Attributes of Family Spirituality and Influencing Factors of Its Decline: Data Triangulation of Literature and Family Interviews ()
1. Introduction
Although spirituality plays an important role in the well-being of individuals and families, spirituality is generally considered an individual phenomenon, and few studies have examined spirituality as a family phenomenon [1]. Almost no research has been conducted on “family spirituality” that targets the family as a whole [2]. In Japan, the word and concept of “spirituality,” as the term is used in the West, have been introduced in recent years, but no suitable translation exists for spirituality, and “spirituality” is generally used as-is as a foreign word borrowing [3].
Spirituality has been defined in various ways. For example, personal spirituality is a common human experience that forms an integral part of all people who seek meaning and purpose in life [4]; it is a fundamental element of the human experience that seeks a relationship with the meaning of life, an understanding of purpose, connection with others, and a sense of peace [5]; and it comprises such aspects as an individual’s internal relationship and human relationships, and relationship with nature [6]. Thus, personal spirituality incorporates the search for the meaning and purpose of life, the meaning of existence and relationships with others and nature.
Nevertheless, no consensus exists on the definition of family spirituality. Some definitions, for example, are based on religion, while others are not. Families that share inner values which give meaning tend to feel connected to the family, community, and universe [7]; others practice family rituals, originating from the spiritual traditions of their parents, and are connected to God/Transcendence and transpersonal beings [8].
In the Family Transcendence Theory (FTT) [3] proposed by Hohashi, family spirituality is defined as “a set of core beliefs of the family system unit that cognize the meaning of the existence of the family system unit in a transcendental dimension.” When family spirituality declines, family well-being declines, impacting negatively on the physical and mental health of family members. In other words, a decline in family spirituality impacts on a family’s problems, issues, difficulties, or suffering, and we believe research is needed into the influencing factors that cause a decline in family spirituality. By clarifying influencing factors, it is possible to prevent a decline in family spirituality so as to promote family well-being.
In this study, we used the Concentric Sphere Family Environment Theory (CSFET), a middle-range family nursing theory that can grasp the family holistically, as a theoretical framework to classify the attributes of family spirituality and its influencing factors macroscopically [9]. CSFET is a theory proposed by Hohashi that focuses on the family environment that affects the well-being of the family system unit [10]. In this theory, the family environment forms a three-dimensional space-time using three assessment axes (structural distance, functional distance, and temporal distance), with six systems arranged within it so as to visualize a three-dimensional overall picture of the family. The six systems of CSFET are: family internal environment system; family system unit; micro system; macro system; supra system; and family chrono-environment system.
The purpose of this study was to clarify the attributes of family spirituality and the influencing factors for deterioration of family spirituality using CSFET as a theoretical framework.
2. Methods
2.1. Operational Definitions of Terms
In this study, operational definitions of terms [9] were assigned to the following:
Family: a unit/organization as a system of the OR operation (logical operation) of individuals, that is, living people, having the cognition of belonging by other constituent member(s).
Family spirituality: a set of core beliefs of the family system unit that cognize the meaning of the existence of the family system unit in a transcendental dimension.
Risk/causal/promoting factors for deterioration of family spirituality: negative factors for maintaining and improving family spirituality.
Preventive/inhibitory/suppression factors for deterioration of family spirituality: positive factors for maintaining and improving family spirituality.
Context-sensitive factors for deterioration of family spirituality: factors that, depending on the condition, are risk/causal/promoting factors in some family cases or preventive/inhibitory/suppression factors in others.
Family internal environment system: the environment that includes family communications ability; family time allocation; beliefs of family/family members; family health-related self-care ability; family economic power; family living environment and others (Figure 1).
Family system unit: a family existing as a system and a unit.
Micro system: the environments that include the local living sphere; relatives, family friends; neighbors and others (Figure 1).
Macro system: the environments that include educational, nursery, adult learning facilities; health, medical, welfare facilities; workplace environment; social resources, public services; politics, economics and others (Figure 1).
Supra system: the environments that include religion; culture; the supernatural and superscientific cosmos and others (Figure 1).
Family chrono environment system: the environments that include adapting to family events; family chronicle; realizing family demands/family hopes and others (Figure 1).
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Figure 1. Model diagram of Concentric Sphere Family Environment Theory (CSFET) (Ver. 3.4).
2.2. Study Design
In order to comprehensively and systematically clarify the attributes of family spirituality and the influencing factors that cause deterioration of family spirituality, the study conducted data triangulation from literature reviews and family interviews [11] [12], and directed content analysis [13] based on the theoretical framework of the six systems of CSFET.
2.3. Literature Review
Using the literature database PubMed, a search was performed with “family spiritual*” as the key word. In order to identify the most recent papers, a search for literature between 2010 and 2023 (conducted in December 2023) yielded a total of 4,826 hits. The inclusion criteria were that the paper must be an original article; that it must be a study targeting a family or multiple family members; and that it must describe family spirituality. The exclusion criteria were that the paper is about personal spirituality and is written in a language other than English. After reading the titles and abstracts of the papers, 165 potentially relevant papers were obtained, and the papers were carefully read and confirmed. The 20 papers that met the inclusion and exclusion criteria were subjected to analysis [14]-[33]. The literature search was conducted in March 2020, October 2021, and October 2022, and was used for analysis at each stage. The literature searched in December 2023 was finally included in the analysis.
2.4. Semi-Structured Interviews
2.4.1. Target Families
The target families for the semi-structured interviews were families with an adult member aged 65 years or older. This is because we assumed that families with older adults have experienced a variety of events over their years of family life, with numerous opportunities to consider the meaning of their family’s existence, which represents a key aspect of family spirituality. We explained this study to the manager of a housing complex and the manager of a visiting nurse station in an urban area of Japan, and recruited the target families. We contacted the families who agreed to participate in the study and set the date, time, place, and method of the interview. In principle, the family interview was conducted with multiple family members, but individual interviews with only one key informant were also possible upon their request. In both cases, the interviews were concerned with family spirituality, not individual spirituality, as based on the operational definitions of family spirituality in this study. The interviews were conducted from May 2020 to January 2022, and each family was interviewed for about 120 minutes to collect sufficient family data.
2.4.2. Interview Method
Semi-structured interviews were conducted using an interview guide based on the Family Environment Assessment Index (FEAI) [34]. The FEAI was created as a family assessment tool based on the CSFET, and is a collection of sample questions in family interviews/meetings, to enable accurate collection of family information necessary for family assessment. The FEAI includes family spirituality. In this study, a pilot test of the interviews was conducted with four families as a convenience sample in advance. After that, based on the opinions of the families, the question wording was clarified and the interview guide was revised to suit the purpose of this study. An example of the completed interview guide is shown in Table 1.
The interviews were conducted by two researchers, one of whom was mainly responsible for the interviews and the other for writing the field notes. With the consent of the subjects, all interviews were recorded using an IC recorder, and the recorded contents were transcribed verbatim after each interview while referring to the field notes, and on each occasion analysis was performed.
2.5. Analysis Method Using Data Triangulation
2.5.1. Analysis Procedure
In order to ensure the complementarity of the analysis, data sources consisted of the descriptions in the papers and the verbatim transcripts of the interviews. The data sources were analyzed using the following procedure while creating an audit trial of data analysis processes based on the data triangulation protocol [11] [12].
Table 1. Example of interview guide.
Example questions |
Intention and purpose of the questions |
Why do you think family exists for your family/the whole family/the people, things, and events surrounding your family? What meaning and purpose do you think family has for your family/the whole family/the people, things, and events surrounding your family? What values and beliefs support your family’s meaning of existence? |
Identify the meaning of family existence. |
Why do you think that way about the meaning of each family’s existence? What is the fundamental idea that makes you think that way? |
Identify beliefs that relate to the meaning of family existence. |
What do you think exerts a positive or negative impact on the meaning of a family’s existence? Specifically, what kind of positive or negative impact would that be? |
Identify factors that influence family spirituality. |
Three researchers independently read the data sources repeatedly to fully understand the contents related to the meaning of family existence. After that, sentences, paragraphs, or sections related to the attributes of family spirituality and the influencing factors of the decline of family spirituality were identified and written in the code column of the codebook. Codes are small, meaningful units. The influencing factors of the decline of family spirituality were classified into risk/causal/promoting factors, preventive/inhibitory/suppression factors, and context-sensitive factors. The classification was based on the similarities and differences of the contents of the codes, and the codes with common contents were classified into subcategories and categories to increase the level of abstraction [35]. Then, using directed content analysis [13], each category was classified into the six CSFET systems and written into the code, subcategory, category, and system columns of the codebook.
A primary coding framework and categories were constructed to compare the codes, subcategories, categories, and systems from the data sources and eliminate discrepancies. The three researchers confirmed the analysis by re-checking the codes, subcategories, and categories to confirm that they were converging on the range of attributes of family spirituality and influencing factors of declining family spirituality.
The codebook was constantly revisited after initial coding, until categories were saturated and no new categories emerged. Saturation was determined to have been reached when interviews had been conducted with 12 families. After that, an interview was conducted with one more family, and saturation was verified, so the codes, subcategories, categories, and systems were finalized through the consensus of all three researchers.
2.5.2. Trustworthiness of the Analysis
To ensure the trustworthiness of the analysis, the following was conducted: One, as an investigator triangulation [36], in order to develop a comprehensive understanding of phenomena, two researchers skilled in family interviews/meetings were used to conduct the interviews. In addition, three family nursing researchers were constantly involved in performing integrative analysis of the data to minimize the risk of researcher bias. Two, the analyses were performed by triangulating data sources from the literature and family interviews [37]. Three, the analyses were first performed by three researchers independently. Following multiple meetings with all, any disagreements were resolved through discussions, and, when necessary, another family nursing researcher reviewed the disagreements until a consensus was reached. Four, we recorded an audit trail [38] of data analysis processes and analytic decisions, and were able to assess at any time whether the findings were grounded in the data. Five, the research findings and interpretations were shared and discussed in regular meetings attended by eight family nursing researchers, and the analysis was carried out repeatedly based on peer debriefing from different perspectives [39]. And six, the results of the analyses were returned to the interviewed families for verification through family member checking [40] and these results were reflected in the analysis.
2.6. Ethical Considerations
This study was conducted following review of and approval by the institutional review board of the university to which the researcher belongs (approval number: No. 938). The interview participants were given written and verbal explanations of the study’s purpose, methods, benefits and risks; confidentiality obligations; freedom to withdraw midway; and that no inconveniences would be incurred for withdrawing midway or for non-participation, and written consent was obtained. In addition, care was taken to minimize the burden on the participants by informing them that they were not obliged to respond to questions they preferred not to answer, and by allowing them to take breaks as necessary.
Full adherence was given to research ethics when handling papers. Cited papers and quoted sections were clearly identified to avoid copyright infringement. When using papers, strict adherence was given to copyright law and sources clearly indicated. We also strived for accurate interpretation of the research content, with efforts to avoid deviating from the authors’ intentions.
3. Results
3.1. Papers Included in the Literature Review
Table 2 lists 20 papers that were utilized for the literature review [14]-[33]. The family characteristics were: one family of individuals with no disease; five families of children with chronic diseases/cancer; eight families of individuals with a terminal illness; three families with older adults; and three families of bereaved individuals. The countries studied were: nine in United States; two each in Australia and Iran; one each in China, Thailand, South Korea, Ireland, Lebanon and Canada; and one multinational study. Eight of the studies were quantitative and 12 qualitative.
Table 2. References subjected to analysis (n = 20).
Reference No. |
Author (year) |
Country/region |
Participants (n) |
Design |
Family of individuals with no disease |
14 |
Chamratrithirong et al. (2010) |
Thailand |
Pairs of parents and teens aged
13 - 14 (n = 420) |
Quantitative |
Families of children with chronic diseases/cancer |
15 |
Livingston et al. (2020) |
United States |
Adolescents with cancer (n = 126) and their family member (n = 126) |
Quantitative |
16 |
Gallagher et al. (2015) |
Ireland |
Parents (n = 31) |
Quantitative |
17 |
Atashzadeh et al. (2018) |
Iran |
Mother (n = 11) and father (n = 4) of children with cancer |
Qualitative |
18 |
Selman et al. (2018) |
South Africa, Kenya, South Korea, United States, Canada, the United Kingdom, Belgium, Finland and Poland |
Patients (n = 74) and caregivers
(n = 71) |
Quantitative |
19 |
Doumit et al. (2019) |
Lebanon |
Parents (n = 11) of children with cancer |
Quantitative |
Families of individuals with a terminal illness |
20 |
Allen et al. (2010) |
United States |
Parents (n = 168) |
Qualitative |
21 |
Kincheloe et al. (2018) |
United States |
Family members (n = 132) and nurses (n = 54) |
Quantitative |
22 |
Chang et al. (2012) |
United States |
Veterans (n = 17) and family
members (n = 9) |
Qualitative |
23 |
Sun et al. (2016) |
United States |
Patients (n = 475) and family
caregivers (n = 354) |
Quantitative |
24 |
Swinton et al. (2017) |
Canada |
Family (n = 13) and clinician
(n = 80) |
Qualitative |
25 |
O’Callaghan et al. (2019) |
Australia |
Patients (n = 30) and their family
caregivers (n = 10) |
Qualitative |
26 |
Gardner et al. (2020) |
Australia |
Patients (n = 24) and their family
members (n = 10) |
Qualitative |
27 |
Nuñez et al. (2019) |
United States |
Hispanic patients’ families (n = 29) |
Qualitative |
Family with older adults |
28 |
Kim et al. (2011) |
South Korea |
Korean family caregivers (n = 157)
and elders (n = 157) |
Quantitative |
29 |
Kim et al. (2016) |
United States |
Elderly Korean-Americans couples
(n = 26) |
Qualitative |
30 |
Kim et al. (2019) |
United States |
Older adults (n = 27) and family
members (n = 24) |
Qualitative |
Families of bereaved individuals |
31 |
Sadeghi et al. (2016) |
Iran |
Participants (n = 24) |
Qualitative |
32 |
Cai et al. (2020) |
China |
Bereaved parents (n = 10) |
Qualitative |
33 |
Hamilton et al. (2018) |
United States |
African Americans (n = 19) |
Qualitative |
3.2. Participants of Family Interviews
Interviews were conducted with 23 people from 12 families, with the average interview time 125.3 minutes (SD = 41.4). The demographic characteristics of the participants and their families are indicated in Table 3. Eleven families (84.6%) were nuclear families and two families (15.4%) were extended families. With regard to religious beliefs, 20 people (85.0%) were Buddhists, and three people (15.0%) were non-believers.
Table 3. Demographic characteristics of interview participants and their families (n of families = 12, n of individuals = 23).
Characteristic |
n (%a) |
M (SD) |
Range |
Participant’s gender |
|
|
|
Male |
9 (39.1) |
|
|
Female |
14 (60.9) |
|
|
Participant’s age (years) |
74.5 (8.71) |
|
51 - 84 |
Participant’s employment status |
|
|
|
Full-time worker |
4 (17.4) |
|
|
Part-time worker |
3 (13.0) |
|
|
Full-time homemaker |
5 (21.7) |
|
|
Retired, not employed |
11 (47.8) |
|
|
Number of family members |
|
9.9 (7.2) |
2 - 29 |
Type of family |
|
|
|
Nuclear family |
11 (91.7%) |
|
|
Extended family |
1 (8.3%) |
|
|
Participant’s religion |
|
|
|
Buddhism |
20 (85.0) |
|
|
Non-believer |
3 (15.0) |
|
|
Interview length (min) |
125.3 (41.4) |
|
67 - 195 |
a. As fractions are rounded off, the percentage may not total 100%.
3.3. Attributes of Family Spirituality
A total of 21 categories and 73 subcategories were extracted for the attributes of family spirituality (Table 4). Based on the CSFET, the 21 categories were classified into 6 systems, with six categories and 26 subcategories in family system unit; five categories and 13 subcategories in the family internal environment; two categories and five subcategories in the micro system; one category and one subcategory in the macro system; three categories and 13 subcategories in the supra system; and four categories and 15 subcategories in the family chrono environment system.
Table 4. Attributes of family spirituality.
CSFET
system |
Category (n = 21) |
Reference
number |
Family number |
Fsu |
Family believes that family members should support each other |
15, 26, 32 |
1, 2, 3, 5, 6, 7, 9, 10, 11, 12 |
Family believes that the family is a kind of microcosm of society |
|
10, 11 |
Family believes that the family is irreplaceable |
14, 17, 20 |
4, 7, 10 |
Family believes that the family has a trusting relationship that allows family members to talk to each other |
|
1, 9, 10, 11 |
Family believes that family members should be close to each other |
25, 26, 30, 31 |
1, 3, 4, 6, 7, 9, 10, 12 |
Family believes that the family is a safe place |
17 |
9, 10, 11 |
Int |
Family believes that the family exists for the sake of children and grandchildren |
17, 23 |
1, 2, 3, 7, 12 |
Family believes that the wishes of family members should be respected |
24, 27 |
9 |
Family believes that parents do not want to be looked after by children |
|
12 |
Family believes that the more family members there are, the more likely they
will be happier |
|
9, 10, 12 |
Family believes that it is important for family members to trust spirituality |
18, 21 |
|
Mic |
Family believes that relationships between its members differ from those of
people outside the family |
15, 16, 20, 31 |
1, 9 |
Family believes that it is important to have connections with those close to it |
14, 16, 20 |
7 |
Mac |
Family believes that mutual understanding with medical professionals is
necessary |
16, 24, 31 |
|
Sup |
Family believes in religious teachings |
17, 18, 20, 25, 29, 31 |
2, 3, 10, 12 |
Family believes that religion is a blessing |
15, 18, 21, 24, 26, 27 |
3, 12 |
Family believes that family spirituality and religion can sometimes overlap |
16, 20, 30, 31, 33 |
|
Chr |
Families believe that the interaction of family members will gradually become routine in nature |
|
9, 10 |
Family desires peace for their family members |
|
10, 12 |
Family believes that family members should share time together |
16, 20, 23, 25, 30 |
1, 3, 10 |
Family believes that they should bequeath their own culture |
23, 30 |
1, 3, 4, 10 |
Note: CSFET = Concentric Sphere Family Environment Theory; Fsu = family system unit; Int = family internal environment; Mic = micro system; Mac = macro system; Sup = supra system; Chr = family chrono environment system.
3.4. Influencing Factors Relating to Deterioration of Family
Spirituality
Altogether, 20 categories and 29 subcategories were extracted as influencing factors for deterioration of family spirituality (Table 5). These consisted of six categories and eight subcategories of risk/causal/promoting factors; 11 categories and 17 subcategories of preventive/inhibitory/suppression factors; and three categories and four subcategories of context-sensitive factors were identified. For example,
Table 5. Influencing factors relating to deterioration of family spirituality.
Classification of
influencing factors |
CSFET
system |
Category (n = 20) |
Reference
number |
Family
number |
Risk/causal/promoting factors for deterioration of family spirituality |
Fsu |
Disharmony in family relationships |
|
9, 10 |
Int |
Family members facing incurable illnesses |
14 |
|
Mic |
Negative information from other family members |
31 |
|
Mac |
Lack of caring for family members |
16, 28 |
|
Sup |
Family members becoming obsessed with religion |
|
9 |
Chr |
When prayers are not answered |
21 |
|
Preventive/inhibitory/
suppression factors for deterioration of family spirituality |
Fsu |
Support among family members |
|
9, 10 |
Family members celebrating events together |
|
11 |
Int |
High level of education of parents |
18 |
|
Smiles of family members |
|
12 |
Realizing growth of family members |
|
12 |
Comments from family members that foster a sense of security |
|
11 |
Mac |
Medical professionals being close to the family |
15, 16, 17 |
|
Sup |
Family members practicing religion |
15, 17, 20, 21, 23, 30 |
|
Family members’ belief in religion |
15, 17, 24 |
9, 11, 12 |
Chr |
Increasing number of family members |
|
9 |
Family members passing on religious teachings |
|
11 |
Context-sensitive factors for deterioration of
family spirituality |
Sup |
Religious consciousness |
14, 15, 18, 22 |
|
National/regional culture |
19 |
|
Chr |
Upon the death of a family member |
|
9, 10 |
Note: CSFET = Concentric Sphere Family Environment Theory; Fsu = family system unit; Int = family internal environment; Mic = micro system; Mac = macro system; Sup = supra system; Chr = family chrono environment system.
the context-sensitive factor “upon the death of a family member” can become a risk/causal/promoting factor when the number of family members decreases and the family loses the meaning of its existence upon the death of a family member. Conversely, it can also become a preventive/inhibitory/suppression factor when the death of a family member increases contacts between other family members and bolsters family ties.
4. Discussion
The results of the literature review showed that a relatively small number (20) studies on family spirituality were published between 2010 and 2023. The participants of the literature review mostly focused on families with family members suffering from cancer or terminal illness. These conditions are thought to be factors that make family spirituality more likely to be manifested in some manner.
The results of this study combine the results of the literature review and family interviews. Furthermore, by applying CSFET, we believe that we have been able to systematically and comprehensively clarify the attributes of family spirituality and influencing factors relating to deterioration of family spirituality. In particular, the fact that we were able to classify these attributes not only into the family internal environment but also into the micro system, macro system, supra system and family chrono environment system can be considered novel findings.
4.1. Attributes of Family Spirituality
The three categories of the supra system are “Family believes in religious teachings”; “Family believes that religion is a blessing”; and “Family believes that family spirituality and religion can sometimes overlap”; all of which are related to religion. For families who have faith in religion, recognizing the meaning of the family’s existence can be said to be related to religion. It has been shown that spirituality is related to the ability of families to deal with risks and recover from crises [41]. Family spirituality is also related to the formation of resilient families [42]. Thus, when facing a family crisis, families are likely to overcome the crisis by channeling religious blessings. Regardless of whether they have religious faith or not, it is possible that they believe that family spirituality and religion are sometimes intertwined, since religion and religious teachings provide comfort to families when a family member is sick or when the family faces difficulties.
In the family chrono environment system, the category of “Family believes that family members should share time” that recognizes the meaning of the family’s existence is understood. It was revealed that “family events” are a way for family members to interact with each other and build good family relationships and promote family well-being [43]. Family togetherness is a characteristic of healthy families, and includes the quality of time family members spend together as well as the amount of time they spend together [44]. Nursing professionals will need to create private spaces and opportunities for communication among family members to improve family well-being.
4.2. Influencing Factors Relating to Deterioration of Family
Spirituality
Risk/causal/promoting factors for deterioration of family spirituality include “disharmony in family relationships” in the family system unit, which has been shown to result in the breakdown of family trust and problems in communication. Families in a situation of well-being are characterized by active communication, spiritual well-being, gratitude, and love [45]. When disharmony in family relationships occurs, family trust is destroyed, making it difficult for family members to support each other, while reducing family well-being, which in turn impacts negatively on beliefs that recognize the meaning of the family’s existence. Good family spirituality is reflected by good harmony and communication between family members [46], and furthermore, family relationships and family well-being [23] are improved, enabling the family to find meaning in its existence. Disharmony in family relationships, therefore, is thought to act negatively on family spirituality.
As for preventive/inhibitory/suppression factors for deterioration of family spirituality, “Medical professionals being close to the family” in the micro system indicates that it is important for medical professionals to suppress the decline in family spirituality. This is related to the micro system attribute of family spirituality, “Family believes that mutual understanding with medical professionals is necessary,” and it is assumed that by medical professionals being close to families, mutual understanding between the family and medical professionals can be deepened. Hohashi [47] advocates the Family Care/Caring Theory, which focuses on families, and states that nursing professionals can be close to families by understanding families and by understanding themselves as nursing professionals. A decline in family spirituality reflects on a family’s problems, issues, difficulties, or suffering, and by understanding this, family nursing based on the Family Care/Caring Theory will enable a decline in family spirituality to be prevented [47] [48].
In the supra system, “religious consciousness” is one of the context-sensitive factors for deterioration of family spirituality. It has been found that differences in family religious beliefs can be risk/causal/promoting factors for a decline in family spirituality, or conversely, preventive/inhibitory/suppression factors. For sick family members, belief in religion can provide emotional support and prevent a decline in family spirituality. On the other hand, it is possible that an incurable illness can lead to spiritual suffering, which can lead in turn to a decline in family spirituality, or that a family member who is a non-believer won’t obtain a sense of security from religion, even in the event of a family crisis. In other words, differences in the manner religion are dealt with are thought to have different effects on decline in family spirituality [3], and nursing professionals will need to be aware of a family’s religious background when providing support for a decline in family spirituality.
4.3. Implications for Nursing Practice
In this study, using CSFET as a framework, we were able to obtain a comprehensive grasp of the attributes of family spirituality and the influencing factors of decline in family spirituality. Nursing professionals can refer to the attributes of family spirituality when providing family spirituality support. By controlling the influencing factors of a decline in family spirituality, moreover, nursing interventions can be provided to prevent a decline in family spirituality. The attributes of family spirituality and the influencing factors of decline in family spirituality belong to all systems of CSFET, and it became clear that intervention is required not only within the family, but also in the external environment. In the future, we hope to develop a measurement scale for assessing family spirituality, using CSFET as a framework, that will holistically improve family well-being, and apply it to clinical practice.
4.4. Limitations of the Study
In the literature review, few studies on family spirituality were found to exist, and the particulars of family spirituality and personal spirituality may be ambiguous. In addition, owing to their sources, many of the literature reviews may reflect some degree of bias toward Western culture. All interview subjects consisted of families with older adults, which may limit the generalizability of the results. The research period coincided with the COVID-19 pandemic, which may have provided participants with greater opportunities to consider the meaning of family, and this may have influenced the results. Moreover, 85% of the interview participants were Buddhists, so a study in countries or regions where other religions are practiced may produce different results.
5. Conclusion
This study focused on the new concept of spirituality of the family as a whole from the perspective of family nursing, as opposed to individual spirituality. Using CSFET as a theoretical framework, we triangulated data from literature reviews and family interviews, comprehensively and systematically clarifying 21 categories of attributes of family spirituality and 20 categories of influencing factors. Nurses can now knowingly conduct appropriate holistic family interventions by understanding the attributes of family spirituality before performing family assessments and making efforts to control the influencing factors of family spirituality.
Acknowledgments
The authors are deeply grateful to our laboratory members and Ms. Qiting Lin for their insightful suggestions during the early stages of manuscript development.
Funding Sources
This research was funded in part by a Grant-in-Aid for Scientific Research (B) from the Japan Society for the Promotion of Science (JSPS) in Japan (Grant Number: JP22H03400).