Healing and the Spiritual Dimension in Hospital Patient Care in Italy

Abstract

This article is based on a research project carried out in 2019 and 2022 in two hospitals in Turin, Italy (hospitals: Le Molinette and Cottolengo). The project aimed to understand the tools available to caregivers to recognize and address the spiritual needs of patients in the hospital setting. The authors conducted multiple semi-structured interviews and focus groups with nurses working in the two hospitals. It was found that religious and spiritual aspects are mainly considered in the context of certain factual aspects of care (e.g., dietary prescriptions) or in the end-of-life in palliative care. A complicated framework emerges from the interviews, as the spiritual aspects of care are considered by nurses as essential for a good therapeutic relationship, but at the same time are not institutionalized within the nursing profession. The emergence of a need such as spiritual care, further challenged by the pandemic, thus becomes a means of analyzing hospital care as a specific relational sphere, where a neglected aspect is highlighted, namely, the care of the spirituality of the carers, which is constantly solicited. It is through the treatment of this second aspect of the illness that the dimension of giving and counter-giving occurs in the patient–nurse relationship.

1. Introduction

Based on data from the project “Le religioni in ospedale. Integrare spiritualità e medicina nelle pratiche di cura” (“Religions in hospitals. Integrating spirituality and medicine in care practices”) and previous research in the field of palliative care, this article aims to understand how the hospital institution—with a primary emphasis on caregivers—takes into account and adopts measures to meet the spiritual needs of patients. This exploration highlights the importance of the relational dimension in care, showing how the therapeutic relationship in a hospital setting is based on constant negotiation between the caregiver and the patient, both actively involved in the care process (Di Placido et al. 2023). At the same time, this research enabled us to investigate the spiritual resources that nurses draw upon in their work.

The analysis of interviews and focus groups with healthcare staff from the hematology department at Le Molinette Hospital and students/nurses from various departments at Cottolengo Hospital provides insight into how healthcare workers negotiate their spirituality within care practices with patients. Considering that spirituality is regarded as a factor that can influence health outcomes (Jobin 2011), this work aims to highlight, through heuristic cases, the often invisible (hidden or unspoken) absence of spiritual inclusion within biomedical practices in the hospital setting. Hospitals—whether secular or religious—are subject to specific obligations regarding the right of patients to exercise personal worship, and secular requirements are integral to the organization of public health institutions (Chelling 2017).

This research is thus situated at the intersection of biomedical knowledge and religious or spiritual representations within the hospital context. It explores how these shared understandings are constructed and circulated within this space (Simonpietri 2017). It considers the individual needs and representations of the subject in a specific context, such as health, which inevitably involves the biopolitical aspects of the body, illness itself, and society as a whole (Foucault 1976; Andrieu 2004).

Whether believers or atheists, human beings constantly define and reshape their identity through religion and spirituality, which manifest according to specific social and political models. Spirituality is an important concept in the field of nursing, with profound implications for patient care and workplace organization (Murgia et al. 2020). Hospitals were originally conceived as quintessentially spiritual spaces, where religious figures tended to the physically or mentally ill (Charuty 1985). Christianity, in particular, throughout history, founded hospitals and caregiving orders. In the Early Middle Ages, infirmitas referred to illness, poverty, or the state of being a pilgrim. Through infirmitas, the suffering person could draw closer to God by seeking healing, while the healthy were called upon to exercise charity (Dericquebourg 1999). The Catholic Church was the first institution to provide organized healthcare in Europe, with Italy’s religious medical assistance rooted in the concept of Christian hospitalitas. Emerging in the early Middle Ages, monastic communities cared for pilgrims, including the sick. During the Crusades, religious orders dedicated to assisting travelers to the Holy Land appeared, and from the 13th century, hospices expanded in Italian cities, gradually evolving into hospitals. These institutions primarily served the poor—since the wealthy received care at home—and laid the foundation for Italy’s hospital network, which developed within Christian caritas from the Middle Ages to the 19th century. Hospitals were not only medical centers but also religious spaces (locus religiosus), where healing was intertwined with spiritual salvation (Steudler 1974). During the Middle Ages, it was the vision of decaying bodies and their miasmas that dominated medicine. The body is composed of corruptible substances, made visible by the incisions in the flesh that were the most common practice among physicians of the time. From the incisions flow the fluids, the humors that impregnate all organs, and to avoid decomposition, the sick must carry objects, stones, talismans, jewelry. As Galienus claimed in the 13th century, he wore a jasper stone on his stomach to aid digestion. It is the material, its mineral substance, that transmits, as if by mimicry, its specific qualities. In the 13th century, infirmities or pains were made up of the same substances, natural causes were rarely distinguished from non-natural ones, and imbalances caused by physical causes could not be distinguished from those caused by occult motives. The world was inhabited by multiple and unknown forces and the object, the stone, the jewel, the talisman could respond to and act upon these forces (Vigarello 1993). Stone manipulation is a magical act, like verbal declarations, which nevertheless constitute performative acts by which a property is imperatively transferred, on an analogical basis, to a recipient, an object, or a person (Tambiah 1985).

The advancement of modern medicine shifted physicians’ roles from traditional healers to specialized professionals dedicated to treating the body and mind rather than ensuring spiritual salvation. Nursing education transitioned from hospital-based programs rooted in religious traditions to secular universities. During the 18th and 19th centuries, hospitals functioned as charitable institutions, some managed by Catholic nuns and others by local elites fulfilling their social responsibilities to the poor and destitute in their communities. However, these institutions often operated under dire conditions, with poorly trained nurses (McPherson 2005).

Institutional recognition of spirituality’s relevance in healthcare is reflected in the policies of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), a leading body operating internationally. JCAHO acknowledges that spiritual care constitutes an essential component of health services, stating the following: “For many patients, pastoral care and other spiritual services are an integral part of healthcare and daily life. The hospital is able to provide pastoral care and other spiritual services for patients who request them” (JCAHO 1999).

Spirituality is operationalized as the human desire for transcendence, introspection, interconnectedness, and the quest for meaning in life, which can be experienced in and/or outside a specific religious context (Villani et al. 2019). The issue of professionalizing those who provide religious and spiritual support within hospital settings is a persistent challenge for healthcare institutions.

In Western hospital settings, the principle of religious pluralism is often operationalized through the presence of both chaplains and spiritual assistants. These two roles, however, do not always enjoy equal institutional status. In the Italian context, findings from the “Respiro” research project reveal persistent disparities in the provision of spiritual care, rooted in distinct legal and organizational frameworks governing these roles. Chaplains, whose presence is guaranteed under the Lateran Pacts—agreements which formally recognize the Catholic Church’s role in public institutions—are fully integrated into hospital staffing structures. Their positions are funded by the Local Health Authorities (ASL), with personnel appointed by the diocesan Curia, and they are allocated specific times and spaces within hospitals to perform their religious and spiritual duties.

In the context of contemporary American healthcare, we observe the implementation of Clinical Pastoral Education (CPE) as a model that transforms traditional religious chaplaincy into a professionalized and secularized form of spiritual care. Through the strategic use of language—favoring the term “spirituality” over “religion”—CPE expands its relevance to patients of all belief systems, addressing the complexities of religious pluralism and secular medical institutions. CPE employs structured tools such as spiritual assessments, which focus on themes like self-worth, reconciliation, and meaning, to justify chaplains’ inclusion in interdisciplinary care teams. In doing so, it aligns spiritual care with biomedical objectives and accreditation standards (e.g., JCAHO), thereby legitimizing chaplaincy within a healthcare economy increasingly driven by cost-containment and efficiency. This approach thus constitutes a secularization strategy that enables chaplains to retain a theological perspective while adapting to a pluralistic, outcome-oriented healthcare environment. In this way, it redefines both the delivery of spiritual care and the professional identity of chaplains in contemporary medical institutions (Craddock Lee 2002).

By contrast, non-Catholic spiritual assistants operate exclusively on a voluntary basis. They lack dedicated spaces in hospitals and their contact information—names and phone numbers—is not publicly available, but rather distributed discreetly in informational leaflets kept in hospital wards. As a result, patients or their families who wish to contact a spiritual representative from a minority tradition must rely on healthcare personnel to mediate such interactions. Consequently, the involvement of non-Catholic spiritual assistants is typically facilitated by hospital staff, particularly in cases involving patients from diverse religious backgrounds. These patients may have specific needs—related to dietary restrictions, reproductive health, end-of-life rituals, or post-mortem procedures—that require the guidance of a spiritual assistant familiar with their religious tradition (Di Placido et al. 2023).

The religious dimension has gradually been marginalized in hospital contexts, nearly disappearing following the processes of medicalization that have characterized the past decades. It is only recently that social sciences and medical humanities have begun to explore the necessity of integrating spirituality into care processes. In the context of the evolution of medicine and the secularization of its practices, nurses can be seen as “bridge figures” within the hospital institution. As we will explore throughout this article, nurses, being the primary caregivers responsible for patients and their suffering, develop a distinct attentiveness and sensitivity that are integral to the caregiving nature of their profession.

Through a focus on nurses and on their perspective on the interaction between spirituality and care in the hospital setting, this study makes it possible to begin to fill a gap in anthropological and nursing research in Italy regarding the non-biomedical aspects of care.

2. Fieldwork and Methodology

The project “Religions in the Hospital. Integrating spirituality and medicine in care practices” aimed to explore the relationship between religiosity, spirituality, and healthcare in a hospital setting. This project was based on a qualitative study designed by an interdisciplinary research group at the University of Turin, Italy. Based on the data that would have been collected, the project had two main objectives: (a) to identify best practices in order to provide guidelines for healthcare professionals, particularly nurses, to help them recognize and address patients’ religious and spiritual needs; (b) to offer the hospital organization policy recommendations regarding the management of religious diversity, adopting a bottom-up approach rooted in the requests and needs expressed by hospitalized patients. The project “Religions in the Hospital. Integrating spirituality and medicine in care practices” was a pilot study conducted by the Department of Cultures, Politics, and Society at the University of Turin, forming part of a broader European initiative, “From Cure to Care: Digital Education and Spiritual Assistance in Hospital Healthcare”. The latter project, coordinated by Professor Stefania Palmisano, was awarded funding in 2021 and involved five academic institutions across four European countries: University College Dublin (Ireland), Universidad de Extremadura and Universidad Internacional de la Rioja (Spain), and the University of Cardinal Stefan Wyszyński in Warsaw (Poland). “From Cure to Care”, financed by the European Commission’s Erasmus+ program, aims to develop an E-Learning Course designed to enhance the training of healthcare professionals—particularly future nurses—in the fields of spiritual assistance and digital education.

The original research design of “Religions in the Hospital” evolved over time due to the unforeseen circumstances imposed by the COVID-19 health emergency. Initially, the study had planned for researchers to conduct on-site fieldwork in hospitals, engaging directly with patients and facilitating focus groups with nurses from selected hospital wards, as well as with key representatives of the initiative “La cura dello spirito (The Care of the Spirit)”. More specifically, this qualitative study sought to investigate the religious and spiritual needs of hospitalized patients through in-depth, narrative interviews conducted by researchers. The data collected would then have informed the development of a tool—co-designed with a selected group of nurses—to assist healthcare professionals in identifying the spiritual needs of hospitalized patients. According to this initial research framework, a significant portion of the empirical study was intended to take place within the Città della Salute e della Scienza hospital in Turin. The initial project “Religions in the Hospital. Integrating spirituality and medicine into care practices” would have involved researchers physically entering the hospital to interview oncohematology patients (i.e., leukemia patients) and kidney transplant patients directly. These were “sensitive” categories of subjects, both in terms of their experience as patients and in terms of the attention the researcher must have when deciding to interface with these issues (Pian 2023). In this case, the concrete conditions for carrying out the empirical work also proved to be sensitive for the research team. The research group identified the possibility of contacting patients through patient associations and contacted oncohematology and nephrology (kidney transplantation) nurses. Even with regard to the possibility of contacting patients of associations, there were difficulties. We found full availability from patients of a national association of people who had had a kidney transplant operation (Palmisano and Pannofino 2023), while for patients of the national oncohematology association, we had no takers because almost all of them were fighting for the promotion of the Italian law regarding the right to oncological oblivion. This law was passed by the Chamber of Deputies and the Senate in December 20231. Our research ground in the hospital for us anthropologists and sociologists actually took place outside the hospital.

However, in response to the extraordinary conditions dictated by the COVID-19 emergency, the project underwent a major revision. Consequently, researchers decided not to investigate patients’ spirituality directly. Instead, nurses became the sole interlocutors of the study. Under this new approach, the project focused on the development of a tool for nurses to collect the spiritual histories of hospitalized patients in the hematology ward, with the goal of addressing their spiritual needs as part of the care process. The field research was carried out in two phases. The first phase involved conducting semi-structured qualitative interviews online with nurses from the oncohematology department who voluntarily participated in the study. Following an analysis of these interviews, the research team assessed existing tools in the literature that could effectively capture the religious and spiritual needs of oncohematology patients. Among the various instruments available, the HOPE questionnaire (Anandarajah and Hight 2001) was identified as the most suitable for addressing both patient and healthcare provider needs. The research team then worked on adapting this English-language qualitative questionnaire into Italian. The HOPE questionnaire consists of four sections and is designed to explore a patient’s personal spirituality and its potential impact on their therapeutic journey. The HOPE spiritual assessment tool is designed to guide healthcare professionals, especially nurses, in exploring patients’ spiritual needs in a structured, respectful way. It stands for H: Sources of Hope, meaning, comfort, strength, peace, love, and connection; O: Organized religion; P: Personal spirituality and practices; and E: Effects on medical care and end-of-life issues. This model encourages person-centered care by helping practitioners understand how a patient’s beliefs influence their coping mechanisms, decision-making, and overall well-being. It also supports nurses in identifying spiritual distress and referring patients to appropriate resources. As spirituality is a vital part of holistic care, tools like HOPE help bridge communication gaps and promote dignity, empathy, and individualized care in clinical settings. Despite its benefits, its implementation requires adequate training and awareness, which is often lacking in nursing education (Whelan 2019).

The questionnaire was administered to patients by the nurses themselves; at no point did the research team enter the hospital ward or interact directly with the patients.

The nurses we contacted work at the Azienda Ospedaliera Città della Salute e della Scienza in Turin (better known as “Le Molinette”) and at Cottolengo, both in the Piedmont region. Le Molinette is one of the largest health centers in Italy and Europe, employing around 12,000 people. It is a secular university hospital and part of the Italian public health system. The Cottolengo is a former sanatorium founded in 1823 by St. Giuseppe Cottolengo as a charity for the care of the indigent.

Attention to respecting religious pluralism is one of the aspects that has developed most significantly in recent years within the Piedmont healthcare system, which is not surprising given that Italy’s religious landscape has undergone considerable change in recent years, marked by a more developed pluralism (Garelli 2020). Building on this shift, in 2005, the quality and participation sector at Le Molinette Hospital launched the “La Cura dello Spirito” project. This initiative identified representatives of the main religious denominations, who made themselves available to patients to be contacted when needed. Through this program, all departments received a list of religious representatives to be contacted at the patients’ request, with the goal of facilitating communication between different religious leaders and patients, as well as creating a space for reflection, prayer, and meditation that accommodates all religions and atheists alike named “La stanza del silenzio” (The Room of Silence). This Room of Silence, made available as a space for contemplation, prayer, or personal reflection, is free of religious symbols and accessible to patients, family members or visitors, and healthcare staff alike.

In the context of the shutdowns imposed by the most acute phases of the pandemic, the nurses thus became the researchers’ only contacts. Data were collected through online interviews and focus groups coordinated by the head nurse of the oncohematology department at Le Molinette hospital. Face-to-face focus groups were organized by master’s students from the Faculty of Nursing with professional experience in various hospital departments, while other online focus groups were also organized by students from the Cottolengo hospital. The absence of the researchers in the hospital wards prevented direct observation of the daily exercise of the gestures of care; thus, the different configurations of power and the processes of constituting the professional identity of nurses (Vega 1997; Pouchelle 2003) emerged in the background, and interviews and focus groups proved to be essential for exploring the spiritual dimension in the processes of care and healing in hospital wards.

Participation in the online interviews was voluntary. The participants provided written consent for the processing of the recordings made during the online meetings. Seven nurses from the hematology department and the head of the department at Le Molinette Hospital were interviewed. Each interview lasted approximately 1.5 hours. Face-to-face focus groups were conducted with master’s students from the Catholic University of the Sacred Heart at Cottolengo Hospital. The group included 15 master’s students/workers, all with at least 5 years of professional experience, with some having up to 20 years of experience in various hospital departments in northern Italy (Piedmont, Lombardy, and Veneto). Two separate focus groups were organized with the students/workers: the first focused on their experiences managing patients’ spirituality during hospital practice, while the second addressed their perception of and the impact of their own spirituality on their professional practice.

Below is the outline that guided both the focus groups and the semi-structured interviews conducted with the nurses.

Track for FOCUS GROUP and SEMI-STRUCTURED INTERVIEW with Nurses

• Topic area—Direct experience with patients

  (a)

  Have you ever been confronted with spiritual/religious needs of patients in your professional activity? If yes, what needs have you encountered? (e.g., request for assistance with prayer, end-of-life rituals, etc.)?

  (b)

  What difficulties or opportunities do you consider there to be in responding to patients’ spiritual needs? (e.g., difficulties in dealing with religious traditions other than one’s own, lack of time or ability to listen, or opportunities to establish empathic and “warm” relationships with the sick, comfort them, give them hope, offer holistic care, etc.).

  (c)

  In your opinion, do hospitals take adequate measures to meet these needs? (e.g., are there or are there not spaces for prayer, do they rely on spiritual assistants, are there other priorities, etc.).

• Topic area—Relationship with colleagues

  (a)

  Do you ever talk about spirituality or religion with colleagues? Does the context of the hospital ward favor discussion on these topics?

  (b)

  How do your religious/spiritual convictions, if any, fit into your professional life? Was your choice to work in this profession influenced by religious/spiritual convictions?

  (c)

  The COVID-19 emergency had a significant effect on the work of nurses. Have there also been significant effects in terms of caring for the spiritual needs of patients?

• Topic area—Rituals

  (a)

  In the course of your hospital experience have you ever felt the need to practice or participate in any “official religious” function together with your patients? (e.g., baptism, last rites, prayer, end-of-life practices)

  (b)

  Do you have small rituals or moments of reflection/meditation/prayer that accompany your work?

  (c)

  In some countries such as France and Switzerland, more or less informally, some alternative therapists have access to hospitals to help patients, such those with shingles. In your opinion, could this also happen in Italy?

3. The Place of Spirituality Within Hospital Institutions

Therapeutic pluralisms can be considered a norm in contemporary Western societies (Kleinman et al. 1978; Schmitz 2006a, 2006b); the presence of non-biomedical therapeutic practices contributes to a holistic vision of the individual, which focuses attention on the spiritual dimension of the subject as a psychic and moral resource and which constantly emphasizes the porosity between body and mind (Fedele and Blanes 2011). When we talk about spirituality, it is important to consider at least two fundamental elements. In contemporary times, spirituality is part of the search for mind–body well-being and the holistic conception of the person, with the various techniques for acquiring bodily well-being presented as ritual experiences necessary for personal change, which, as such, has a therapeutic dimension. By adhering to these spiritual practices, the individual acts according to a new relational configuration that enables them to ritually renew their relationship with themselves (Barthomé and Houseman 2010).

Spirituality within the hospital context takes on a technical dimension, that is, in order to respond to the need for spiritual attention, we see how some hospitals allow the entry of alternative therapeutic techniques that contribute to the taking care of spiritual needs. Such is the case with yoga or mindfulness, which in some contexts are part of the therapeutic pathway proposed to patients. One notable example is the introduction of a Mindfulness and Yoga program for patients with Interstitial Lung Diseases (ILDs) at the Hospital of Modena (Italy). ILDs are characterized by symptoms such as chronic dyspnea and cough, which often lead to significant psychological distress that can be difficult to manage. As part of a two-month research project, patients participated in eight weekly sessions lasting two and a half hours each at the hospital. They also attended a full day at the Yoga Asia Centre in Modena, engaging in yoga and meditation sessions—both static and dynamic—as well as Aikido exercises. The objectives of the research were to evaluate the safety and adaptability of mindfulness in these patients, to measure its effectiveness in reducing suffering, managing stress, and combating mood swings, and to assess any clinical improvements. Although not to be regarded as a clinical study to quantitatively measure the efficacy of the treatments offered to the patients, they did experience positive changes in mood and stress; a decrease in tiredness, nervousness, and anger was perceived, and vigor increased in the patients (Sgalla et al. 2015).

The literature on the benefits and significant positive impact of addressing patients’ spiritual needs on their clinical therapeutic journey is extensive (Timmins and Caldeira 2019; Isaac et al. 2016). Spiritual care, most often implemented within palliative care, has proven to be a practice that can potentially improve the patient’s quality of life (Yang et al. 2016; Gusman 2016). It allows the therapeutic relationship to focus on the patient, seen not only as a person with an illness but as an individual to be treated holistically, encompassing their psychophysical and spiritual dimensions.

The ability of healthcare professionals to address and understand patients’ religious and/or spiritual needs enables the creation of specific interventions that deepen the meaning within the nurse–patient relationship (Lazenby 2018). Studies on the relationship between healthcare and spirituality build upon the knowledge emerging at the intersection of religious and medical anthropology. Notable contributions include Ilario Rossi’s work (Rossi 2007) and his studies with Patrice Cohen (Rossi and Cohen 2011) on unconventional cancer treatments, as well as the analyses of physician–anthropologist Jean Benoist (Benoist 2010), which explore the various possibilities of interaction between healing, care, caregivers, and patients.

As highlighted in Battey’s work (Battey 2009), humanism serves as a foundational principle in nursing, advocating for holistic, person-centered care grounded in genuine communication. This approach extends beyond technical proficiency, encompassing the emotional, spiritual, and relational dimensions of patient care. Central to this model is the belief that effective communication fosters empathy, trust, and dignity, thereby fulfilling the ethical imperative to address the full spectrum of patients’ physical, psychological, social, and spiritual needs.

Due to the nature of their profession, healthcare workers are directly called upon to develop competencies in spiritual care and to gather patients’ spiritual histories, as emphasized in the first article of the Code of Ethics for Nurses, approved on 13 April 2019, by the 102 presidents of the National Council of FNOPI (Federazione Nazionale Ordini Professioni Infermieristiche—National Federation of Nursing Professions). Article 1 defines the values of the nurse, identified as the “health professional, registered with the Nursing Professions Council, who acts consciously, autonomously, and responsibly”. From the outset, the code highlights the spiritual aspect of the nurse’s active role in the care process, along with the moral commitment and cultural promotion it entails.

One of the most prominent findings from interviews conducted during the initial phase of the “Religions in Hospitals” project is the nurses’ sense of inadequacy in identifying and addressing patients’ spiritual needs. Most interviewees acknowledged that addressing this aspect of patient care is an important element of nursing, as recognized in the Code of Ethics. However, the prevailing sentiment is that they lack the necessary training and tools to manage these aspects of care. Although nursing is centered on an ideal of holistic care (Puchalski et al. 2014), there are still very few training programs for nurses focusing on the spiritual dimension of care (Hawthorne and Gordon 2020). Both the work organization within departments and patient care records lack a structured approach to address this need. Giovanni, a nurse at Le Molinette, commented on this issue:

“At university, during the nursing degree program, we were told that spiritual needs are just like any other need and must be considered. But in reality, they are largely overlooked”.

The absence of religious figures further reflects the secularization process characterizing contemporary society. As Lucia, a master’s student at Cottolengo and a nurse in a small hospital in Piedmont, explained:

“Before COVID, the priest used to organize masses, but attendance wasn’t particularly high, especially in recent years. In the past, many patients wanted to attend masses. In recent years, it has become more difficult; it almost seems like the staff have to convince patients to go to mass”.

Despite the limited consideration given to the spiritual dimension of care, it emerges in various forms in the nurses’ experiences. In the absence of an organizational structure to identify patients’ spiritual needs and standardize interventions, nurses reported feelings of uncertainty and described how addressing spiritual matters often relies on individual sensitivity. Giovanni’s testimony confirms this:

“From an organizational standpoint, spirituality is not addressed. On the contrary, it becomes more of a personal matter, perhaps a question of sensitivity. It’s very much linked to the caregiver, as they are the ones who may notice that a patient has a prayer book on their bedside table. Once, I noticed that, and it started a conversation with the patient. From there, they opened up, began talking about their problems and needs, to the point where one day they asked if a priest could visit because they needed spiritual guidance. They even asked if I could listen to them. But I’ve also seen this in other departments—it’s very subjective and very much tied to the nurse’s sensitivity”.

Spirituality thus proves to be a fundamental variable in how individuals respond to the traumatic event of illness, particularly in their ability to find new meaning in life amidst the suffering they face (Jobin and Pujol 2017).

As surveys conducted with nurses have shown, nurses recognize the importance of taking care of patients’ spiritual needs and consider spiritual care as an integral part of the healthcare provision and as a way of improving the quality of care provided. However, they warn that their training is still inadequate to provide such care (McSharry and Jamieson 2011). Other studies show the ambiguous attitudes and tensions that emerge in nurses’ perceptions of complementary and alternative medicine (CAM), including those of a spiritual nature. While they acknowledge the holistic and open nature of nursing care, they also have doubts regarding the efficacy and even the potential harmfulness of some of these alternative treatments (Trail-Mahan et al. 2013).

4. Why Focus on the Spirituality of Caregivers?

As we have seen, while literature thrives in terms of analyzing the spiritual or religious dimension of patients in relation to medical care and how this dimension can become a valuable tool within the therapeutic process (Lai et al. 2017), the importance of spirituality for healthcare professionals through the tools of anthropology has been less explored. We observe how the spiritual dimension of the individual is increasingly regarded as a constituent element of the nursing profession. Thus, to name just a few examples, individual spirituality is known in nursing as “intrapersonal spirituality” (McSherry et al. 2020 (EPICC)), in social work as “intrinsic spirituality” (Holland et al. 1998), in psychology as “spiritual well-being” (Seligman 2011), and in psychiatry as “spiritually sensitive care” (Loboprabhu and Lomax 2010).

Numerous studies highlight the importance of patients’ individual spirituality and emphasize how nurses are constantly confronted with various demands related to their technical skills, entrepreneurial organization, personal relationships with colleagues and patients, and the physical difficulty of shift work, which requires a complex organization with personal and family routines—all of which compel them to demonstrate empathy in order to relate to the suffering of patients. The opportunity for patients to express their own spirituality and their need for care from nurses thus becomes a means of connecting with the suffering others, limiting the risk of self-isolation that could undermine the success of the therapeutic act itself.

In situations of illnesses that are incurable for biomedicine, nurses may be uncomfortable in the presence of patients who place their hope for recovery on a spiritual level. Waiting for a “miracle” or divine healing even after a bleak prognosis has been declared is described by some palliative care workers interviewed as an inability to accept the situation that has arisen, a way of not “facing the truth”. Most of them state they do not believe in the possibility of divine healing, although some do not exclude it and rather take an agnostic stance. Despite the greater training—and often greater attention—to the spiritual component of those working in palliative care, the relational difficulty of healthcare workers when it comes to talking about spiritual healing with patients also emerges in this context. What Erica, a nurse working in a palliative care service in Turin, said during an interview exemplifies this discomfort well:

“I can call myself a spiritual person, I believe in the presence of something beyond our physical world. But when it comes to healing, I was trained as a nurse, I trust medical science, everything else is belief for me. I don’t mind if a patient prays for healing or relies on other practices. Once here in the hospice we had an evangelical pastor come in; with three other people they prayed for hours to cast out the demons they thought were killing the patient. When they left, the patient asked me if I thought it would have recovered. I replied that I didn’t know, but I felt uncomfortable, I wanted to tell him that no, it wouldn’t save him, he had very little time to live. He died after ten days. I wondered if he had lived those last days under the illusion that he would recover, when we knew it was not possible. I wondered if it wouldn’t have been right to speak to him more clearly”.

Healthcare providers find themselves spontaneously managing the spiritual aspects arising from their relationship with patients, often without sufficient guidance. Although the primary objective of healthcare practices is to carry out technical actions for the benefit of others, it cannot be overlooked that care also becomes a form of self-work for each practitioner. This is in line with a clear concept from ancient Greek philosophy, which posits that every person has the task of taking care of themselves in order to be able to care for others—“that is, ‘care for oneself’ as a prerequisite to shape and fulfill one’s own existence” (Benini and Magenti 2021, p. 114). Focus groups organized with nurses from hospitals in Turin revealed, for example, that in certain neonatal intensive care units, a small bottle of holy water was always present to baptize dying babies. This customary practice is carried out regardless of the parents’ religious affiliation, directly by the nurses, who are considered legitimate in doing so. We have observed that this act counterbalances the feelings of failure and grief felt by nurses upon the death of a newborn (Lombardi Forthcoming). These observations confirm that “healthcare services are increasingly concerned with crisis situations (emergencies, maternity, end of life, etc.) where the religious factor manifests itself” (Chelling 2017, p. 91).

The nurse is never neutral in the practice of their profession. As illustrated by Andrea (Le Molinette), a hematology nurse, spiritual aspects constitute a permeability in the therapeutic relationship capable of generating a relational continuum between the caregiver and the hospitalized person:

“I remember a few years ago, a Muslim patient with whom I had a lot of empathy… At one point, during a period of both physical and spiritual suffering, we talked a lot… I was sorry because I had to go on vacation, so I decided to take (metaphorically) this patient with me. It’s silly, but as soon as I stepped into a church, even though it was Catholic and thus different from his religion, my thoughts turned to him, and I prayed to my God, because there is only one God—whether I’m Catholic or Muslim, it doesn’t matter; I know he hears me anyway”.

Introducing or reintroducing spirituality into healing practices does not mean weakening them or introducing chance into the biomedical field. In a world of care that is increasingly dominated by technology, there is a risk of dehumanizing the patient or, worse still, of reifying them to the point of making them even more passive than they are at present in care practices. For this reason, the reintroduction of spirituality in a programmed way, rather than in a random way and dependent on the good will of the caregivers, becomes a central element in strengthening the relationship with the patient and their recovery. The human qualities required of a professional carer can fruitfully integrate technical knowledge with the relational aspects of care. “Caring, prudence, prud’homie, resilience, ethical reflection … are not soul supplements, but human, behavioral, psychic and psychosocial capacities to be developed in carers to enable them to be more effective in caring for patients” (Velut 2020, p. 25).

5. Religious Pluralism in Hospitals

Within the generally limited attention paid to spiritual matters in healthcare, two exceptions emerge: (a) the reference to religious pluralism and how it requires attention to the formal aspects of respecting other religious traditions, and (b) end-of-life care, as this is an area where medicine, having fulfilled its function, is seen as making room for other dimensions of the individual. The relevance of reflecting on the existence of spiritual practices in places related to illness is tied to the evolving religious landscape itself. In the Italian context, this landscape has recently seen the emergence of marked pluralism, notably due to—though not exclusively—the migratory history affecting the country since the 1990s. Debates on managing religious and cultural diversity in public institutions have proliferated both in academia and the public sphere (Ozzano and Giorgi 2016). Consequently, it is necessary to show how the long-standing Catholic presence in Italian hospitals is now being renegotiated in response to a renewed religious context. This context is characterized by increasing secularization (Palmisano and Todesco 2017; Diotallevi 2019) and the rise of religious minorities (Giorgi 2018).

First, regarding the emergence of significant religious diversity, it is noted that most of those surveyed emphasize the relationship with patients from religious minorities—especially Muslims, Jehovah’s Witnesses, and Evangelicals—as raising many questions concerning the spiritual sphere. The way to approach these issues within the nursing profession is questioned, both in terms of rituals related to illness and end-of-life care (for example, the request of some Orthodox families to keep a candle lit to accompany the dying) and in terms of the ability to communicate with patients about religious matters.

The presence of non-Catholic patients has now become the norm in hospitals, even within the Catholic structure of Cottolengo. However, the nurses surveyed declare that neither religious affiliation nor other aspects related to the spiritual sphere are recorded in patient files. Thus, even in internal communication among the team, this dimension rarely emerges and almost exclusively in situations that “interfere with care”, as expressed by Anna, a nurse from the hematology department at Le Molinette. These are cases where, for example, Jehovah’s Witness patients refuse blood transfusions or where dietary prescriptions for Muslim patients need to be recorded. In most cases, the spiritual dimension of care is reduced to a few religious rules that specific patient groups deem important and require the healthcare staff’s attention.

Even in internal staff discussions, the questions that arise most frequently regarding patients’ religious affiliation are of a practical nature. Marta (Le Molinette) explains:

“Spirituality and religion are topics that almost never come up, and if they do, it’s superficial. It’s not something we particularly worry about; sometimes, there’s a Muslim patient, and we tell our colleagues: ‘Be careful, don’t go into the room if possible when they’re praying’. But that’s it, we don’t go further into talking about the patients’ spiritual sphere”.

In some cases, it is the patient’s relatives who request the intervention of a religious expert in the hospital setting. Roberta (Cottolengo), a nursing coordinator in a psychiatric department, recalls a spontaneous arrangement for non-Catholic families when it is necessary to consult a religious representative:

“Family members asked for the intervention of the imam from the mosque in Turin for a very ill and agitated patient who needed emotional restraint. It was the woman’s husband who requested the imam’s intervention because he thought his wife was possessed. The imam and the husband entered her room to pray for about fifteen minutes; at the end of the prayer, the imam came out stating that the patient had no religious issues but was simply crazy, not possessed, but insane”.

In the following section, we will show how the spiritual dimension of care—outside of the specific cases related to religious pluralism that we have just discussed and which seem to focus on formal aspects (for example, dietary requirements)—is only considered central when the patient’s hope for healing fades, that is, when medicine retreats and makes room for other conceptions. End-of-life care is, in fact, the only phase where attention is paid to the spiritual dimension in hospitals, which is almost absent during other stages of the care process.

6. Nursing and Spiritual Dimension at the End of Life

As we have seen in the previous sections, the search for healing as the main objective in the different stages of care leaves little room for spirituality in hospital wards, where healthcare staff and patients focus on the therapeutic trajectories defined by biomedicine. On the other hand, the emphasis placed on spiritual aspects is more pronounced in the end-of-life phase, a stage that is commonly associated with religion. Here too, however, there are major differences between hospital wards, as not all patients experience death in the same way. Claudio, a nurse from Le Molinette, explains:

“In the nineteen years I spent in emergency medicine before coming here to haematology, there was certainly more attention paid to the religious aspect of the end of life. When the situation arose, we would ask the relatives of terminally ill patients if they wanted religious support. I did this very often, freely and spontaneously. In haematology, on the other hand, I’ve noticed that less emphasis is placed on the end-of-life aspect, because haematology patients tend to be sent to medicine or other departments when they are terminally ill. But in the few end-of-life cases I’ve seen here in haematology, there hasn’t been that sensitivity, so I think it’s an aspect that doesn’t come up much here”.

Even when it comes to end of life care, the spiritual dimension is often reduced to recourse to a religious agent who can provide comfort, or to ritual assistance that may be necessary in the terminal stages of the illness. The subject of existential crisis and the questions of meaning that emerge as the state of illness worsens certainly seems to be well understood, but does not find its place in care practice. However, the relatively recent spread of palliative care in Italy has led to the development of a debate on the spiritual care of the terminally ill (Gusman 2018). Palliative care integrates spiritual care as a fundamental part of support during the patient’s end-of-life journey (Yang et al. 2016). From this perspective, the patient must be seen not only as a sick person, but as an individual who needs to be cared for in his psychophysical and spiritual wholeness, in order to facilitate a process by which he is able to make sense of the history of his illness, even if it has had a harmful outcome. The vision of care proposed by palliative care services therefore emphasizes the wholeness of the person (Janssen and MacLeod 2010). However, palliative care itself, when mentioned by the nurses interviewed, seems to be associated mainly with technical competence, particularly as support for symptom reduction in dying patients.

Another way in which the spiritual dimension emerges in relation to illness is the fear of illness and death, and the resulting questions of meaning that patients discuss with nurses. In this respect, the nurses interviewed pointed out that there were major differences depending on the ward and the stage of the patient’s hospitalization. In particular, in the hematology unit (Le Molinette), a distinction must be made between the situation of those who are in the unit for treatment or pre-hospitalization while waiting for a transplant, and that of those who are in the transplant area, where they live in forced isolation. Illness is a biographical fracture and, in the specific case of hematological disease, it occurs suddenly, disrupting the person’s life and the context in which he lives. The planned treatment uproots the patient from his social environment and immediately places him in hospital procedures that involve isolation. The hospital is thus experienced even more than before as a place of isolation and loneliness (Colombo 2021). The physical distance marked by personal protective equipment and the restrictions on visits from family and close friends have dramatically accentuated the process of distancing patients from their domestic and emotional spheres, a process already highlighted by Norbert Elias in his work on the hospital ward (Elias 1987). Collecting the spiritual stories of people in hospital takes on even more significance in these contexts, involving an in-depth exploration of personal concerns and sources of help and hope, and requiring that what is understood in this way can be integrated into a broader framework with the description of the dimensions of physical and psychosocial care (Miccinesi et al. 2019). As Anna (Le Molinette) tells us, the oncohematology patient is:

“A patient who laughs very little. A patient who thinks a lot about his condition, often repeating to himself: “Why did this happen to me? A frightened patient… who tends not to be aggressive but… a bit resigned, as if he wasn’t expecting any more answers. Because this is a patient who comes back often. There are few new diagnoses. They’re regular patients, so … I mean, they’re used to …”.

In a department such as hematology, the question of sociality highlights the importance of relational aspects in the hospital environment. The exclusion of family members from healthcare services is justified for health, logistical, organizational, and economic reasons, but this contributes to the feeling of loneliness of the sick person and to the suffering of relatives who, due to their exclusion, can potentially turn antagonistic to healthcare professionals (Lupo 2014). The caregiver becomes the only source of relationship for the patient, and although it is a relationship of limited duration, it is characterized by being particularly significant and likely to leave its mark on the psychic experience of both parties, since it can become a source of enrichment for the caregiver too. Anna (Le Molinette) tells us:

“Yes, I have always worked here in hematology, and I have stayed because this department continues to give me a lot. The hematology patient, even if you give them a lot, manages to give you three times more on an emotional level, and this allows me to have a different perspective on the world of daily life, on the situations you normally experience, because you take everything too much for granted. The cancer patient allows you to live differently. It fills your life… Just from the point of view of prioritizing and realizing what is important, in short, it is something I specifically hear from professionals working in departments that treat oncological diseases”.

What emerges in this short exchange is the relational dimension of the profession, akin to a dimension of giving and counter-giving, which becomes essential in this specific type of relationship. “The gift is a personalized exchange that engages the individual, who gives themselves in the relationship. And the counter-gift ensures recognition, the (re)acknowledgment of the given part, a return that reconstructs, compensating for the initial loss” (Bourgeon 2013, p. 165). In other words, the nursing profession thus becomes a means of addressing not only the patient’s physical suffering but also their psychological and emotional suffering; it is through addressing this second aspect of the illness that restitution occurs in the nurse–patient relationship. This relationship is not only configured as a dyadic relationship of “caregiver vs. cared-for”, but also as the establishment and constant negotiation of interdependence and bodily proximity relationships, which are more or less constrained and prolonged. It is important to emphasize that in any therapeutic relationship, the actors are placed in a particular relational context where what is given as context consists of multiple relational structures embedded within each other. The hospital institution presents relational dynamics of power within the medical staff, and in which the patient finds themselves in a dual relationship, both as an object of caregivers’ care and as an experiential subject of their own illness, with all its representations and treatment possibilities. The therapeutic act must be considered within a multi-faceted relational configuration. We observe thus that “what appears as a ‘context’ concerning the relationships for which it represents the conditions of actualization is at the same time a relationship or a system of relationships whose conditions of actualization are provided by a broader context, itself constituted by a set of relationships” (Houseman 2003, p. 292).

In hospital departments where death is a highly probable eventuality, it is in the reciprocity of exchange that caregivers manage the emotional difficulties related to patient care. Since this type of relationship is generalized without being systematized in hospital protocols, nurses do not always manage to handle this dimension of giving and try by all means not to be overwhelmed by it. As recounted by Laura (Cottolengo), a nurse working in a postoperative rehabilitation department:

“There are many cases that have stayed with me, but one in particular, a COVID patient, an elderly very kind man who came to us for rehabilitation with the hope of recovery, because those who come to us after resuscitation think they are going to make it. But his condition was immediately serious and it showed in his eyes; he couldn’t move to lift his torso, he couldn’t eat, and this patient would say, “Help me, help me”, until we had to transfer him to the civil hospital because his condition was too severe. And when we transferred him, we knew we would never see him again and we all had tears in our eyes, because he always had a smile on his lips and laughing eyes behind his mask, pleading eyes, the kindness he showed us was truly touching… (as Laura speaks, she is moved). It’s difficult in certain situations not to get involved; with us in rehabilitation, the hospital stay is a bit long and then they come back and see us, and it creates a very familiar environment”.

As highlighted in other studies (Vega 1998), social relationships within the hospital institution exhibit varying degrees of complexity, determined both by the technicality of the profession, the organization of the work itself, and the obligatory relationships to which patients and nurses are constantly subjected. To survive optimally in the hospital ecosystem, one must learn to channel and manage the emotions triggered by the presence of the other, often too old or too young, too foreign or too close. But it is precisely through contact with this “other” and the practices dedicated to them that the nurse’s identity is formed and defined throughout their profession.

7. Discussion

The findings of this study reveal a complex relationship between spirituality and healthcare in hospital settings. On the one hand, nurses recognize the significance of spirituality in patient care; on the other, their ability to address spiritual needs is often constrained by a lack of institutional guidelines and formal training. This gap is in line with previous studies highlighting the challenges faced by healthcare professionals in integrating spiritual care within biomedical frameworks (Puchalski et al. 2014; McSherry et al. 2020).

One core theme that emerged from the research is the informality of spiritual care. Rather than being an institutionalized component of nursing practice, spirituality is addressed on an ad hoc basis, mostly relying on individual attitudes and personal experience. This situation reflects broader tensions within contemporary healthcare systems, where a highly technical and efficiency-driven approach often marginalizes aspects of care that do not fit into standardized medical protocols (Velut 2020). Our research confirms that nurses feel ill-equipped to engage with patients’ spiritual concerns, despite recognizing their importance; this resonates with other studies conducted in European hospital settings (Timmins and Caldeira 2019).

Another crucial aspect that emerged from the research is the relational dimension of spiritual care; spirituality in healthcare is in fact deeply intertwined with the emotional bonds formed between caregivers and patients. Nurses often navigate spiritual concerns intuitively, through gestures of care, attentive listening, and other actions that provide comfort. In this sense, spiritual care is not only about addressing the patient’s needs, but also about supporting the well-being of caregivers, who often face emotional burdens in their professional roles.

Additionally, the study examined the intersection of spirituality and institutional structures. In some cases, such as at “Le Molinette”, hospitals have taken steps to acknowledge the spiritual needs of patients through initiatives like the “Spirit Care” project or the “Room of Silence”; however, these efforts remain largely peripheral to the medical decision-making process. Unlike palliative care, where spiritual support is more widely recognized as part of the holistic approach to the patient, hospital settings often fail to integrate spirituality into care trajectories. This is even more evident in the Italian context, where little research has been conducted on these topics; studies from the United States and the United Kingdom suggest that healthcare systems with explicit policies on spiritual care achieve better patient satisfaction and improved emotional well-being among staff (Isaac et al. 2016; Lazenby 2018).

8. Conclusions

This article has provided an examination of the role of spirituality in hospital patient care, with a particular focus on the experiences of nurses working in Italian healthcare institutions; on this basis, it has shown that while spirituality is acknowledged as a fundamental aspect of holistic care, its integration into hospital practice remains inconsistent and largely dependent on individual initiative.

The spiritual dimension is increasingly recognized as part of the healthcare process (Puchalski et al. 2009), with the World Health Organization replacing the idea of health as the absence of disease with a broader definition: “a state of complete physical, mental, and social well-being”. In Italy, since the 1980s, the spread of perspectives related to holistic care, such as Medical Humanities and Palliative Care, has promoted reflection on these issues (Spinsanti 2021). However, the biomedical approach that healthcare workers are trained in still often treats spirituality as a separate sphere from medical care—something that nurses, as highlighted in interviews and focus groups conducted for the project Religions in the Hospital, feel as beyond their competence and as a challenging dimension to address in patient care. When the subject arises within the nursing profession, it is often in relation to dietary practices or potential “barriers” to care, such as Jehovah’s Witnesses refusing blood transfusions.

Moreover, when spiritual needs arise, they are typically referred to representatives of the major religions in the Turin region, without subsequent discussions between religious leaders and healthcare providers about what emerged from the dialogue with the patient, as if this were of no relevance to medical staff. This reflects the longstanding Western philosophical tradition of separating the spiritual and physical dimensions of the individual, a concept that continues to shape contemporary healthcare practices.

However, confining spirituality to a marginal role within hospitals seems increasingly unjustified, given the growing interest in alternative medicine and spiritual healing techniques in Italy (Lombardi 2023; Lombardi 2018). Additionally, as long recognized by medical anthropology and sociology, illness is a biographical fracture that causes a crisis of self and existential meaning. In many cases, this search for meaning is expressed in spiritual terms. Spiritual care and the integration of this dimension into healthcare structures are, therefore, essential for addressing the suffering caused by illness and trauma, in an effort to fulfill the need for meaning through various resources, from faith and prayer to psychophysical well-being and active listening.

A key outcome of this research is that the emotional and existential dimensions of illness demand a response that goes beyond purely biomedical approaches, and nurses are often at the forefront of this process. However, without adequate training and institutional recognition, they are left to navigate these challenges on their own, and this leads to uncertainty and emotional strain.

In addition to this, the study has explored the significance of spiritual care not only for patients, but also for caregivers. Engaging with the spiritual aspects of care can provide nurses with a deeper sense of meaning in their work, potentially reducing burnout and improving their overall well-being.

Moving forward, the Religions in Hospital project suggests several critical areas for future development: the first dimension that need to be addressed is institutional recognition of spiritual care as an integral part of the trajectories of care; to this aim, hospitals should incorporate spiritual care into official policies, ensuring that it is recognized as a legitimate component of patient care. Secondly, concerning training and education processes, nursing curricula should include modules on spiritual care, providing healthcare professionals with the tools to engage effectively with patients’ spiritual concerns. In addition to this, the study suggests the need to increase collaboration between medical staff, psychologists, chaplains, and social workers to foster a more integrated approach to spirituality in healthcare.

Finally, we suggest that future studies should explore best practices for institutionalizing spiritual care and investigate its impact on both patient recovery and caregiver well-being. By addressing these gaps, hospitals can move towards a more holistic and compassionate model of care, where spiritual well-being is considered an integral part of the healing process. In a rapidly evolving healthcare landscape, acknowledging the spiritual dimensions of illness and recovery will be crucial in fostering a truly patient-centered approach to medicine.