Beliefs and Practices Regarding Spirituality as a Healthcare Strategy

Objective: This study examined the perceptions and practices of medical personnel regarding the spirituality in the treatment management plan of their patients. Methods: A spirituality survey was administered to doctors and nurses, soliciting responses about their beliefs and willingness to include spirituality practices in treating patients within their facility. Respondents were asked to give their views on daily practices regarding the use of spirituality in patient care and patient response to treatment. Results: The doc-tors’ responses suggest that they believe that solutions to medical problems, patient recovery, and coping are related to mind and body stress issues that surgery and drugs may not necessarily cure. The emphasis on self-care for some of these medical problems can put the patient back in control and eliminate the use of excessive drugs in the treatment process. Chances for health and well being of patients are improved if good medical practices are combined with a strong mental and psychological disposition to provide a vi-tal foundation for directly confronting diseases. Conclusion: Spiritual en-gagement helps to support a psychological outlook that is necessary for fight-ing diseases and coping adequately with life’s tragedies. This approach provides a well-balanced attack on disease and increases the patient’s chances of coping and surviving.

Because of the teachings of Rene Descartes, who proposed the separation of mind and body for medical treatments, many patients have endured enormous amounts of misery during illness and the death process due to the reluctance of physicians and other medical personnel to address all of the domains of suffering that would serve to make this process a peaceful and dignified one [1] [2]. Descartes's philosophy valued only diagnostic and intervention approaches to deal with physical pain and discouraged consideration of psychological and social interventions. Over the last few years, however, spirituality has gradually been infiltrating the ranks of the medical profession as a viable option for enhanced medical achievement [3]. Much of this transition in medical orientation has been facilitated by the work of George Engel, who, in 1977, proposed the introduction of the biopsychosocial approach to treatment, taking into consideration the biological, psychological and social factors that could positively impact recovery and improved quality of life [2] [3] [4]. In recent times, it has become acceptable to think of patients as having spiritual, as well as biological, psychological, and social lives [5].
What is spirituality? Spirituality is derived from the Latin word spirare, which means to breathe. Spirituality implies that there is a deeper dimension to human life, an inner world involving expressions of the soul. It assumes that humans are fundamentally spiritual beings living in a spiritual, as well as a physical universe [5] [6]. The term spirituality is sometimes confused with religion [7]. Even though they are used interchangeably by many, they are considered by the experts to be two distinctly different terms. Spirituality focuses on the capacity of individuals to have faith and hope, to extend themselves beyond the present circumstances, and to transcend the borders of their surroundings in search of peace and harmony with a superior being and a superior kingdom [1] [2] [3] [8]. Spirituality is a state of mind that transcends the biology of the human and represents an individual's ability to respond to the divine spirit that is not addressed routinely in modern healthcare [9] [10] [11] [12] [13]. Spirituality makes it possible to develop the art of abstract thought, imagination, empathy, the ability to represent biological experiences symbolically, and the capacity to integrate experience and knowledge with a meaning that goes beyond the pain of the individual. Spirituality enables people to take each other seriously, whatever the state or condition may be, and inhibits one from looking upon any member of the human family as worthless or as a human deviant [14]. The kind of concern a person would have during times of suffering relates to the meaning of life, the meaning of death, and the opportunity to become a part of a much larger and meaningful experience [8]. For many people, spirituality represents the search for the sacred [6]. To the 20th-century mystic Thomas Merton, spirituality included at least two basic concepts: a union with God and the transformation of consciousness [15]. The Desert Fathers expressed spirituality as the struggle for the divine encounter and for human identity [6], and Willard [15] described it as the range of activities in which people cooperatively interact with God. The most fundamental concept of spirituality, however, suggests that there is a transcen-dent dimension to life, something or someone with capabilities that extend beyond ego and experience. The feeling of connection to this larger, sacred reality is what gives life ultimate meaning [16].
Religion, on the other hand, is the organization founded on the belief in a God or superior being that involves a structured code of ethical behavior and philosophy. This involves the participation in, or endorsement of practices, beliefs, attitudes and sentiments that are associated with an organized community of faith. Religions can provide foundations for making sense of existence, and through rituals, creedal beliefs, participative community, and ceremonies, provide mechanisms for expressing spirituality [8] [10] [14]. With the changing times and the advent of new generations adopting new habits and customs, many religious leaders have complained about the declining presence of spirituality. However, most Americans maintain that they are spiritual [17]. Americans' membership in houses of worship continued to decline last year, dropping below 50% for the first time in Gallup's eight-decade trend. In 2020, 47% of Americans said they belonged to a church, synagogue or mosque, down from 50% in 2018 and 70% in 1999. U.S. church membership was 73% when Gallup first measured it in 1937 and remained near 70% for the next six decades, before beginning a steady decline around the turn of the 21st century [18].
The interest in adopting a spiritual approach to combating illness stems from the belief that human beings represent an expression of divine creation. Many people believe that their spirituality in conjunction with divine intervention results in reduced anxiety, depression and suicide [19], and incorporating the health benefits of the spiritual needs into clinical practice may enhance a patient's ability to recover from illnesses [20]. This has led to the belief that programs of wellness and health should include emotional, physical, and the often neglected and highly effective spiritual dimensions. All of these dimensions interact and should be considered critical benchmarks when evaluating a person's capacity to recover from illness. By incorporating the emotional, physical, and spiritual/human dimensions of health as part of a disease management intervention program, health care professionals can demonstrate their commitment to "wholeness"-healing diseases by incorporating spiritual and wellness strategies. Faith, prayer, and divine intervention are significant vehicles to a healthier life, enhanced quality of life and longevity, and many studies have demonstrated an association between increased religious involvement and spirituality and better health outcomes including greater longevity, coping skills, and health-related quality of life [21].
Most patients are amenable to discussing spiritual issues with a physician who exhibits interest and empathy, communicates well, displays nonjudgmental respect for the patient's beliefs, takes time to listen and adequately addresses spiritual concerns in an empathetic and efficacious manner [8] [22]. Efforts are ongoing to arrive at a new synthesis between medicine, religion, and spirituality, extending notions of healing to include concern for the body, mind, and spirit [23]. In addition to the growing popularity of workshops and programs on spi-rituality and healing, spirituality has also been added to healing services, and reports and research articles relating to spirituality have also appeared in leading medical journals and major medical conferences [24] [25] [26]. More than 30 medical schools have introduced courses in the academic study of the relationship between spirituality and medicine and have become actively involved in promoting the inclusion of spirituality as a tool in the treatment and recovery process. For the past 2 years, the American Association of Medical Colleges has co-sponsored annual conferences with the Maryland-based National Institute of Healthcare Research regarding spirituality in medical school curricula, which have drawn representatives from more than 40 to 50 medical schools each year [23].
Some researchers on spirituality believe that activities of the mind and body should be purposefully undertaken to bring personality and total being into effective cooperation with the divine order [15]. Spiritual support from positive religious belief, seeing oneself as a collaborator or partner with God, and receiving support from clergy or church members help sick people to mentally reframe their stressful situation, and this generally contributes to positive health outcomes. On the other hand, a situation where one negatively regards events as divine punishment for one's sins is sometimes related to negative health outcomes. Both positive and negative outcomes have been associated with the presence or absence of spirituality, whether it is passively deferring control to God, or deploying self-directive coping skills [27].
According to Koenig [28], the beneficial health effect of spirituality may be achieved through reductions in health risk behaviors, greater social support, and reduction of the harmful effects of stress, including less depression and anxiety. The health benefits that would result from the prohibition of unhealthy practices, such as smoking or drinking, or promotion of healthy habits such as vegetarianism, and the social support provided by close communication with other spiritual advisors are fairly obvious. Spirituality induces less stress, enhances health resistance, and promotes overall well-being and positive health status.
In a study of 1902 female twins in Virginia, personal devotion was found to buffer the debilitating effect of stressful life events [29]. Severe stress and depressive symptoms are known to be associated with a decrease in measures of immune system function [30] [31]. Thus spiritual individuals, having an underlying sense of meaning and purpose for their lives, and access to spiritual methods of coping with stress, including prayer, may have greater resistance to stress-related health breakdown and heightened resistance to disease-causing agents and environments [32] [33]. Several specific and concrete conditions and interventions that spirituality is useful in alleviating distress include; controlling physical symptoms; providing a supportive presence; encouraging life review to assist in recognizing purpose, value, and meaning; exploring issues of guilt, remorse, forgiveness, and reconciliation; abetting and facilitating expression; reframing goals into short-term endeavors that can be accomplished; and encouraging the use of meditation, guided imagery, music, reading, poetry, and art that focus on heal-ing rather than cure [8] [22] [34]. When caring for chronically ill patients, medical personnel must consider the whole person including the spiritual dimension, since everyone who experiences such debilitating hardships needs the extra support and assistance in addressing spiritual concerns [35]. Objective The purpose of the study was to assess the willingness of various medical pro-

Research Question
This study was designed to address the following questions: 1) How do health care providers view the incorporation of spirituality in the health care of their patients?
2) What kind of spiritual activities are they prepared to incorporate in their therapeutic practices?

Sample
The sample for this study included physicians, nurses, and other medical professionals employed in chronic-care clinics operated by a major medical teaching university in Jackson, Mississippi, the state's capital city. All of the medical professionals attached to these chronic disease clinics were invited to participate in this study. A purposive sampling technique was utilized to determine the study sample and to reduce the opportunity for bias while minimizing sampling error.
A total of 100 medical professionals, made up of surgeons, physicians, pharmacists, anesthesiologists and nurses attached to the chronic disease clinics were administered a survey that solicited information related to their practices and beliefs.

Instrument
This study sought to understand the views of a population that comprises many who may identify with a broad religious tradition such as Christianity along with its core concepts and practices. One of the challenges of this study was to determine how to also measure the spirituality of persons who do not identify with an organized religious group or any specific faith tradition. The answer to this was to identify the presence of beliefs or practices that are generally accepted as spiritual by all faith traditions, such as frequency of prayer or meditation, or determining the degree of importance of spirituality in one's life.
Many individuals consciously borrow concepts and practices from a variety of spiritual traditions, even though they identify exclusively with no one religion [35]. Many individuals, who enter deeply into the life of a specific faith commu-nity, adhere rigorously to its traditions and practice its spiritual disciplines.
In an attempt to directly measure spiritual experiences, the authors decided to use the Human Spirituality Scale (HSS) which is a 20-item instrument with a 5-point Likert rating scale that indicates the degree each item is true for the respondent. Item analysis established the internal consistency of the instrument. All the items on the 20-item instrument had a discrimination value greater than 0.30. Cronbach's alpha for the HSS was 0.89 using a sample of 285 men and women between the ages of 25 and 65 [36]. Content relevance established the content validity of the instrument. Relevance determination was based on a panel of experts. For this study, we used the 16 questions of the HSS that asked about such factors as larger context (feelings of closeness to God and frequency of spiritual practices with patients), awareness of life (whether the subjects have experienced any of a list of different occurrences such as sharing experiences of God's presence, presence of angels, or complete joy and ecstasy), and compassion. All of these were verified through factor analysis (orthogonal-varimax and oblique-oblimin). The survey was administered to healthcare providers (doctors and nurses) in a medical complex in a southern state. The survey solicited responses from the medical personnel on their beliefs and practices in treating patients within their facility. Respondents were asked to give their views on daily practices regarding patient care and their beliefs about the patient's response to illness and treatment. The questions on the survey required them to reflect on and respond about whether they were willing to establish awareness of spirituality with patients, initiate prayer with patients, and fulfill patients' prayer requests.
The major dimensions of spirituality that were examined in this study were: 1) "belief"-the medical personnel's acceptance of doctrines of a tradition, beliefs in answered prayer and an affectionate, spiritual relationship to God; 2) "ritual"-the medical personnel's professional and personal spiritual practices and spiritual knowledge; 3) "experience"-the medical personnel's sharing of experiences of God's presence and divine intervention; Participants answered 16 questions using the Likert scale: 1 = "Strongly Agree", 2 = "Agree", 3 = "Neutral", 4 = "Disagree", 5 = "Strongly Disagree".
Statistical Analysis Data gathered from the participants in this study were analyzed using SPSS. We conducted descriptive statistics to address the questions of interest. The responses of the participants were reported in the form of frequencies and percentages to give a general description of the perceptions of this group of medical personnel as they relate to their belief in the influence of spirituality on the well-being of patients. Limitation In measuring spirituality, the instrument asked about some experience, attitude, ethic, belief or practice that are all influenced by cultural and historical circumstances. It was hoped that what was being measured was religious beliefs and practices that are good benchmarks for spirituality. Since a culture-free measure of spirituality is sometimes believed to be unattainable, the approach used in this study was to measure specific religious beliefs and practices with a measurement tool that seemed appropriate to the religious tradition of the target population. This is the approach taken by most of the studies in the religion and health literature, nearly all of which used mostly Christian target populations. Other limitations are the following:

Results
Participants were asked if they would be willing to conduct prayers if the patient requested them to do so. Over 80% of the doctors and nurses expressed a willingness to conduct prayers for their patients at office visits or at hospitalization. In addition, more than 92% of the medical personnel indicated that they would be willing to conduct prayers for a patient who was dying ( Figure 1). When asked if they felt that they needed to be aware of a patient's spirituality, the majority of the medical personnel surveyed expressed a need to be aware of a patient's spirituality. However, only half of the nurses surveyed expressed the need to get information about a person's spirituality ( Figure 2). That is possibly because, as one nurse put it, they are not allowed by hospital management to discuss religious issues with patients.  The responses of the medical personnel to questions about their willingness to inquire about a patient's spirituality, based on job profession, revealed some interesting divisions. Physicians (100%) and most surgeons (66.4%) expressed a willingness to inquire about a patient's spirituality, whereas only about half of the registered nurses (50%) and 55.6% of the licensed practical nurses, along with 44.4% of the anesthesiologists, agreed that they would do that (Figure 3). Inquiries about patients' spirituality at hospitalization, again, had support from only half of the nurses and less than half of the surgeons (44.4%). The OBGYN specialists and pharmacists surveyed, as well as 66.7% of the anesthesiologists and physicians agreed with this practice (Figure 4). Figure 5 is a graphic presentation of the medical professionals' views on inquiring about spirituality from a dying person. Almost all of the respondents to this question indicated that they would be willing to ask a dying person about spirituality. Again, the nurses (66.7%) had the smallest number who would be willing to do so. When asked about praying for a dying person, only 50% of the nurses indicated that they would be willing to do so, while the majority of the other medical personnel would be willing to pray for a dying patient ( Figure 6).    The medical professionals were also asked if they would be willing to pray for patients during routine visits. None of the pharmacists and internal medical specialists would do so, and only a small number of surgeons (33.3%), licensed practical nurses (22.2%) and half the registered nurses (50%) would be willing to do so (Figure 7). Figure 8 shows that only about half the surgeons, registered nurses and anesthesiologists would be willing to do so.
The medical professionals were also asked if they would be willing to initiate prayer with patients. About 75% of them as a group indicated a willingness to initiate prayer with a patient who was dying (Figure 9). When asked if they would be willing to establish awareness of a patient's spirituality, more than 77% of the medical professionals declared that they would be willing to establish awareness of a dying person's spirituality, compared to 57.2% who would ask when a patient is hospitalized and 47.5% who would ask when a patient visits at the office. Over 82% of the medical practitioners surveyed believed that they should be aware of a patient's spirituality when they have to treat them for diseases ( Figure 10).

Discussion
Doctors and nurses expressed a willingness to conduct prayers for their patients at office visits or during their period of hospitalization because spiritual practices tend to improve coping skills and social support, foster feelings of optimism and hope, promote healthy behavior, reduce feelings of depression and anxiety, and encourage a sense of relaxation. By alleviating stressful feelings and promoting healing ones, spirituality can positively influence the immune, cardiovascular (heart and blood vessels), hormonal, and nervous systems. The question could be asked "What are the implications of these issues for healthcare and the research on religion and health?" Most of the medical personnel participating in this study seem to support the proposals by religious researchers that the open utilization of spirituality in healthcare could be beneficial to patient well-being and recovery. They felt the need to be aware of a patient's spirituality because there are certain definite medical benefits of patients' association with spirituality [37]. The willingness of key medical personnel to inquire about a patient's spirituality is supported by previous studies that have suggested that religious commitment or behavior correlates positively with a large variety of beneficial health outcomes, including longevity, lower cancer rate, overall health, life satisfaction, lower blood pressure, decreased physical and psychological symptoms, lower rates of substance abuse, and increased survival after cardiac surgery [ [32]. In the study by Schlundt [38], the finding of positive associations among religious belief, healthy behaviors, and better health outcomes is consistent with the views of the many providers in this study. Many of them insist that they would be willing to ask a dying person about spirituality because measures of religious involvement have been associated with better physical and mental health and decreased mortality in older populations. Nurses were willing to pray for a dying person because religious attendance has been positively associated with decreased depression, improved physical health and lower blood pressure, boosted immune functioning, enhanced physical functioning and improved subjective health. Many providers share the belief that the impact of spirituality and the quest for meaning in life on patients' spirituality and subjective well-being (SWB) is strong, and this relationship appears the same regardless of the individual's religious status. The researchers reported that the spiritual dimension that was strongly connected with SWB, both in its cognitive and affective aspects, was that of purpose and meaning in life [39]. This sentiment is shared by frequent church members who rated religion as high importance and had diastolic blood pressures an average of 5 mm lower than infrequent church members who rated religion as low importance. The impact of spirituality demonstrated by the providers is supported by smokers in a previous study who rated religion as very important and who proved to be 7 times less likely to be hypertensive than their smoking non-religious counterparts [40]. The providers emphasize the need to encourage patients to use religion/spirituality and turn to faith when they experience depression and mental struggles during illness [41] [42]. The extent to which the patients relied on their religious faith to cope is a characteristic that can predict better mental health [28] [30]. That type of intrinsic spirituality can lead to positive health outcomes and prepare the heart for the divine encounter. If the health benefits of a patient's religious beliefs and behaviors are due to an underlying spirituality, then these beliefs and behaviors are good indicators of internal spirituality. A spiritual healing strategy complements scientific practices. Religion deals with themes that cannot be answered in the domain of science and logic alone. It addresses both the positive and negative mysteries of life, advocating that a person is a part of something larger than self. It highlights the limitations of human being while projecting a meaningful world in which a person can gain tremendous benefits.

Conclusion
As part of a universe with deep meaning, principles, and values, people from many different cultures believe that their own lives operate with deep meaning and significance, and they are travelling on a spiritual journey in search of that meaning, which is usually a search for a closer relationship with the Almighty God or superior power. Spirituality is a personal journey of moving closer toward wholeness and encounter with God. A medical treatment plan combined with a spiritual ritual provides structure and language that connects the outer worlds of people with the inner world of spiritual experience, and this enables patients to persevere to overcome stress and depression and to promote their own well-being. The practice of a religion will continue to be associated with a variety of favorable health outcomes, and teaching universities and health organizations should endeavor to actively promote the use of spirituality as a psychological tool and as an effective healing agent.