data collection whereby the researcher is guided in his or her choice of participants by previous answers received from the participants, and by the need to fill the gaps in the emerging categories and concepts (Glaser & Strauss, 1967: 45).This meant that the researcher would not begin with the fixed number of par ticipants, but would continue selecting and adding partici pants until the theory was fully developed and saturation of categories was reached (Chenitz & Swanson, 1985:103).
This study focussed on patients/clients and the nurses who were providing direct patient care on the units.The patient participants were chosen on the basis that they had a chronic and, or, terminal illness, they were adults who could give voluntary consent, they were well oriented, fully conscious, mentally sound and aware of the clinical prog nosis of their illness.The researchers consulted the regis tered nurses who were responsible for patient care to as sist in identifying such participants.This group was se lected for the study because research has revealed that terminal illness tends to increase the patient's vulnerability or interest in spirituality (Reed, 1987: 339).These patients were more likely to seek a relationship that is beyond the material realm (Ross, 1994:410).
The second group of participants that was included in the study was a group of patients who suffered from acute or chronic illnesses that were life threatening but not terminal.This group was selected on the basis of the similarities it might have with the first group to minimize the differences in the data, and to maximize similarities that bear on a cat egory of interest (Glaser and Struass, 1967:45).
The third group of participants that was selected was a group of healthy mothers who had just given birth to healthy infants in the hospital.The reason for selecting this group was to provide the researcher with a range of participants who varied along the continuum from healthy to terminal illness.It was assumed that these sources would provide a variety of data that were rich, complex and dense in order to verify categories and their properties as they developed.As the categories developed and the concepts emerged, the researcher continued with theoretical sam pling until all gaps were filled and a theory based on differ ent levels of conceptual generality was developed (Glaser and Strauss, 1967:55).
The fourth group of participants that was selected was a group of nurses who gave direct patient care either in the hospital or hospice settings.This group was also chosen so that the differences between what the nurses say and what the patients say could be maximized.Finally the re searcher included the relatives of some patients as the pa tients themselves felt that their relatives should be involved.
Interviews with relatives increased the richness of the data.
The Professional Nurses who were on duty at the time the researcher came to the units were very helpful in assisting the researcher to identify potential patient participants.

Sample description
The sample was composed of 56 participants recruited from the three settings mentioned above.Of the total number of participants, 71.4 percent of them were nurses, 25 percent were patients, and 3.6 percent relatives of patients.The reason for having more nurses as compared to patients and their relatives is that nurses were mainly interviewed in focus groups while patients were only interviewed in one to one interviews.Since the nursing profession is a female dominated profession, 80.4 percent of the participants were females and 19.6 % were males.Nurse participants reported varied years of nursing experience.The range was from 6 months to 26 years of experience.Patient participants were admitted for various reasons, which included burns, acci dents, major operations, cancer, tuberculosis, diabetes mellitus, immune deficiency related conditions, delivery and postnatal complications.

Data collection
Data collection and analysis were done simultaneously over a period of six months from the middle of April to the middle of October 2000.In-depth semi-structured interviews were conducted with nurses, patients and patient's relatives on a one to one basis.In addition to one to one interviews, seven focus groups were conducted with nurses from all the settings.One focus group was held at the beginning of data collection to introduce the topic and allow brainstorm ing.This focus group helped to identify areas of impor tance in the phenomenon under investigation and it also acted as a means of developing rapport with the partici pants.The interviews were audio taped and then transcribed into a text by the researcher.Hand written notes and memos were utilized to provide back up information.All interviews were conducted in the language the participants felt com fortable with.Zulu and Xhosa speaking patients were in terviewed in their language and the recorded information was translated into English by the researcher.An inde pendent nursing colleague who was not part of the study and was fluent in all three languages checked the accuracy of translation.(Table .1)

Data analysis
Data collection and analysis were conducted simultane ously.The data were analysed using the editing style.Ac cording to Crabtree (1992: 3) editing style of data analysis is an appropriate approach when analysing data for devel oping a grounded theory.The guidelines that were followed were extracted from Cheniz and Swanson (1985: 121), Tesch (1992:2), Wilson (1988:452), Glaser and Strauss (1967:49), Morse (1994:23).The software that was utilized is the Quali tative Research Solutions Non-numerical Unstructured Data ways of Indexing Searching and Theorizing modified as NVIVO QRS NUD*IST.Richards (1998: 1) developed this software to assist researchers in handling and managing complex non-numerical data (Clarke, 2000b: 1.To describe the sample composition, the researchers utilized SPSS for Windows.This software was useful in handling quantita tive demographic data (Clarke, 2000a: 1).
As data collection and analysis were carried out simultane ously, the researchers read every piece of data as it came to her line by line and paragraph by paragraph identifying words or statements made by the participants about their experience of the phenomena of spirituality and spiritual care.Wilson (1988:456) calls this process substantive cod ing, while Glaser and Strauss (1967: 47) refer to the same process as concept specification.Substantive codes are used to describe dimensions, properties and consequences of the phenomena under study.The researcher went back and forth into the data verifying them with the participants, carefully reading and analysing them until all categories were fully developed and the relationships between cat egories and their properties were identified.The theory grounded on the data was developed through the use of both inductive and deductive modes of reasoning (Cheniz and Swanson, 1985: 127).This paper will focus on the con cept of spirituality.

Scientific rigour
Scientific rigour is measured in quantitative studies by their trustworthiness or their being true to the data and their context (Lincoln and Guba, 1985: 21;Khalifa, 1993:281).
Trustworthiness refers to the quality value of the final re sults and conclusions reached in a qualitative research (Lin coln and Guba, 1985: 22).Trustworthiness is composed of four main aspects.The first aspect of trustworthiness is credibility.Credibility means being authentic to the data.
To achieve this the researchers utilized several measures.The data and categories discovered were also discussed with the co-investigator at regular intervals.
Secondly, the researchers used triangulation, which refers to the use of different methods of data collection to en hance credibility.Triangulation was achieved by use of one to one interviews and focus groups interviews.Thirdly, the researchers utilized membership check that refers to the researcher's ability to check back with the participants to validate accuracy of information given and recorded.The researchers validated information by playing the tape back to the participants and by reading written notes back to the participants.Where possible, the participants were visited a few days after the interview to validate the accuracy of information recorded and transcribed.
Transferability is the second aspect of trustworthiness (Lin coln and Guba, 1985:24).Transferability refers to the appli cation of the study findings to the context in which the data were derived and to other similar context depending on the degree of fittingness between context.To ensure that the grounded theory of spiritual care can be applied to all nurse/patient interactions in all settings, the researchers utilized a variety of participants as stated under sample selection.They used patients from different units, nurses who were also from different units and relatives of patients.These participants differed in age, sex, diagnoses or expe rience in nursing, religious affiliation and cultural back ground.
The third aspect of trustworthiness of a qualitative study is its dependability (Lincoln and Guba, 1985: 24).Depend ability is concerned with the stability of data in the study.
The process of data collection, analysis and interpretation needs to be monitored by experts in the method of grounded theory studies (Khalifa, 1993: 280).To ensure dependabil ity, the researcher used the dependability audit trial tech nique whereby external experts were utilized in analysing data and interpreting them.
The fourth aspect of trustworthiness that was ensured in this study is confirmability.Confirmability refers to the de gree to which the data confirm the findings (Lincoln and Guba, 1985: 23).To ensure that the findings represent the data, the researchers went back and forth into the data, field notes, memos audiotape and with the participants to confirm that the findings reflect the participants' responses not the researchers' own constructions and biases.When this was done, the findings were written in a descriptive form indicating the major themes, categories, concepts and their relationship with one another.

Ethical consideration
Qualitative research like all forms of research is subjected to codes of ethics for the protection of human subjects.
Before the study was conducted, it was first given ethical clearance by the University of Natal research committee.
Permission to conduct research was also granted by the Department of Health of KwaZulu Natal province and by the hospital / hospice authorities.The participants were given a written informed consent or informed refusal.The information about the purpose of the study, the process of data collection and analysis and how the results will be disseminated was discussed with the participants.The dis cussion included the risks involved in the study.
For this study there were no physical risks involved, but there were emotional discomforts associated with the na ture of the topic.Some people consider spiritual issues to be private and not fit to be discussed in open.To overcome this problem, the researchers first established rapport with the participants.The participants were given opportunity to ask questions about the research procedure and pur pose before giving consent to be part of the research study.
During interviews, the researchers ensured privacy by con ducting interviews in a side ward that was empty.In other settings there were patient counselling side rooms.These side rooms were used to interview both nurses and pa tients participants.Some patients were alone in their wards.
In that case the ward was used for the interview.The par ticipants were informed that they were free to discontinue their participation at any time during the study.

The concept of spirituality
The meaning of the events was understood from the per spectives of the participants.How they defined their real ity and how they acted in relation to their beliefs were im portant considerations in data collection.The interaction of the participants was understood at the symbolic and behavioural levels.Meanings were derived through social 19 Curationis May 2004 interactions hence the participants were interviewed and observed in their context (Chenitz and Swanson, 1985: 120).
person who is in need, like the person who has a problem needs someone to talk to.To me that is spirituality " The concept of spirituality emerged from the responses given by participants to the question, what do you under stand by the term spirituality?These responses were ana lysed and the concept of spirituality was developed along with its antecedents, characteristics, and consequences.

Spirituality defined
From data analysis of the responses given by the partici pants on the definition of spirituality, spirituality was de fined as an individual quest for a transcendent relationship by establishing and or maintaining a dynamic relationship with God / supernatural being as understood by the person and with significant others.Spirituality was defined in rela tionship to either a person seeking a relationship with God as the superior being or a relationship with other people in order to reach out to God.This relationship is sought through belief, faith, and/or, religious practices such as prayer, worship or reading books or magazines that inspire a person to develop or maintain this transcendent relation ship.A quest for a transcendent relationship was identi fied as the basic social process and a core variable through out the data analysis.
In their description of spirituality, the participants often specified a relationship with God/ supernatural being and a relationship with other human beings.This demonstrated that spirituality as a quest for a transcendent relationship has a vertical direction and a horizontal direction.Verti cally, the relationship is directed to the supernatural being.Horizontally, the relationship is directed to other human beings.To illustrate a vertical relationship one participant said, "Well, with me, spirituality means the person' s relation ship with the supernatural power, the power that person thinks it is above his or her own ability" Another partici pant said, "That is just the person's relationship with God, or sometimes it is not God.The person' s relationship with some type o f like a Prophet or whoever they see as a spir itual leader.I think is universal." The second quotation includes a relationship with a hu man person who is thought to represent the superior be ing.This is an example of a horizontal relationship wherein the aim is to achieve a vertical relationship.
Sometimes the horizontal relationship was described by the concept of "ubuntu".''Ubuntu" is the African word that describes the socially desired relationship of a person to other people."Ubuntu" is to be a good human being, loving and being concerned with another person as described by the community mem bers.It is a concept difficult to translate to English.One participant maintained that spirituality is "ubuntu" "Spirituality is what I consider to be ubuntu ( being hu man to the person).Another participant said, "To be hu man is to do something good to another person, helping a The above statement infers that being a spiritual person is also being a social person and it involves being part of the community and being concerned about other people's af fairs.The same participant further explained what she meant by saying spirituality is "ubuntu."For her to be "ubuntu" also meant knowing God and living in accordance to His laws."To be a human (ubuntu) is to know God, is to live in accordance to God' s laws.There are laws o f nature and there are laws o f God".
Linked to the concept of "ubuntu" is human value.Value to the participants referred to respect that ought to be given to the person as a human being.When these concepts were raised they were stated with regards to the patient / nurse relationship.To value human dignity is another con cept that described a person's relationship with another.Valuing a patient's belief and valuing a person's religion was also mentioned.The following participant said,

"Ok, I don' t know how you see it but in simple English it is to value a patient' s dignity. So spirituality is valuing some body ' s dignity, somebody 's beliefs and leave them to do what they want to do "
Other concepts which participants described as spiritual ity were found to be antecedents of spirituality rather than 'spirituality' and will be addressed next.

Antecedents of spirituality
The concepts that were identified as antecedents to spir ituality included religious beliefs, faith and trust.Religious belief refers to an acceptable idea that is recognized as true and is also put into practice and it becomes part of the person's philosophy of life.Linked to religious beliefs is a concept of faith.Faith comes from the Greek word "Pistis" which incorporates belief as well as trust in its meaning.In our modem language, belief refers to a mere mental assent or an acknowledgment of facts and faith has also been used to refer to a belief in something for which there is insufficient evidence (Steed, 2000: 12).Some participants made a difference between religion and spirituality.One participant said, "I think what happens is that religion puts people in differ ent brackets.Religion brackets people, you are a Chris tian, I am a Hindu, that' s an example / am giving you.I think with religion each person has his/her own practice but they all believe in the supernatural power, they all believe that but they have different means o f getting to it.So religion limits people.I t' s practices that are handed down from generation to generation, from fore fathers to fore fathers.So we all believe in some type o f supernatural power.We have different ways o f showing it by having a religion." The above statement affirms that religion is a means of expressing our spirituality, but it is not spirituality.Partici pants who viewed spirituality as a belief system put it this way, "I see spirituality as a belief system fo r a person.It in volves what you believe, it grows from there on, it grows to include who you are and how you perceive things" Another participant said '7 think spirituality is a belief that human beings are being ruled by a certain super natural power o f which they are o f different kinds" One participant trying to emphasise her point regarding spirituality and trust or faith said, "One may not always be able to give a rationale fo r pain, suffering and death, but trusting in God makes it easy to say "one day He will make plain those things that may not be fully understood today" Faith, belief and trust are important prerequisites for a transcendent relationship.Pierson (1974: 35) said "we may with certainty trust Him where we cannot always trace Him" The exercise of faith is like that of a muscle it grows stronger with use.The more faith is exercised, the stronger it becomes (Knowles: 1990:53).

Characteristics of Spirituality
Spirituality as a quest for establishing and or maintaining a transcendent relationship is characterized by the following important variables; Firstly, spirituality is based upon the value of a person as a human being with human dignity that is derived from the link that human beings have with God / supernatural power and with one another as one participant said,

"Ok, I don't know how you see it, but in simple English it is to value a patient' s dignity. So spirituality is valuing somebody' s dignity, somebody 's beliefs and leave them to do what they want to do "
Secondly, spirituality is a unique human experience.Every being has a different spiritual experience and thus a unique relationship with God / supernatural being and with others.The uniqueness of each person's spirituality gives that individual his or her own identity.One participant expressed this uniqueness this way, "Spirituality is something that is within a person whether a person is in church or not or with the people that she/he fellowships with or not, that spirituality is there all the time in what the person believes in, whether among the people or all by herself/himself spirituality is always there." Another participant said, " But I still think you can be part o f a congregation in the church, but each person in that congregation has indi vidual spirituality, even though you are sitting in the church listening to the same sermon, each person totally attacks it at a different way that is "you." Thirdly, spirituality is a universal phenomenon.The uni versality of spirituality stems from the fact that every hu man being is a spiritual being.Some people acknowledge their spiritual nature, while other people do not.The fact that some people do not acknowledge their spiritual nature does not make them non-spiritual.Spirituality remains uni versal whether people universally recognize that or not as this participant said, '7?' .vvery hard to define the spiritual part o f a person, but we all have it whether we want to or not.Whether we acknowledge that we have the spiritual part.Spirituality is universal" Fourth, spirituality is dynamic.The dynamic spirituality refers to the power a person has within himself or herself to change and grow and increase a relationship with God and with others."You can change your spirituality you can be a spiritual person in a certain way according to your environment, according to the way you were brought up, your school ing, your parents, but through the passage of life you as an adult can change it, it is not something that is static, you can increase it or change it or make it deeper, it is not some thing that is just there.

Consequences of spirituality
In this section we will examine the consequences of spiritu ality.One of the most frequently mentioned concepts linked to spirituality was hope.Hope refers to an assurance that the present situation though it may be gloomy will have a solution "To me spirituality is giving hope to someone, like when the person is sick or discouraged then you tell them not to lose hope so to me spirituality is hope that God will not leave me alone in whatever" Hope wherever it is mentioned is in reference to belief or religion, or to God or that supernatural being the person worships or is perceived as the source of hope.What the participants believed gave them hope.In a way hope is derived from belief.One participant said; "After praying I feel better because I have hope that all will happen.That which I ask fo r I have hope that it will happen, even health I have hope that when I have put everything in His care, I will recover" Secondly, spirituality results in inner peace.The hope of knowing that the person was not alone in the struggle with illness or death gave inner peace.Inner peace refers to peace that is found within a person whether that person is in good health or not.It comes from knowing that a person has made things right with the one claimed to be the source of power and also with the significant others.The inner peace can be drawn from the person's religious beliefs and from knowing that one has a reliable relationship with God / supernatural being and with others.Some participants defined inner peace this way, "It means what the patient sees as giving him or her the inner peace.From the spiritual point o f view, the inner peace that the patient gets, whether is from his religious background.Inner peace is reconciliation with the self, the acceptance o f the self fo r me, it is also very important, the relationships with other people " Thirdly, spirituality gives meaning in life, illness and in death.When things go wrong in life as they sometimes do, when tragedy strikes in the family, or a person finds himself or herself faced with life threatening situations, the meaning for life is usually lost and the person begins to question the purpose for life.The participants cited their spiritual re sources such as their religious belief and their relation ships with God or the Supernatural power as the source of meaning.The following are the few examples of statements given by participants in reference to spirituality as giving meaning, human existence.We are created to be in relationship with the rest of the created order, each other and God".Spiritu ality within a South African context with her diversity of culture, religious beliefs and nationality, needs to adopt a more holistic approach.Kretzchmar (1995: 67) says "In the most generous sense spirituality has to do with how we experience ourselves in relation to what we designate as the source of ultimate power and meaning in life, and how we live out this relationship".
Spirituality is not merely an inner feeling; it has to do with the integration and coherence of our selves as experienc ing and interacting persons.The essence of spirituality is inescapably linked to the pursuit of a closer walk with God / Supernatural Being (Kretzschmar, 1995:65).
" It is anything that the patient believes gives meaning to life or gives meaning to their suffering.That' s what I con sider spirituality.I t ' s just anything that gives meaning to the fact that one has a life and may be his/her death" Another significant outcome of spirituality mentioned by the participants was that spirituality also gives the will to live.Participants stated that their spirituality gave them the will power to live and a reason to live as this participant said; "Without it (spirituality) I don' t think life is worth living, you have got to have that, you have to.I mean you got to have a will power, other wise life is not going to have any meaning, you are just going to live fo r today, you are not going to have a goal in life."

Discussion
The purpose of this study was to find a relevant definition of the phenomenon of spirituality from the perspectives of both patients and nurses, with an aim of uncovering a shared meaning of the concepts from a South African context.The concept of spirituality was conceptualised as a unique, dynamic quest for a transcendent relationship.A quest for a transcendent relationship was manifest in an individual's desire to establish and/ or maintain a dynamic relationship with God / supernatural power, self and significant others.This definition of spirituality uncovered in this study agrees with several definitions found in the literature such as the definitions given by Carson, 1989: 5;Golberg, 1998: 838 & Newshan 1998: 1236).These authors agree on the fact that spirituality has to do with one's natural inclination towards transcending relationships.Human beings are also social and spiritual beings.They need to relate meaningfully to themselves, to others and to God / supernatural being as they understand Him.
The definition given by Kretzshmar (1995:64) in his discus sion on prerequisite for reconstruction of South Africa shows how vital the spirituality of individuals is to the d ev elopm ent and re co n stru ctio n o f South A frica.Kretzshmar (1995: 64) says, "a holistic spirituality seeks to integrate rather than separate the various dimensions of Spirituality is also defined as the dimension of a person that is concerned with values or ultimate reality.Spirituality is that aspect of a person that inspires a desire to transcend the realms of the material Carson (1989:4), Me Connochie (1994:36), (O 'Brien, (1999:5), Piles (1990:37), Ross (1994b: 33) Simsen (1988:31).Spirituality is also identified in the literature as closely related to an individual's faith (Rasi, 1994:225).In this study, faith was identified as an essential factor in realizing the transcendent relationship.Sometimes spirituality is referred to as an unfolding mystery related to one's attempts to understand the meaning and purpose of life (Ross, 1994:439).Nolan and Crawford (1997:292) in their discussion of spiritu ality in relation to mental health state that spirituality must be viewed on four different levels.The first level may be viewed as how a person relates to himself or herself.The essence of a healthy relationship with one's self is related to the authenticity of the person to herself or himself.Ac cepting what the person really is, accepting one' self and reject the pretence of being someone else is an integral aspect of a healthy spirituality.The second level is con cerned with how a person relates to others.A healthy rela tionship with others brings inner peace and also contrib utes to self-acceptance.The third level of spirituality is concerned with relationships between and within groups.Personal growth and self-awareness are achieved through others.This statement agrees with the concept of "ubuntu" that was identified as one of the important principles of providing spiritual care in this study.There is a need for social awareness and communal involvement in realizing spirituality.
The fourth level is the relationship that a person has with the transcendent or with the power a person considers to be the ultimate reality.For most people transcendent rela tionship is realized through religion, while for others it is realized in terms they use to think about life and death.On every level spiritual aspirations are mediated through the social structures such as education, religion trades union, social organizations and health services (Nolan and Crawford, 1997:292).
Stuart, Deckro and Mandle (1989: 36) also view spirituality as a process of coming into a relationship with reality.They make a clinical application of the usage of the concept and they suggest a clinical program that integrates the body, mind and spirit to health and healing.The focus of their program was cardiovascular therapy.This program could easily be adapted to other illnesses.A positive attitude towards life achieved through nurturing of hope and faith decreased the blood pressure of most patients that were on the program.By opening the mind of the patients to the possibilities that exist, they were able to change the life styles that were detrimental to their health.Therefore, un derstanding the patient's spirituality can be an effective therapy (Flemming, 1997: 14).Haegert (2000: 495) purports that an African ethics for nurses is based on the principle of 'ubuntu'.In this study the concept of 'ubuntu' was identified as one of the as pects of spirituality.Ubuntu is based on the value of a person as a human being.The nurses guided by the princi ple of ubuntu will demonstrate respect for human dignity, accepting and understanding the patient as really is and maximizing the power of the patient to control his or her own care.Burkhardt (1989: 70) states that the concept of spirituality has no antecedent because it is a thing on its own, it can not be explained by something not spiritual, it is irreduc ible, it can be conditioned by something without being caused by it.She further lists some consequences of the concept of spirituality that are; inner peace, joy, making life giving choices, drawing on inner strength and health.In ner strength manifests joy, peace and self awareness, it gives ability to grow within, to touch into one's well being, it manifests hope and has ability to see beyond the present realities and is able to live with ambiguity and uncertainty.Cawley (1997: 198) also commenting on antecedents and consequences of spirituality says that spirituality is a broad concept and it may be difficult to identify the antecedents and consequences because these will present differently in each person and they are very personal and individualis tic.This study has identified faith, trust, and a commitment to a personal relationship with self, others and with God as the antecedents of spirituality.On the other hand, hope, inner peace, finding meaning and purpose in life has been identified as the consequences of spirituality.Hope has been largely investigated and has been proven to be effec tive in caring for patients with chronic illnesses such as cancer.What nurses need is to learn how to increase a patient's hope and trust so that patients may find meaning in life, illness and in death.McGrath (1998:17) also views illness as a problem of mean ing.Her emphasis is on the influence of culture on the individual's spirituality.She argues that culture is a tem plate that outlines the possibilities, so culture is learned through social interaction and therefore, spiritual expres sions are also learned through social interaction.The mean ing people have for their illness is derived from their social integration or culture.The way the persons express their spirituality is greatly influenced by their cultural back ground.

Summary and conclusion
This paper reported the results of the analysis of the con cept of spirituality that emerged from interviews of nurses, patients and their relatives.It has uncovered new dimen sions of spirituality as used in the nursing profession within the South African context.Spirituality was defined as a quest for a transcendent relationship with significant oth ers and with God/Supernatural power as understood by the person.The antecedents of spirituality were faith, trust and religious belief.Spirituality was described as a unique, dynamic, universal experience that is based upon the value of a person as a human being.The consequences of spir ituality were hope, inner peace and finding meaning in life, illness and in death.
The definition of spirituality given by Kretzshmar (1995: 64) in his discussion on the prerequisite for reconstruction of South Africa shows how vital the spirituality of indi viduals is to the development and reconstruction of South Africa.According to Kretzshmar (1995:63) holistic spiritu ality seeks to integrate rather than separate the various dimensions of human existence.He also states that we are created to be in relationship with the rest of the created order, each other and with God.
Spirituality within a South African context with her diver sity of culture, religious beliefs and nationality needs to adopt a more holistic approach.Spirituality from a South African perspective is the integration of our experiences of God into ourselves, and the effect that this ongoing experi ence has on the way in which we act within all spheres of reality.Spirituality therefore, is not what is inside, it is the person in totality.Spirituality is one's total being.In this study an effort has been made not to extract the spiritual aspect from the whole.

Implications for nursing education and practice
This research has vital implications for the clinical practice as well as the education of nurses.If nurses are to continue to claim that they are providing total patient care, the spir itual component of their patients will be an integral part of their practice.As well, if nurse educators are to develop and deliver nursing curricula that are based upon the con cept of holism, spirituality will form part of this education.This study contributes to nursing science by moving spir ituality from the intuitive level to the scientific level of knowl edge.

Recommendations
The hypotheses that have been developed in this study need further investigation and testing.A larger sample and a different setting may expand the findings of this study.A quantitative research approach can be utilized in subse quent studies to measure specific concepts such as faith, inner peace, hope, meaning of life, and will to live.To ad vance clinical practice and education, research on specific aspects of spirituality and spiritual care will provide scien tific foundation for practice.Furthermore, spirituality should form an integral part of nursing curricula and in-service education for nurses in the clinical practice.It is hoped that this research will advance such development.
Fifthly, spirituality grows.One participant stated that spir ituality grows."It is something that grows.It grows in you.You can grow in spirituality along with indifferent things that happen to you in life, it changes your spirituality, it makes you see things in a more.. .It involves what you believe, it grows from there on, it grows to include who you are and how you perceive things."