Spiritual comfort, spiritual support, and spiritual care: A simultaneous concept analysis

Abstract Background Spirituality is a dimension of life and the human being that should be included in holistic healthcare. One major barrier often described by nurses on implementing spirituality in practice relates to perceiving the concept of spirituality as subjective and sharing confounding similarities with other concepts. In this sense, the concepts of spiritual comfort, spiritual care, and spiritual support may require more distinct theoretical definitions aimed at clear and effective nursing interventions within spiritual care. Aim To provide a definition of spiritual comfort, spiritual support, and spiritual care. Methods Simultaneous concept analysis (SCA) of three concepts according to Haase et al., which is grounded on Rodgers' evolutionary view. The method was based on a literature review with the search of electronic databases on May 2020. Search and analysis have been blinded conducted by two reviewers. Results One hundred thirty‐six studies were included in the SCA. Findings suggest that spiritual comfort is an immediate state and an outcome. Spiritual support is related with an intimate and positive relationship with God. Spiritual care is defined as a complex and interactive process. Both spiritual support and spiritual care are grounded in a therapeutic context. Conclusion This SCA allowed the attributes of each concept to be identified and provides definitions that may facilitate the understanding of these concepts and promote the implementation of spirituality in nursing practice, but which has also led to future research on this topic.


| BACKGROUND
Spirituality is recognized as a fundamental dimension of life that can contribute positively to patients' health and well-being and in dealing with illness and diseases. 1 Understanding spirituality in nursing may start with the recognition of this dimension as part of the global human being in a context of holistic nursing care. Spirituality represents a broad concept, often described as a subjective and multidimensional component of being human. 2 Spirituality is broader than religiosity, and has been defined in nursing as "(…) a way of being in the world in which a person feels a sense of connectedness to self, others, and/or a higher power or nature; a sense of meaning in life; and transcendence beyond self, everyday living, and suffering." 3,p.93 Despite being defined, the concept seems to be far from being integrated into practice and the barriers in the delivery of spiritual care by nurses are already described in the literature. The main barriers are education and training on spiritual care, lack of time, and clear guidelines regarding spiritual care, and the difficulty of defining spirituality and spiritual concepts because of their subjectivity. 4 Due to the subjectivity of the concept often reported by nurses, discussing the boundaries between personal belief and professional practice is still a difficult task. 5 The subjectivity of the concept and considering other concepts as similar may affect the implementation of spiritual care at the beginning of the process of being aware of the meaning of spirituality and related concepts. Concept development therefore seems to be essential in the process of clarifying concepts before being used in practice, but also for use in research.
In this regard, the concepts of spiritual comfort, spiritual support, and spiritual care are examples of the scope the subjectivity of spiritual dimension may have and of the gray areas among concepts, which may reflect on nursing care. Spiritual care and spiritual support have been studied more frequently than spiritual comfort, which remains poorly analyzed and defined.
Comfort is a subjective concept and has been analyzed from different perspectives. Kolcaba,6 in her theory about comfort, defines the concept as an immediate state of being strengthened by the feelings of relief, tranquility, and transcendence satisfied in four contexts (physical, psychospiritual, social, and environmental).
Although the spiritual dimension of comfort is explicit in this theory, the concept remains mainly associated with promoting physical care, such as hygiene care (and comfort), pain relief or positioning, or by the absence of comfort care in other dimensions that are perceived by patients as critical, specifically in nursing practice. 7,8 The physical domain of comfort is related to the gaps and inconsistencies based on the difficulty of measuring the concept, and the association with physical emphasis of the concept persists mainly in daily care practice. Current scientific evidence also demonstrates this limitation.
Further studies that develop the knowledge of comfort in other dimensions, such as the spiritual dimension, are needed.
Spiritual care as a concept is related to implementing spirituality and is grounded in the use of self of "being there" or of the presence of the healthcare provider which brings hope and peace to the patients and families. 9 Spiritual support is considered a nursing intervention and is included in the Nursing Intervention Classification; it is defined as "assisting the patient to feel balance and connection with a greater power." 10,p.1199 These concepts share similar attributes not only in the spiritual dimension, but in the understanding of comforting, supporting and caring that are common to other areas. A conceptual clarification may facilitate the understanding and implementation in clinical practice, particularly in assessing and addressing patients' spiritual needs.
There is missing in the literature a clear definition of spiritual comfort, to make a clear distinction between the concepts. This clarification that this paper intends to give may help both theory and practice.
The simultaneous analysis of concepts (SCA) procedure was developed by Haase et al., 11 and allows the clarification and development of related concepts in addition to the potential for strengthening the professional language. This method is based on Rodgers' evolutionary view of concept development. 12 SCA "is designed to analyze interrelationships and identify theoretical overlap, common themes, and distinguishing characteristics among similar or complementary concepts." 11,p.227 Therefore, the aim of this study is to achieve a clear conceptual definition and a greater understanding of the individual meaning of spiritual care, spiritual support, and spiritual comfort as singular concepts, to provide exclusive theoretical definitions for each one, and to highlight their interrelationships and distinguish characteristics.

| METHODS
This is a SCA study, composed of the nine steps proposed by Haase et al., 11 which is grounded on Rodgers' evolutionary view. SCA model is based on the rationale that many concepts cannot be individually analyzed due to interconnections among concepts. They can, however, be understood by related comparison, since concepts are often similar enough that those closely associated need to be addressed. This is the situation with the concepts of spiritual care, spiritual comfort, and spiritual support. This decision is related to the need to establish a conceptual foundation for each concept as complete as possible, retrieving the most information possible. Details of the search strategy and search results are presented in Table 1.

| Data sources
Research papers written in English, Spanish, or Portuguese that discussed spiritual care, spiritual comfort, or spiritual support directly, including those that provided oblique definitions, antecedents, or attributes of each concept were included in this review.
A total of 3036 articles was identified specifically about spiritual care, 317 about spiritual support, and 34 about spiritual comfort.
After the blinded screening, 4 articles specifically on spiritual comfort, 28 articles on spiritual support, and 104 articles on spiritual care were included in the SCA. PRISMA flow for each individual concept is available in Supporting Information: Appendix A.

| Data analysis
According to Haase et al., 11 the purpose of data analysis is not to develop a complete and finished definition of the concepts, but to provide an initial point for continued conceptual exploration in the discipline of nursing. Thematic analysis was performed as suggested by Haase et al. 11 and each article was read as often as necessary to determine the attributes, antecedents, and outcomes from each concept, that precedes the construction of the validity matrix. These aspects of three concepts were identified based on a rigorous analysis and the process of information collection was systematic, confirmable, and repeatable. In fact, attributes, antecedents, and outcomes of the three concepts were extracted from relevant articles and compared between and across disciplines before creating a validity matrix for comparison. In the next step, critical attributes, theoretical definitions, antecedents, and outcomes were derived for each concept independently.

| Spiritual comfort
Four papers were analyzed on spiritual comfort. Despite no clear definition of the concept being found in that literature, spiritual needs were reported to have implications for patients' comfort needs.
Spiritual comfort is described as a result of the perception of the patient, which means that it relates to inner consciousness of self. It is an immediate state and an outcome that establishes spiritual comfort as a goal from nursing interventions. As presented in the literature it becomes clear that providing spiritual comfort requires effective communication. Regarding the attributes of the concept, we realized that spiritual comfort is related to connection with self, others, environment, superior entity, God, or the transcendent. When a patient experiences spiritual comfort, he/she obtains a sense of inner peace, well-being, and feels supported by family and healthcare professionals. No enablers for the spiritual comfort concept were identified in literature. The process model of spiritual comfort is explained in Table 2.

| Spiritual support
Spiritual support was described in the literature reviewed as being potentially therapeutic in nature. In fact, spiritual support was discussed as based on a holistic approach of patients' needs, which is grounded in an affective relationship and communication between patient and staff. To achieve an effective communication, it is mandatory to establish a trustful relationship and empathic caring.
One of the attributes of spiritual support is the perceived positive influence of the concept by patients, also spiritual support is an intrapersonal concept. However, when we deeply analyze the several attributes of spiritual support, we can perceive that the concept is very focused and related to the intimate and affectionate relationship with a higher power or God, and closeness to the sacred or transcendent.
The results on spiritual support are displayed in Table 3.

| Spiritual care
According to the literature, spiritual care represents a complex and multifaceted phenomenon with a therapeutic nature. The process of spiritual care delivery is interactive and intentional and begins with the identification and assessment of spiritual needs of the patients.
The relationship between patient and nurse must be based on trust and a multidisciplinary team approach, as this is vital for promoting patients' feelings of inner peace, gratitude, hope, comfort, and spiritual well-being. The literature emphasizes the role of nurses as key elements in the providing of spiritual care. The intuitive sense, the spiritual/transcendent, and self-awareness must be developed as well as moral skills.
The results are summarized in Table 4.

| DISCUSSION
This SCA was focused on three concepts related to spirituality that needed further analysis and clarification. This analysis is bringing the attributes, the antecedents, and the consequences of each concept and, in addition, disclosed the similarities and differences between the three concepts. Spiritual comfort, spiritual support, and spiritual care are interrelated concepts, and this is the main rationale of this review. Concept analysis is growing in some particular dimensions of nursing knowledge, and regardless of some criticism, some authors reinforce the need to conduct these studies to achieve an effective definition of a concept to promote nursing science and clinical care. 13 It is clear that the difficulty in defining the proposed concepts is not a contemporary problem, that is, it lies above all in the definition of the attributes of the process of caring, supporting and comforting, which are not yet clear in the literature, therefore, this difficulty is a current reality in different contexts.
In these findings, spiritual comfort is defined as an immediate state and an outcome. However, this concept is still insufficiently developed for application and testing and only slightly operationally Spiritual support is more focused on an intimate and personal relationship with God and seems to be mainly related to the vertical dimension of spirituality. This connection with God or a superior being or entity is perceived as something positive. Several studies reinforce the positive relationship with God as a source of love, hope, coping with difficult times, and improves spiritual well-being, much needed in times of illness and crisis. [15][16][17] The results concerning the analysis of the concept spiritual care are similar to Ramezani et al. 18 In what concerns the attributes of the concept of spiritual care, the intuitive sense, therapeutic nature, and the therapeutic use of self, have also been found to be critical attributes in this study. The therapeutic use of self is considered a core element in spiritual care and contributes to effective holistic care. The use of self is a step forward in the way of "being" in the provision of spiritual care by health professionals. 19 The antecedents of sensitivity and awareness regarding spiritual care had already been referenced in previous analyses of the concept. It is essential for health professionals to be aware of their own spirituality to feel more comfortable talking to patients about this topic, which has a personal and intimate perspective.
The analysis of these three concepts found similarities and differences, that allows a differentiating framework to be established.
The concept of spiritual comfort is reported as an immediate state and an outcome, that is a consequence of a nursing intervention. We  Being confident in their spirituality Education and training in spiritual care Self-satisfaction Supportive environment Definition Spiritual care concept is an interpersonal and multifaceted phenomenon with a therapeutic nature based on a trust relationship between nurse and patient that requires intentionality, respect, and professional commitment aiming to promote hope, inner peace, quality of life, and comfort.
higher power or God, refers to an interconnectedness and a connection with God, others, and environment, but it also refers to an interpersonal phenomenon. It means that spiritual care is an interactive and intentional process that includes, beyond the intimate and affectional connection with self, others, or God, the nursing intervention that is holistic and patient-centered. | 1565