Hrev_master Healthcare in Low-resource Settings 2024; volume 12:12261 Psychospiritual care: a concept analysis Khotibul Umam,1,2 Ira Suarilah,2 Eva Belingon Felipe-Dimog,3 Ah. Yusuf,1 Imam Susilo2,4,5 1Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia; 2Faculty of Vocational Studies, Universitas Airlangga, Surabaya, Indonesia; 3College of Health Sciences, Ifugao State University-Lamut Campus, Nayon, Lamut, Ifugao, Philippines; 4Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia; 5Universitas Airlangga General Hospital, Surabaya, Indonesia Abstract Psychospiritual care has taken many forms and approaches. In the clinical setting, the meaning, variations, and inconsistencies in the delivery of psychospiritual and its related terms persist. The purpose of the study is to identify the meaning and attributes of psychospiritual care and enhance collaborative practice by pre- senting a concept analysis. This review used Walker and Avant’s eight-step approach to concept analysis. Psychospiritual is a broad, dynamic, and unique concept that integrates psychological and spiritual methods. In this analysis, the defining attributes of psychospiritual care are intuitive self-awareness, therapeutic use of psychological and spiritual perspective, and cultivation of psy- chological and spiritual environment. Providing psychospiritual care promotes positive consequences, such as therapeutic effects for patients and promoting psychospiritual awareness among psy- chospiritual interventionists. A comprehensive definition of psy- chospiritual care has been developed. The findings contribute to science by creating a platform for developing practice standards, research, and theory. Implementing psychospiritual care may improve overall occupational health and well-being, thereby improving patient care delivery. Introduction The term “psychospiritual” is commonly used to refer to a variety of therapeutic systems that incorporate psychological and spiritual dimensions holistically.1 The literature has acknowledged the importance of the psychospiritual role because it mirrors an individual’s lifespan,2 as well as the relationship between this role and human well-being.3 Watson (2007) described an individual being as having a wide range of physical, psychological, social, emotional, intellectual, developmental, cultural, and spiritual needs. In the healthcare service, psychospiritual care refers to the provision of body, mind, and soul,4 psychological,5 emotional and mental,6 belief,7 spiritual,8,9 and religious practice.10 Those approaches have been widely applied to deal with the complexity of human beings. Psychospiritual care was found to be a common practice among individuals with psychological distress associated with chronic disease,7,11 chronic illness,12,13 mental health problems,6,14 or those without the aforementioned conditions who were aiming to improve their overall health.15 Recently, in clinical practice, mindfulness-based practice has gained popularity as a non-phar- macological intervention to alleviate psychological distress.16 In contrast to psychospiritual, the root of mindfulness was Buddhism, where monks performed this religious practice in daily routine.17 As well as psychospiritual, mindfulness was also imple- mented to holistically benefit the individual’s body, mind, and soul.18 To this point, it seems that mindfulness-based interventions are often used interchangeably to fully cover one’s psychospiritual need. The implementation of psychospiritual care in healthcare services is widely captured in the academic database. Discrepancies in the delivery of psychospiritual care were cap- tured. For example, in Western countries, such as in the US7 and UK,19 the delivery of psychospiritual care was found to not always be connected to religious practice, while in the context of Indonesia, considering the Indonesian National Nurses Association (INNA), psychospiritual care was designed with aims to encompass both psychological and religious matters.20 Those underlined, individual ways of coping with life stress are complex. Religion and spiritual coping mechanisms should be assessed prior to the delivery of psychospiritual care. Nevertheless, there is no clear agreement on what constitutes psychospiritual care in the concept, terms, and delivery. According to Walker and Avant (2019), it is necessary to clar- ify the nature of the field or concept of interest before developing Correspondence: Ira Suarilah, Faculty of Nursing, Universitas Airlangga (UNAIR), Kampuc C Mulyorejo, Surabaya 60115, Indonesia. Tel.: +62.31.5913257 – Fax: 5913752. E-mail: ira.suarilah@fkp.unair.ac.id Key words: psychospiritual care, concept analysis, well-being, health- care, health service. Contributions: study conception and design, KU; data collection, IS, KU; data analysis and interpretation, IS, EBFD, AY, ImS; drafting of the arti- cle, IS, EBFD; critical revision of the article, all authors. All the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. Conflict of interest: the authors declare no potential conflict of interest. Funding: none. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Acknowledgments: the authors are grateful to the Doctoral Nursing Program, Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia, for great support during the study. Received: 6 January 2024. Accepted: 24 March 2024. Early access: 6 May 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12:12261 doi:10.4081/hls.2024.12261 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 348] [Healthcare in Low-resource Settings 2024;12:12261] Non -co mmerc ial us e o nly it into relevant knowledge. The conceptual analysis method of Walker and Avant (2019) clarifies existing meaning and has the potential to be used to develop or add new definitions. The authors believe that the growing interest in psychospiritual care as a sub- ject area in holistic care has highlighted its importance. The pur- pose of this concept analysis is to provide a comprehensive defini- tion of psychospiritual care. Materials and Methods Study design Walker and Avant’s framework is used to examine and clarify the phenomenon of psychospiritual care in nursing.21 The eight steps of Walker and Avant’s concept analysis approaches are as fol- lows: i) selecting a concept; ii) determining the purpose of the analysis; iii) identifying all uses of the concept; iv) determining the defining attributes of the concept; v) constructing a model case; vi) constructing additional cases; vii) identifying the concept’s antecedents and consequences of the concept and viii) defining empirical referents. Literature search strategy Literature in this analysis was collated from academic databas- es. Cumulative Index of Nursing and Allied Health Literature (CINAHL), Web of Science, ProQuest, Google Scholar, and Scopus were all used for literature searches. Because of the nature of this concept, a focus on health-related databases was required. In consultation with librarians, the literature review was conducted using the following search terms: TI (psychospiritual), T2 (psy- chospiritual), AND “care” OR “intervention” OR “strategies” OR “best practice”. This review considered studies written in English and published between the years 2000 and 2022. A total of 470 articles were retrieved (CINAHL=49, ProQuest=253, Web of Science=104, Scopus=64, Google Scholar=144). It consists of 614 journal articles and four books. After eliminating duplicates and assessing the full-text articles, 33 articles were examined. Because concepts can change over time, this 22-year time frame demonstrates the inclusion of the most recent information. The literature searches retrieved an abundance of articles focused on psychospiritual interventions; all articles that addressed psy- chospiritual care solely outside of patients’ involvement were excluded from the review. However, literature that commented on psychospiritual care delivered by healthcare and social workers or interprofessional health teams in clinical and community settings was included. Concepts, according to Walker and Avant (2019), are context-dependent. As a result, this analysis focuses on psychos- piritual care and incorporates patient-involved psychospiritual practice. Results Defining attributes Attributes provide profound insight into the concept of interest and distinguish it from surrounding concepts, and it was found that psychospiritual care is a unique integrative dimension of care. It possesses three defining attributes: i) intuitive self-awareness, ii) the therapeutic use of psychospiritual perspective, and iii) the cul- tivation of a psychospiritual environment (Table 1).22-25 Case examples A model case is a real-world application of the concept of interest that embodies all of its defining attributes. A model case can be either a real-world example drawn from the literature or a hypothetical scenario created by the researcher.21 Review Table 1. An example of mapping the attributes of the psychospiritual care concept. Study (Author, year) Concept description Attributes Nursing care for a patient with lupus • Being fully caring by way of actively listening, engaging in unhurried and meaningful conversations with patients 2 erythematosus systemic using ICNP22 • Assisting patients to cope with the burden caused by the disease 3 • Detection of the characteristic symptoms of the expected disease through physical examination, and selection 2 and application of an alternative intervention that meets the priority Hypnosis within a psychospiritual • Offering a specific a care that retain a beneficial religious/beliefs tradition 2 approach in the case of a woman • Making appropriate plans and tackling complex tasks in a systematic manner. 2 diagnosed with dystonia23 • The psychospiritual practitioner is present with the person rather than doing something for them. 3 Psychospiritual care for parents during • Establishing unconditional acceptance 1 the COVID-19 pandemic24 • Initiating therapeutic relationship 2 • Intuitively recognized self-awareness to assist patients to cope with the burden associated disease 1 The development of Islamic caring • Offering a specific care that retain a beneficial religious tradition 2 model to improve psychospiritual • Reflecting patient’s reality and positivism 3 comfort of coronary disease patients10 Bridging spirituality/religiousness • Awareness on the uniqueness of patient with her/his personal characteristics 1 and ecotherapy: four psychospiritual • Understanding spiritual’s need as and provide appropriate interventions 2 themes to guide conceptualization and practice13 Spirituality and occupational therapy: • Offering for specific care that is integrated in psychological practices 2 the application of the psychospiritual • Cultivating psychospiritual conversation with patient 3 integration frame of reference25 Note: *1 intuitive self-awareness *2 therapeutic use of psychological and spiritual perspective *3 cultivation of psychological and spiritual environment. [Healthcare in Low-resource Settings 2024;12:12261] [page 349] Non -co mmerc ial us e o nly Model case 1 Ajeng, with tearful eyes, expresses difficulties living with hemodialysis. She received health education to manage depres- sion, stress, and anxiety. However, the feeling of being empty and isolated persisted. “I know that in my religion (Islam), losing hope is forbidden; I was raised with a spiritual belief that every disease, except death, has a cure. But, as a person with end-stage renal disease who needs hemodialysis twice a week, I instantly become tired, empty, and frustrated. But the more I think about it, the more lost I feel.” The nurse puts her hands on Ajeng’s hand, looks her in the eyes, and answers. “Psychological and psychosocial distress may impact the severity of the disease. You may feel hopeless and have less motivation to undergo hemodialysis treatment, so please feel free to make an appointment for a psychological consultation.” The nurse then asked Ajeng if she had any self-healing tech- niques that could help her overcome her fears. Ajeng said that she would like to practice a monologue with Allah. This is not a com- mon religious practice but a spiritual one. “I talked to Allah, I begged Allah to help me to rediscover the meaning of life in my current condition. Please connect me to anything that will improve my life.” The nurse says, “Your current decision makes me truly happy. Can I help you?” Ajeng replies, “I need to be surrounded by positive things. Can I sign up for a psychology service? and I would like to be accompanied by my husband or daughters during that service” The nurse guarantees that the hospital provides that service and that she will receive it. Constructing additional cases According to Walker & Avant (2019), constructed cases illumi- nate the concept and support the analysis by describing the con- cept’s presence in a model case, the absence of a concept in a con- trary case, and the difference between the concept and a closely associated concept in a borderline and related case. Contrary case The contrary case does not demonstrate the intended concept.21 In other words, it shows that whatever the concept of interest is, it certainly is not an instance of this case. Contrary case 1 Harjo (55 years old) went to the Public Health Center (PHC) for regular diabetes control and weekly diabetic foot exercise. Ten years ago, he was diagnosed with Diabetes Mellitus type 2. He had attend- ed a religious ceremony in the community the day before a sched- uled consultation. He had been admitted to the Intensive Care Unit (ICU) due to hyperglycemia in the previous six months. A commu- nity nurse who delivers the diabetes program says, “I know that adhering to the diabetic regimen is difficult. Culturally, we celebrate special occasions with foods and beverages. So, it is not easy to say ‘No’”. The nurse examines him to ensure that he is taking the med- ication and diet and that his blood sugar level is normal. Identifying the antecedents and consequences of the concept Antecedents are events that exist or occur before the occur- rence of the concept. On the contrary, consequences are the con- cept’s results or outcomes.21 Antecedents The antecedents of psychospiritual care are caring, cultural belief, insight, and professional commitment (Figure 1). Caring is a necessary prerequisite for psychospiritual care.10 Recognizing that humans are psychospiritual beings allows health professionals to identify and plan for each patient’s unique psy- chospiritual care.11 Factors such as the patient’s psychospiritual needs and the health professional’s holistic care awareness pro- mote psychospiritual care. The second antecedent of the concept of psychospiritual care is cultural beliefs. It includes religion,26 personal beliefs,11 attitudes,7 life values,27 uncertainties,5 and critical analyses of self and per- sonal experiences.2 Religious affiliation, insight, and self-improve- ment of psychospiritual professionals11 aid in identifying a patient’s psychological needs and providing religious belief, and spiritual care. Being insightful represents the psychospiritual pro- fessional’s attention to relational processes, such as building trust while assessing psychospiritual needs and practice.28 Psychospiritual professionals can interact and communicate with patients in a compassionate and considerate manner.29 Their inter- action with patients influenced their approach, whether it is more concerned with assessing and controlling the risk of psychospiritu- al distress or acknowledging and connecting with the person as a Review [page 350] [Healthcare in Low-resource Settings 2024;12:12261] Figure 1. Antecedents, attributes, and consequences of the psychospiritual care concept. Non -co mmerc ial us e o nly whole.30 Furthermore, responsibility, accountability, and compe- tency,31 as well as the ability to understand and accept others’ feel- ings and behaviors,32 are among the essential prerequisites for a professional commitment in psychospiritual care. Commitments are thought to be a type of focused consciousness33 that leads to the identification of personal patterns and symptoms, and has an impact on enhancing the uniqueness and holisticness of psychos- piritual practice.34 Consequences The provision of psychospiritual care fosters the individual’s ability to hope,35 helps in restoring and maintaining the integrity of body, mind, and spirit,36 enhances positive illness perception,4 pro- motes the restoration and sustenance of body, mind, and spirit,37 and supports the adaptation of those who provide psychospiritual care.12 On the professional’s side, assessing the need and imple- menting psychospiritual care promotes psychospiritual aware- ness,38 sharpens capability,13 and enhances work satisfaction.39 Defining empirical referents The final step in concept analysis is to define empirical refer- ents for the defining attributes of the concept. The empirical crite- ria are directly related to the defined characteristics or attributes of the concept of interest, facilitating identification.21 In this study, the empirical criteria for psychospiritual care are the key compe- tencies that psychospiritual caregivers need to professionally grasp patients’ priority problems to resolve their health problems and improve their health outcomes. A psychospiritual intervention increases patient satisfaction, improves psychospiritual awareness among practitioners, and illu- minates the meaning and purpose of professionalism.11,40 For example, in the healthcare service, the psychospiritual intervention helps patients flexibly cope with the changes of living with chronic disease41,42 and cultivates self-care behavior in patients with chron- ic disease.43 Given the chronic nature of the disease and the asso- ciated burdens of stress, anxiety, and depression related to their ill- ness,44,45 psychospiritual care can provide those living with chronic disease with a driving force to cause healthy behaviors.43,46 Discussion The aim of the study is to provide a comprehensive definition of psychospiritual care. This study found that psychospiritual care is a broad and dynamic concept. The ability to assess the patient’s condition professionally and select a holistic alternative to effec- tively solve the patient’s health problems is the primary attribute of psychospiritual care. In addition, the attributes of psychospiritual care are intertwined with one another and are regularly re- arranged. These are leading to desirable consequences in achieving individual health outcomes. Past studies reported that psychical, mental, and spiritual activ- ities are connected to a person’s trust to alleviate signs and symp- toms associated with disease or illness, and result in psychospiritu- al well-being.47,48 In the healthcare service, psychological care was widely applied to alleviate psychological distress associated with disease.49 The following psychological distress signs and symp- toms, depression, anxiety, stress, and post-traumatic stress disorder were also reported among people who were physically healthy50 and those with physical illness and mental health disorders.51,52 Meanwhile, spiritual care aims to fulfill a person’s spiritual or religious needs,53 establish a sense of purpose and meaning in life, including one’s morals and ethics54 that may be distinct from reli- gion. The delivery of spiritual care may or may not involve reli- gious activities.55,56 For example, cognitive behavioral therapy with a religious approach was applied to attain spiritual well-being among a group of American Eastern Christians.57 In another case, a group of veterans with moral injury received spiritual care con- sisting of acceptance and forgiveness therapies to attain spiritual well-being.58 The human needs for psychological and spiritual well-being are persistent along the circle of health and sickness.59 Psychospiritual care exists to accommodate the individual’s need that a single psychological or spiritual care may not be able to fully cover, personal matters involving physical, psychological, reli- gious, values and beliefs. Therefore, the delivery of psychospiritu- al care relies on cultural-belief sensitivity, the ability of health pro- fessionals to perform caring, being insightful, and professional commitment. Despite earnest attempts to raise awareness of psychospiritual well-being, interdisciplinary health professionals need more cer- tainty on the definition of psychospiritual well-being and the deliv- ery of psychospiritual care.26,60 Empathy and intense, active listen- ing are required in psychospiritual assessment, as well as a willing- ness to hear. Recognizing self-awareness to assist patients in cop- ing with the burden caused by the disease,61 establishing uncondi- tional acceptance,24 and being aware of and respecting the patient’s unique characteristics are all important.13 The interaction is more than merely as a professional to a client: patients undergoing psy- chospiritual treatment need to be viewed as a whole.62 It has been massively studied that religion-based practice does not always present as the best healthcare.63 Indeed, spiritual care may not pro- vide a resource to help healthcare practitioners understand patients’ needs and provide appropriate interventions in a context of religious decline or non-religiousness.64 In clinical practice, the nurse’s ability to utilize predictable therapeutic instruments prior to the implementation of psychospiritual care is necessary. In terms of the simultaneous decline of religion and growth of spirituality, a spiritual involvement and belief scale65 might help to clarify and translate the individual’s need into integrated psychospiritual care. A very broad range of coping responses that involve the use of religious and spiritual concepts classifies religious coping as either positive or negative.66 Positive religious coping includes forgive- ness, seeking spiritual support, and establishing spiritual well- being. Negative religious coping includes spiritual discontent and punishing God reappraisals.7,66,67 Those encompass the psychospir- itual environment as a complex, wide-ranging area of practice that integrates disease management,5,12 spirituality,13,68 psycho-educa- tion,51 mental health provisions,14 wellness,69 religion,26 belief,70 across all stages of the life cycle. Promoting and cultivating the psychospiritual environment has potential implications for health professionals to tailor individual psychospiritual care that has a positive impact on patient health status10 and overall well-being.9,26 Cultivating through the complex assessment by health profession- als22 facilitates the patient’s needs for information, respect, valida- tion, and emotional support.22,23 Despite the definition of the concept confirmed in various psy- chospiritual-related literature, a patient has a right to practice psy- chospiritual care under the guidance of a spiritualist,71 a religious leader,72 or interdisciplinary professionals. A collaborative practice involves nurses and other professionals. These are regarded as psy- chospiritual practices that ethically respect and support patients’ autonomy to think and act in their preferred psychospiritual manner. Psychospiritual care can help patients to cope with urgent situations and dynamic health conditions. A better understanding of psychos- Review [Healthcare in Low-resource Settings 2024;12:12261] [page 351] Non -co mmerc ial us e o nly piritual care improves the workplace and provides key competen- cies for health professionals and health services.24 Research on psy- chospiritual care should consider the patient’s characteristics and identify additional variables influencing health status. Limitations Claims that Walker and Avant’s method is linear exist. This method lacks contextual data, as scientific concepts should be pre- cise and are highly dependent on context for meaning. It was thought that following a systematic approach for the analysis of content would help to define context while adding to the study’s trustworthiness. Analysis may have benefitted from peer-checking; however, all authors contributed to the research process, and peer- checking by co-authors was achieved. In this study, articles were limited to publications in English. The data sources used for this concept analysis were restricted to psychospiritual in healthcare practice. Thus, reviewing the literature of other disciplines may illustrate similarities and differences in the application of the con- cept across a wide range of disciplines. Conclusions A review of the published nursing literature suggests that psy- chospiritual care presents to accommodate individual needs that a single psychological or spiritual care may not be able to fully cover, personal matters involving physical and psychological well- being, religious beliefs, and values. Implementing psychospiritual care can improve overall health and human well-being, thereby improving healthcare delivery. Therefore, clarity and consistency in psychospiritual care are needed to assist in the development of dependable guidelines, protocols, and tools in healthcare practice. Future research, practice, and theory development will be guided by the proposed operational definition. References 1. 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