This article has been developed from the original work of Revd Robert Lloyd Richards who wrote the material for the MSc in Pain Management when he was a Senior Anglican Chaplain at the University Hospital of Wales NHS Trust and from a dissertation completed by Jamie Given, a previous MSc Student.
There are a number of terms often used in describing issues of spirituality and here we attempt to define some of these. However, like spirituality, it is not always cut and dried.
The concern for meaning and purpose in life is a prominent feature in the concept of spirituality according to Greasely et al . They aimed to clarify the issue of spiritual care in the context of mental health nursing, by conducting a series of focus groups to obtain the views of service users, carers, and mental health nursing professionals into the concept of spirituality and the provision of spiritual care in mental health nursing. All groups agreed that spirituality is a difficult concept to define, but were able to use words and phrases that were associated with the concept, which include, the notion of ‘God’, ‘religion’ and ‘metaphysical beliefs’, and the concern for the meaning and purpose of life. When the focus groups discussed any differences between spiritual care needs and religious care needs, the majority saw the two as being very distinct, arguing that individuals do not need to adhere to any religious beliefs to have spiritual needs or beliefs According to the views of the focus groups, spiritual care relates to acknowledging an individuals sense of meaning and purpose to life, which may, or may not, be expressed through religious beliefs and practices.
Frankl  describes his experiences as a prisoner during world war two and believes that striving to find a meaning in one’s life is the primary motivational force in man. The individual is confronted with, and reoriented towards the meaning of his/her life . Albaugh  examined the lived experience of individuals when confronted with a life threatening disease and found that spirituality provided comfort and strength, many blessings and a sense of meaning and purpose despite the illness. They described their experiences with critical illness as a wakeup call to clarify what is really important in life.
The above contributions may help us in understanding spirituality as the literature suggests that the search for meaning and purpose may be a defining characteristic of spirituality. However, some have interpreted spirituality as something that goes beyond the search for meaning and purpose. For example Oldnall , argues that an individuals spirituality is the driving force that gives meaning and purpose in life and that in doing this they create values and beliefs that have an influence on how they live their lives. In this case, spirituality may be seen as a dynamic concept influenced by individuals behaviour. Shaffer's  expert opinion offers that during critical illness, patients may be confronted with questions about their values and source of spiritual support, and as nurses have frequent contact with patients, they also have a unique opportunity to address their patient’s spiritual needs. Shaffer  and Oldnall  seem to agree that spirituality is individual and may transcend the material world and give meaning and purpose at all stages of life. The search for meaning and purpose may be seen as one of the characteristics that add to our understanding of spirituality and may help us understand the spiritual needs of the high care population.
Spirituality and religion
Health care professionals often make a link between spirituality and religion, but it has been suggested that while religion may be an aspect of spirituality for some individuals, the two concepts are not the same . Others have suggested that religion is only one facet of spirituality (, ). A key question asked by McEwan  is can there be a belief in a God without the affiliation of a theistic religion? This may be an important question to ask in helping us to understand spirituality. Reading the literature, spirituality is almost always discussed synonymously with religion, yet, at the same time, the two concepts are recognised as being different. This would suggest that religion is an important aspect of spirituality for those who believe in God, yet God may mean many things to different people and for some, their God may not be a God in the religious sense. McSherry  points out that if spirituality is viewed only as synonymous with religion and a belief in God, then certain individuals, such as atheists would be excluded from the possibility of using spirituality as a means of coping with life events.
Taylor & Mamier  conducted a study designed to understand from the perspective of cancer patients and their family care givers, what spiritual care is wanted from nurses.
The Spiritual Interests Related to Illness Tool (SpIRIT) was used and included items reflecting the spiritual needs identified by cancer patients and family care givers, 20 items asking about patients and family care givers preferences regarding spiritual care nursing therapeutics, and seven items about requisites of a nurse who would provide them with spiritual care. The study found that both patients and care givers preferred therapeutics using humour, helping to have quiet time or space, and nurses private prayer. The least preferred therapeutics for both groups were teaching them about writing or drawing about their spirituality, and offering to talk with them about the difficulties of praying when sick. Based on this study, it may be seen that cancer patients and their family care givers desire some level of spiritual care that is not overtly religious.
It must be stated that, more studies are required using individuals and care givers from a variety of cultural and religious backgrounds as many are undertaken in Western cultures.
Not everyone agrees on there being a clear relationship between religion and spirituality. This view has been taken by Rassool  who considers religion and spirituality in relation to Islam. Rassool asserts that Islam does not consider the concepts of religion and spirituality as at all separate and states ‘there is no spirituality without religious thoughts and practices’ (, p1479). This may be taken to imply that in Islam, spirituality and religion are seen as one entity. Rassool  also emphasises that it is important for Muslim nurses to provide spiritual care for patients of all beliefs, but does not discuss how the spiritual needs of non Islamic patients may be met. These views also suggest that Western concepts of spirituality, which are often associated with Judeo Christian tradition, are not applicable to those of Islamic faith. This may further indicate that Western models of spirituality would have a certain bias toward those of the Islamic faith. This would seem to go against the concept of providing holistic care and add to the possibility that the provision of holistic care in spirituality may already be hindered by the lack of an agreed definition of spirituality.
This discussion on religion and spirituality has shown that although the two concepts may be linked, they may also be separate dimensions, although this is not agreed on by all. The literature also reveals that there is a broad spectrum in our understanding of spirituality as it relates to religion and that the implementation of spiritual care in the context of a multicultural, multi faith society is not yet clear.
There is a lack of literature approaching the concept of spiritual pain specifically and on how to define it. Satterly , attempts to explore this difficulty by contrasting spiritual pain with religious pain. He explains that spiritual pain is a much more complicated issue as it centres on a persons relationship with the source of their life, and when that relationship is damaged it is difficult to see a way through that pain. Religious pain is seen as a persons’ set of moral codes which centre on behaviour and can be measured and healed by forgiveness. This explanation may not be sufficient in explaining why spiritual pain as a concept may be difficult to define, because although many authors agree that spirituality and religion may be linked (, , ), they are also seen as separate dimensions and so it may not be appropriate to compare them. Also, a relationship with the source of ones life is only one aspect of spiritual pain. Rather than forming a concise definition of spiritual pain, others have looked at what is meant by spiritual pain using narratives from patients and have identified that a focal theme consistently emerging is the quest to find meaning and purpose in life .
It may be seen from the discussion on spirituality that it is an elusive concept, difficult to define and has many aspects associated with it. It may come as no surprise then, that health care professionals may need help in recognising and caring for the spiritual needs of their patients. Narayanasamy  found that there was confusion over the notion of spirituality and the health professional’s role in spiritual care. McSherry & Ross  found that there was little research published that provided health professionals with a potential framework for the assessment and delivery of spiritual care. Although spirituality is a complex phenomenon, it is not so complex that it becomes meaningless and unworthy of investigation .
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