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Abstract

Spirituality is important when caring for the whole human being. Earlier research found Love in connectedness to be a core category in spirituality. The study aim is to deepen our understanding of Love in connectedness, and contribute to the theoretical knowledge development of the concept of spirituality from a caring science perspective. The method was a review of 20 research articles concerning connectedness and love, which were interpreted through a Gadamerian-based hermeneutical approach. Emerging themes were three forms of connectedness, compassion, and the risk of losing love in caring for the patient. In addition, we reflected on love and ethics, based on the writings of Tillich. According to Tillich, love is a drive toward unity of the separated. This drive can be seen in both connectedness with others, in connectedness with something larger than oneself, and may indirectly apply to connectedness with oneself. We find that both connectedness and love are key concepts in caring for the patient.

Keywords

connectedness compassion love spirituality

Introduction

Theory development should be the overall purpose when conducting qualitative nursing research (Bunkers, 2012). Eriksson (2010b) points to the paradigmatic shift in the 1970s, toward the development of nursing knowledge and caring science based on a human science way of thinking. The humanistic-oriented thinking gave caring science a new significance in the search for the core of caring, and fostered the development of fundamental concepts and theory to bring to light knowledge that may help the patients in an increasingly complex world (Eriksson, 2002, 2010a). Concepts are essential elements of theories that describe a part of the reality (Eriksson, 2010a). Through concepts, the theoretical structures of nursing may become visible, and this knowledge may as well guide observations and nursing actions in practice (King, 1988).

According to Meleis (1992), nursing theory development is important and may contribute with knowledge that is relevant for many health care professions. Within caring science, knowledge development is of significance to all personnel involved in caring for the patients and their next of kin. However, nursing theory development should be elaborated within the structure of an explicit framework (Cody, 1999). The theoretical basis for our research is the humanistic tradition of caring science and the caritative caring theory of Eriksson (Lindström, Lindholm, & Zetterlund, 2010). In caring science, the human being is viewed as an indivisible entity of body, mind, and spirit (Eriksson, 2002). It is essential in caring to include the spiritual dimension so that the patient may feel whole as a human being, and this may be viewed as a premise for dignity and health (Eriksson, 2002; Lindström et al., 2010). The basic motive for caring is caritas, and caring implies alleviation of suffering in charity, love, faith, and hope (Lindström et al., 2010). As stated by Råholm and Lindholm (1999), caritative caring ethics means being there and confirming the patients’ dignity, which is seen as a manifestation of the love that “just exists.”

This study focuses on spirituality, and there is compelling evidence supporting spiritual care as a force in health and well-being (Becker, 2009; Pesut & Sawatzky, 2006). Although the concept of spirituality and the provision of spiritual care are recognized as fundamental aspects of nursing care, it is however challenging to incorporate spiritual care into clinical practice (Carr, 2010; Cone & Giske, 2013; McSherry & Jamieson, 2013; Pesut, 2012). We suggest that the perspective from which spirituality is investigated is of importance (Florczak, 2010). Earlier research in light of caring science found Love in connectedness to be a core category in spirituality (Rykkje, Eriksson, & Råholm, 2011). Love in connectedness concerns the presence of a transcendent or universal love, which can be viewed as a power and a potential health resource. Love is a motivator and the “glue” that enables human beings to form durable connections with their inner space, others, community, Higher Powers, and nature. Love in connectedness motivates spiritual thoughts and actions, and provides inner strength. Universal love is present in caring relationships and concrete caring acts, presented by phenomena of both receiving and giving love. Inherent in love is compassion, concern, being seen, and being confirmed (Rykkje et al., 2011).

The study aim is to deepen our understanding of Love in connectedness, and thereby to contribute to the theoretical knowledge development of the concept of spirituality from a caring science perspective.

Method

There are different ways to contribute to theory development, and the development of qualitatively derived concepts and theories is challenging (Morse, Hupcey, Penrod, & Mitcham, 2002). We chose to perform a review of research articles pertaining to care, and to explore connectedness and love separately. Reviews may be the basis of theory development because of the potential to integrate research findings into broader theoretical accounts of the investigated topic (Kirkevold, 1997). To deepen the understanding of Love in connectedness, we chose also to reflect on some philosophical issues regarding love and ethics, based on the writings of the theologian and philosopher Tillich.

Selecting Literature

Searches in CINAHL and Medline were conducted during March–September 2013, and some articles were found by exploring cited references. Inclusion criteria were as follows: (a) Connectedness or love was found in the abstract or was central in the article, and (b) the theoretical perspective of the article was relevant to caring science, and our research aim. After reading the abstracts, 17 and 23 articles about connectedness and love, respectively, were selected for further reading. Nine articles about connectedness and 11 articles about love were found to be the most relevant, and thus included in the final analysis. Table 1 presents an overview of the articles.

Table 1.

Overview of the Included Articles.

Author(s)	Aim	Methodology	Main results
Connectedness
Bellingham, Cohen, Jones, and Spaniol (1989)	Explore ways to foster connectedness and to help people achieve lasting spiritual health	Theoretical study. Explores the relationship between connectedness and spiritual health	There are three forms of connectedness: connecting with oneself, with others, and with a larger meaning or purpose. Connectedness skills may lead to an enhanced sense of spiritual well-being
Burkhardt (1994)	Expand the knowledge base of nursing relative to spirituality from a female perspective	In-depth, face-to-face interviews with 12 adult women in Appalachia. A constant comparative process of naturalistic inquiry and grounded theory was used	Spirituality shapes and gives meaning to life and is expressed in one’s being, knowing, and doing. It is experienced within caring connections with Self, Others, Nature, and Ultimate Other
Younger (1995)	Explain the mechanisms through which suffering affects an individual’s sense of community and connectedness with others	Theoretical study. Develops the concept of suffering and its influences on relationships and the concept of alienation within the context of suffering	Suffering is a human experience that may bring loneliness or alienation from others with it. Explains how and why care can reverse alienation and support connectedness
Predeger and Mumma (2004)	Explore connectedness in the lives of women living with chronic illness	Narrative data were gathered from multiple qualitative studies over a 13-year period, which describe the experiences of women with chronic illness. This was a secondary analysis guided by an interpretive–descriptive approach	Women reported that chronic illness provided an awareness of their patterns, connections with others, and movement toward health. The strongest connections were relationships with loved ones, particularly family and friends
Pesut (2008)	Illuminate how spirituality is understood within a diverse society and how those understandings might influence patient–provider relationships	Theoretical study. A hypothetical narrator and three participants representing the positions of theism, monism, and humanism discuss their understandings of spirituality and religion and how those understandings influence the intersections between nursing ontology, epistemology, and spiritual care	Meeting the needs of patients requires a nuanced understanding of spirituality. Conceptualizations of spirituality derived from different traditions make claims about the nature of humanity. These claims determine what constitutes moral and ethical nursing care. The implications of the various approaches to spirituality should be debated for nurses to embrace the responsibility for spiritual care
Teixera (2008)	Expand the knowledge and the development of self-transcendence	The study followed Rodgers’ method of concept analysis. Search for literature on transcendence, self-transcendence, and spirituality, inclusive of the Years 1996-2007. Twenty-six articles were selected	There are four major attributes of self-transcendence: awareness, inter-connectedness, expanding consciousness, and creative energy. Self-transcendence as a dynamic, nonlinear process that broadens a person’s life perspectives can help a person adapt to life circumstances, overcome uncertainty, find relief from suffering, and enhance well-being
Register and Herman (2010)	Develop a new middle range theory in which connectedness is a focal concept	A concept synthesis guided by Walker and Avant, based on three approaches: literary synthesis, qualitative synthesis (interview of 12 older adults), and quantitative synthesis (survey of 428 older adults)	Found six categories of connectedness: metaphysical, spiritual, biological, connectedness to others, environmental, and connectedness to society. Connectedness in community-dwelling older adults can be defined as engaging life by self-regulating, facing aging, being part of a family, having friends, and being spiritual
Register and Scharer (2010)	Study the process involved with connectedness in community-dwelling older adults	A grounded theory study based on Glaser and Strauss. Interview of 12 older adults from South Carolina	Identified four processes of connectedness in older adults: having something to do, having relationships, having a stake in the future, and having a sense of continuity. Connectedness provides older adults with a mechanism to engage life in meaningful, positive, and purposeful ways
Phillips-Salimi, Haase, and Kooken (2012)	Clarify the concept of connectedness by evaluating how it has been examined in social relationships	A hybrid concept analysis guided by Haase et al. Search for literature on connectedness in the period from 1983 to 2010. Twenty-seven articles and one book chapter were selected	Identified seven attributes of connectedness: intimacy, sense of belonging, caring, empathy, respect, trust, and reciprocity. Connectedness in social relationships is the degree to which a person perceives that he or she has a close, intimate, meaningful, and significant relationship with another person or group of people
Love
Wahlin, Wieslander, and Fridlund (1995)	Find out how loving care is practiced by one ambulance service	A critical incident technique was used. Twelve paramedics described, in writing, critical incidents in which they had acted with loving care	The paramedics showed solicitude that demonstrated their loving behavior toward the patient through humbleness, consideration, closeness, and being in rapport
Von Dietze and Orb (2000)	Demonstrate the relevance of the moral dimension of compassion to nursing care	Theoretical study. A general discussion of the meaning of compassion and an examination of its common usage	Compassion is more than just a natural response to suffering; rather, it is a moral choice. Compassion is an essential moral value of the caring role
Fitzgerald and van Hooft (2000)	A dialogue on the question “what is love in nursing?”	A qualitative research methodology using real-case focus group studies known as “Socratic dialogue” to generate data for a grounded theory	“Love in nursing” was understood as the willingness and commitment of the nurse to want the good of the other before the self without reciprocity. Western health care systems limit professional caring and loving possibilities. Nurses who love in the practice of caring go beyond the role definition of the duty of care
Stickley and Freshwater (2002)	Examine the therapeutic role of the nurse, focusing on love and its healing potential, and the concept of clinical caritas	Theoretical study. Explore the concept of caring utilizing theoretical and experiential examples to illustrate ways in which health care systems can both drain and nurture the practitioners’ capacity to care	Presents a framework for developing the art of loving within nursing care, with balance between discipline, concentration, patience, concern, and activity. Outlines the boundaries in which genuine love may be expressed within the parameters of a professional role
Arman and Rehnsfeldt (2006)	Explore how love can be visible through virtue, caritas, and the art of caring, which creates evidence of it	Theoretical study. Deepen the understanding of love as a concept related to caring and caring ethics through a dialogue between the authors and relevant academic and philosophical literature	Caring as a virtue and an act of ethics is, in both its natural and professional aspects, inseparably related to love as a universal/ontological value. Human beings require constant participation in the giving and the receiving of love. Expressions of love can enhance the patient’s understanding of life as well as provide relief from suffering
Schantz (2007)	Clarify the meaning of the concept “compassion” and examine its relevance in the context of everyday nursing practice	A concept analysis using Walker and Avant’s method as well as Rodgers’s evolutionary paradigm	“Compassion” is distinguished from “caring,” “sympathy,” and “empathy” by its intrinsic motion-generated effects. Only compassion impels and empowers people to not only acknowledge but also act toward the alleviation or removal of another’s suffering. Compassion is incited by the recognition of suffering
Sand, Olsson, and Strang (2010)	Investigate the motives of family members who take responsibility in palliative cancer care	A qualitative hermeneutic study from Sweden. Twenty family members of enrolled palliative care patients were interviewed in depth	Love, attachment, and outlook on life were the main reasons for shouldering responsibility. The participants experienced love and gratitude from the patients and others, a meaningful deepening of relationships within their families, and an increasing awareness of life values.
van der Cingel (2011)	Understand the benefit of compassion for nursing practice within the context of long-term care	A qualitative analysis of in-depth interviews with nurses and patients in three different care settings in the Netherlands	Found seven dimensions: attentiveness, listening, confronting, involvement, helping, presence, and understanding Discusses the difference between pity and compassion
Kenny (2011)	Explore how the experience of love and its expression might inform and guide reflection and inquiry into love	Theoretical study. A synthesis between rational inquiry and subjective experience. Explores Yeats’s notion of a gyre as a metaphor for integrating different understandings of love	Love can be a way to freedom because the mediating force of love has an ability to make connections, heal, and make whole. Love carries with it a quality of spontaneity that creates the conditions for the mind and the body to become more integrated
Straughair (2012)	Explore the concept of compassion and its implications for contemporary nursing practice	Theoretical study. Focus on the origins of compassion from a theological and early nursing perspective. Discuss the ethos of compassion from a contemporary perspective and problems identified by negative patient experiences	The ethos of compassion and the concept of altruism as essential professional virtues seem to have been eroded. Problems with compassion are reflected in reported instances of poor standards of nursing care. Compassion is a core value underpinning nursing care and nurses need to ensure this principle is implemented for a high standard of care
Thorkildsen, Eriksson, and Råholm (2013)	Explore the essence of love when encountering suffering	An interpretative research synthesis of 15 articles focusing on different aspects of love, guided by a hermeneutical perspective with an abductive approach	Found three themes: love as a holy power, love as fundamental for being, and love as an ethical act. The core substance of love can be understood as agape

Interpretation

With the purpose of gaining a deeper insight into the meaning of connectedness and love in relation to caring science, the articles were interpreted through a Gadamerian-based hermeneutical approach. According to Gadamer (2004), understanding is always interpretation, and involves applying the text to be understood to the interpreter’s present situation. Thus, to support the trustworthiness of the analysis, it was important to clarify the study’s horizon of understanding and the theoretical framework from the start. The hermeneutical reading was a search for meaning through the dialectic movement of interpretation and understanding of the parts in relation to the whole, and the chosen theoretical framework (Eriksson & Lindström, 2007). Then, the essential features of the text were placed into preliminary themes. In this process, the first author drafted the preliminary findings, and the interpretation was then commented on by the co-authors in several rounds of dialogues. The major themes that emerged were three basic forms of connectedness, compassion, and the risk of losing love in caring for the patient.

We find, in agreement with Gadamer, that there cannot be an understanding free of all prejudice. Hermeneutical reading and interpretation involve application, “so that a person reading a text is himself part of the meaning he apprehends” (Gadamer, 2004, p. 335). Therefore, it was important for us to reflect the main findings against the study’s theoretical horizon.

Findings and Reflections

First, we portray findings regarding connectedness and love through reflective summaries, and then we reflect on the findings in light of Tillich’s view of love. In addition, we reflect on how Love in connectedness may deepen our understanding of human spirituality, in relation to patient care.

Connectedness

The selected articles portray connectedness as a concept of great significance inherent in human spirituality. Burkhardt (1994) describes spirituality as a unifying force permeating all of life, a force expressed in one’s being, in one’s knowing, and in one’s doing, and manifested through one’s becoming and connecting. Register and Herman (2010) portray being spiritually connected as one major category of connectedness, whereas Pesut (2008) claims that connectedness is an important aspect of spirituality. Bellingham, Cohen, Jones, and Spaniol (1989) point out that connectedness and spiritual health are vitally and integrally related.

Connectedness is described by Register and Herman (2010) as an ultimate expression of human existence that comes from within and determines how people engage in the world. Furthermore, connectedness concerns the growth through and toward relationships, both inside and beyond oneself, and may be understood as the extent to which a human being experiences shared and meaningful relationship, and engage life in meaningful, positive, and purposeful ways (Bellingham et al., 1989; Burkhardt, 1994; Register & Scharer, 2010). Connectedness is also a central feature in the concept of self-transcendence, as found in human development or maturity based on enhanced awareness of the world around us, and an orientation toward broader perspectives about life. Teixera (2008) views the essence of self-transcendence as the capacity to connect with self, others, the universe, and beyond. Self-transcendence may foster peace, finding purpose and meaning in life, and a sense of being healed.

We found three basic forms of connectedness: connectedness with oneself, connectedness with others, and connectedness to something larger than oneself.

Connectedness with oneself

Connectedness is being at one with self (Younger, 1995). It is both a reflection and inner strength, and a sense of connection with oneself, which include the essence of one’s being, one’s knowing, and one’s doing (Burkhardt, 1994). On the concrete level, it might also apply to being connected biologically to ones’ physical body, and perception of health and well-being (Register & Herman, 2010). Being connected with oneself means living a life that fits with or is in congruence with one’s feelings and values (Bellingham et al., 1989). Losing connectedness with oneself may result in self-alienation, which is linked to cultural norms of “going it alone” that may lead to increased isolation. One example is from the American society: The more persons fulfill their commitment to individualism, competition, and independence, the more they become disconnected, bored, and lonely (Bellingham et al., 1989). We reflect on the importance of being in balance and in touch with one’s inner space as human beings, and if not, the self-alienation can be experienced as spiritual suffering.

Younger’s (1995) starting point is that suffering affects an individual’s sense of community and connectedness with others. Transcendence is considered the most powerful way in which human beings are restored to connectedness and wholeness after an injury. Suffering may bring closer a transpersonal source of meaning, which locates the human being in a far larger landscape (Younger, 1995). Our reflection is that suffering may be the result of losing connectedness with oneself; however, there are many forms of suffering. Other research support that suffering may trigger spiritual awakening or a search for the greater answers in life, which may lead to peacefulness (Råholm & Eriksson, 2001; Sivonen, 2000).

The reestablishing of connectedness may include solitude. Furthermore, Younger (1995) refers to Tillich, stating that estrangement is part of life and the step immediately preceding connectedness is solitude. Solitude is being alone but not lonely, sensing the eternal presence that includes everybody and everything from which we are separated. Just being with oneself gives opportunities of thoughtfulness, creativity, and rest. Sources of solitude can be nature, poetry, music, or pictures (Younger, 1995). Solitude can easily become loneliness if it obscures connectedness. However, solitude or disconnectedness does not equate loneliness, because loneliness implies a longing or anxious, painful yearning for someone or something (Bellingham et al., 1989). We reflect on that the process of finding meaning is somewhat a lonely journey, meaning that the person’s inner search requires “quiet moments” in solitude (Råholm & Eriksson, 2001). Solitude as a means for spiritual search should not be mistaken as loneliness.

Connectedness with others

Connectedness with others may include loved ones, particularly family, friends, or acquaintances, as well as the society or culture (Bellingham et al., 1989; Burkhardt, 1994; Predeger & Mumma, 2004; Register & Herman, 2010; Register & Scharer, 2010). Connectedness is a sense of membership and belonging in the human community, of recognizing unity between self and others, that is, a sense of being part of a group, a country, or even the world (Younger, 1995). Being connected with others necessitates creating a space that people can visit and a willingness to come out of that space to visit others (Bellingham et al., 1989).

Phillips-Salimi, Haase, and Kooken (2012) aimed to clarify the concept of connectedness in social relationships. Attributes of connectedness are caring, being affectionate toward others, experiencing warmth from others, and displaying concern for the well-being of others. Respect, feeling valued, and/or displaying value for others are also important attributes. Connectedness also implies reciprocity, mutual affection, and interest that people have in one another. Based on these attributes, connectedness is the degree to which a person perceives that he or she has a close, intimate, meaningful, and significant relationship with another person or group of people. This perception is characterized by positive expressions that are both received and reciprocated, either by the person or between people, through affective and consistent social interactions (Phillips-Salimi et al., 2012). Our reflection is that connectedness with others is expressed through caring acts of both receiving and giving, and such connectedness can contribute to confirm the individuals’ worth (Råholm & Eriksson, 2001).

Connectedness with something larger than oneself

Connectedness is being at one with timelessness and a sense of being in touch with the eternal, of being a part of something that is greater than oneself (Younger, 1995). It can be connectedness with the environment (Register & Herman, 2010; Teixera, 2008), the nature (Burkhardt, 1994; Pesut, 2008; Predeger & Mumma, 2004), or the universe (Teixera, 2008). It can also be connectedness with a larger meaning or purpose, that is, an Ultimate Other—God or Higher Power/Being (Bellingham et al., 1989; Burkhardt, 1994; Teixera, 2008) or with a power or divine being that does not need to be limited to God, or a universal consciousness (Pesut, 2008; Register & Herman, 2010). Being connected to something larger than oneself or one’s surroundings is perceived as a basic human need and necessitates having a profound purpose in life. Purpose can be equated to meaning, direction, mission, or duty; it is a person’s larger goal (Bellingham et al., 1989).

Bellingham et al. (1989) believe that emptiness and meaninglessness may result in anxiety. These authors refer to Tillich who relates anxiety to the loss of an ultimate concern, of a meaning, which gives meaning to all meanings. This anxiety is aroused by the loss of a spiritual center, and of answers to the question of the meaning of existence. Being connected to something larger requires being an active participant in the creative aspects of life. Losing connectedness with one’s guiding principles may bring feelings of pervasive dread or boredom (Bellingham et al., 1989). Thus, we reflect on that loosing connectedness with a larger meaning may result in spiritual suffering.

Love

During the hermeneutical interpretation of the articles, we found love as a key concept in caring for the patient. However, there are many forms of love and different understandings of this concept. In the English language, love is often misunderstood as sexual desire, whereas the classical Greek language distinguishes between the love that is Eros and that of Agape. Moreover, the word charity, which describes both the state of and the manifestation of love through caring for another, is often reduced in contemporary notions to organizational activities (Stickley & Freshwater, 2002). In this article, we focus on Eriksson’s notion of caritas, which means human love, compassion, and charity, manifested through caring for others (Lindström et al., 2010). Based on the emerging themes from the selected articles, we center our reflections on compassion and the risk of losing love in caring for the patient. In addition, we reflect on love and ethics based on the writings of Tillich.

Compassion

Love in the form of compassion for the suffering human being is an idea that has shaped caring for hundreds of years (Thorkildsen, Eriksson, & Råholm, 2013). Von Dietze and Orb (2000) claim that the English word compassion has been used since the 14th century, and is derived from the Latin com (together with) and pati (to suffer), literary to suffer with. They find that although compassion may contain or require emotion, it also holds the notion of deliberate altruistic participation in another person’s suffering. Hence, our reflection is that compassionate care is quite relevant in relation to connectedness with others.

Compassion embraces more than emotions, and concerns the ways we relate to other people and demands that we act (Von Dietze & Orb, 2000). The nature of compassion suggests that caregivers are able to provide attentiveness, listening, confronting, involvement, helping, presence, and understanding in relations with patients (van der Cingel, 2011). Von Dietze and Orb point out that empathy can put a distance between the nurse and the patient, whereas compassion implies that there is a deeper level of participation in the suffering of the other. Compassion deliberately seeks to avoid paternalistic care and is not to be misunderstood as pity (Von Dietze & Orb, 2000). Although both pity and compassion are used to refer to an emotion that indicates a feeling of being sorry, feeling sorry in pity victimizes a patient and evokes powerlessness (van der Cingel, 2011). Von Dietze and Orb (2000) states that compassionate care is not “simplistically about taking away another person’s pain or suffering, but is about entering into that person’s experience so as to share their burden in solidarity with them and hence enabling them to retain their independence and dignity” (p. 169). Compassion may represent an internalized motivation for doing good, which impels and empowers people to not only acknowledge but also act toward alleviating another human being’s suffering or pain (Schantz, 2007). Love is an ethical act, and compassion is a mutual experience given two or more people who act together for its realization (Thorkildsen et al., 2013). We assume that compassion is a prerequisite for experiencing connectedness with others, not only in caring relations but also in all meaningful relationships between human beings.

The risk of losing love

Several authors are concerned about how love seemingly has lean times in patient care. The articles point to how love or compassion in some contexts may sound threatening and unprofessional, and that to care with love has been considered subservient and of inferior value in caring for the patient, a weakness, or even a taboo subject (Arman & Rehnsfeldt, 2006; Stickley & Freshwater, 2002; Von Dietze & Orb, 2000; Wahlin, Wieslander, & Fridlund, 1995). Western-style health care systems are critiqued for limiting professional caring and loving possibilities, leaving caregivers who love in the practice of caring to go beyond the role definition of the duty of care (Fitzgerald & van Hooft, 2000). Consequently, the lack of love is causing the intuitive and natural part of life to get lost. Altruistically motivated caregivers are said to take responsibility and being supportive because they feel love, concern, and responsibility for the other person (Sand, Olsson, & Strang, 2010). However, the innocent altruism and desire to genuinely care for people in need are challenged by the attitudes of perhaps more cynical colleagues and governments requesting patient involvement without providing adequate resources. Love is discrete and modest, appreciated in the silence of a genuinely caring relationship. This means that rewards of loving are invisible, and nurses may even fear reprisals for demonstration of love (Stickley & Freshwater, 2002).

Straughair (2012) claims that today, in the profession of nursing, some of the ethos of the compassionate nursing character is seemingly lost in favor of technical skills based too heavily on evidence-based practice. The religious origin of compassion, since Nightingale formed her ideals for the professional nurse, has been challenged in contemporary health care. This is supported by evidence suggesting that nurses have a decreased affinity with the ethos of altruism and reports from patients who experience lack of compassionate nursing care. According to Straughair (2012), there are forces to reendorse the concept of compassion as a core and fundamental nursing value, and restore the image of the nurse who responds to patients with humanity and kindness through high-quality compassionate care.

Wahlin et al. (1995) observe that the primary cause for pain and distress is a lack of love, and that the path of coming to wholeness and healing is the ability to accept and give unconditional love. Where caregivers are genuinely concerned for the whole person, love is evident and the prospect for healing increases (Stickley & Freshwater, 2002). Arman and Rehnsfeldt (2006) argue that the offering of unselfish loving care to someone explicates the core of the character of human beings. The ability to care originates in man’s natural behavior and encompasses the appreciation of both the giving and the receiving of loving care. The mediating force of love has an ability to make connections, heal, and make whole (Arman & Rehnsfeldt, 2006). Love as fundamental for a being brings human beings in touch with themselves and enables binding to other people (Thorkildsen et al., 2013). Hence, our reflection is that love must be a fundament in connectedness with oneself as well as in connectedness with others. Furthermore, movement and change are crucial qualities of love, and love has the capacity to move beyond the limitations of an individual standpoint and surrender to a greater reality. The experience of love can therefore bring about a sense of moving toward greater harmony and unity (Kenny, 2011). Thus, it seems that love also is a fundament in connectedness with something greater than oneself.

Tillich’s view of love

It is highly relevant to be concerned about the lack of love in caring for the patients (Straughair, 2012). Arman and Rehnsfeldt (2006) think that caring risks losing love as an important ethical and ontological value, and find that it is necessary to search for love’s ontological basis. We have chosen to reflect on Tillich’s writings about love as an ontological concept. In our opinion, Tillich provides a meaning of love that is consistent with the understanding that love and connectedness are interrelated. In the book Love, Power, and Justice, Tillich (1954) elaborates on these three basic concepts and their interrelated relationships. His concern is that none of these concepts can be understood in a broad sense without an ontological analysis of their root meaning. This means that one must ask about how these concepts are rooted in the nature of being as such. Bringing the full potential of Tillich’s text is not possible in this article, and we base our reflections on the ontological or root meaning of the concept of love. Tillich reminds us that no human relations exist in a void; there are contextual structures behind all encounters. Perhaps what is most interesting in Tillich’s text is how he brings the ontological root meaning of the concepts together with the concepts of concrete and contextual meaning in personal encounters.

Tillich (1954) believes love is a driving force and a constitutive element of life, as being in actuality. This is the ontological nature of love. He states that love is “the drive towards the unity of the separated” (p. 39). Tillich argues that the central core in being is love as a driving force toward unity of that which originally have been units, but that have been separated. There is no question of uniting the strange, but a reunion of the estranged. Alienation presupposes original unity, and love’s greatest power is where it overcomes the separation that makes us independent individuals. Our reflection is that this can be understood from a perspective in which human beings are part of the infinite universe, and that all people are “one.” It can be viewed as an experience of unity with something universal that we all belong to, and this is consistent with connectedness with something greater than ourselves.

Love, according to Tillich (1954), is a constitutional element in life itself, and the individual is separated and at the same time carries the most powerful love. This is reminiscent of Watson (2003) who points out that our human existence is grounded in love for each other. Love overcomes the separation between people, although without separation, neither love nor life itself can exist (Tillich, 1954). This is, however, a necessary contrast whereby the individual is preserved as a self-centered self in person-to-person relationships, and at the same time, the reunion with others in love is actualized. Our reflection is that love reunites individual persons, and as such, love must be part of connectedness with others.

Tillich (1954) points out that love involves passion and emotion. Love as an emotion may ontologically be viewed as the expectation about reunion that takes place in every relation based on love. Although love involves more than just emotions, there is no love without the emotional element. He explains that the human movement against the other expresses itself in emotional ways. A prerequisite for love’s emotions is the separation of the self-centered self, which is seen in the human ability to relate oneself as an “I” to a “thou.” Thus, the human being can be preserved as both a subject and an object of love. At the same time, Tillich points out that people also have an innate propensity to continue to exist and enhance themselves, an intrinsic motivation toward a fulfillment of oneself through union with others. Thus, there is an element of passion and desire in man, in the sense of self-fulfillment of one’s own potential. Tillich claims that love as a desire can be understood from its ontological basis. He is opposed to desire only for pleasure, but points out that all living beings strive for fulfillment of their desires. This process in life is wrongly understood if it means that life essentially consists of fleeing from pain and striving for pleasure. However, desire, according to Tillich, is a normal drive toward vital self-fulfillment, and desire is a true quality in any love relation. Both the intimate and romantic love called eros and the love of family and friends called philia are united with the desire of love in the meaning of vital self-fulfillment (not pleasure). Furthermore, Tillich views self-love as a metaphor that in itself cannot bring meaning if love is the drive toward reunion of the separated. He finds that self-love could be replaced by three different and contradictory senses: in the sense of natural self-affirmation, in the sense of selfishness, and in the sense of self-acceptance, according to the given context. Our reflection according to this is that love also is a fundament in connectedness with oneself.

Tillich (1954) believes that the concept of love also has a strong ethical character, and states that it is love that shows what is just in the concrete situation. The relationship between justice and love in personal encounters is described by three functions for creative justice: listening, giving, and forgiveness. No human relationship is possible without mutual listening. The other calls on us and urges us to listen, and understanding the other’s intrinsic claims and justice of being can only be given through the love that listens. Listening love is the first step toward justice in person-to-person encounters. Giving as an expression of creative justice serves the purpose of reuniting love, and it belongs to the right of anyone we encounter to demand something from us, at least the minimum of acknowledging the other as a person. Forgiving is a paradoxical form in which justice is united with love. To forgive unjust actions is a fulfillment of justice because it is the only way to reunite those who are estranged by guilt. Without reconciliation, there can be no reunion (Tillich, 1954). We reflect on love’s ethical character as an important basis for compassionate patient care, and this we will elaborate further in the next section.

Reflections of Love in Connectedness

This article attempts to explore how Love in connectedness may deepen our understanding of human spirituality. In this section, we elaborate further on how love and connectedness may be interrelated and work together as a life-giving force (Råholm & Eriksson, 2001; Sivonen, 2000) in patient care. Spirituality is considered an inner strength and a potential health resource (Becker, 2009; Lindström et al., 2010), and we believe that Love in connectedness is a powerful resource inherent in human spirituality. In light of Tillich (1954), one can describe love as the moving power of life. In this article, we have tried to portray love as a vital part in spirituality and connectedness. Mok, Wong, and Wong (2010) found in their study about spirituality that receiving and giving love in relationships and connectedness are part of finding meaning in life. Thus, we suggest that love may be a force that can alleviate spiritual suffering caused by meaninglessness and emptiness, as described by Bellingham et al. (1989). According to Kenny (2011), there is a quality of spontaneity within love that creates the conditions for mind and body to become more integrated. Love as a life-giving force comprises movement and a restoring power (Råholm & Eriksson, 2001). It can seem that love is a vital force both in connectedness with others and in feeling like a whole human being.

Arman and Rehnsfeldt (2006) claim that if love is seen as the ontological basis for caring and ethical acts, then caregivers’ practices and expressions of love can enhance the patient’s understanding of life as well as give relief to their suffering. In this regard, Tillich’s reflections about the ontological meaning of love may provide insights into how love can be a creative force in caring for the patient. Love is viewed as the drive toward unity of the separated, and we find that this drive can be seen in both connectedness with others, and in connectedness with something larger than oneself. It might not straightforwardly apply to connectedness with oneself, although Tillich (1954) points out that love of oneself may be described by self-affirmation and self-acceptance.

Perhaps the most intriguing about Tillich’s (1954) point of view is the ethical function of love in personal encounters. Somehow, love is both a force in creating relations between the caregiver and the patient, and the ethical guide to caring actions through creative listening, giving, and forgiving. We believe love is present in caring relationships and concrete caring acts (Rykkje et al., 2011). The literature on love is, however, concerned about a lack of compassionate care for the patient. Von Dietze and Orb (2000) claim that compassion involves moral choices, and that it requires shared experiences and actions. We find this to be in line with the notion of connectedness with others, meaning that the caregiver may touch the patient through genuine concern and compassionate care. According to Schantz (2007), the power of compassion in promoting healing lies in the health personnel’s development of a relationship of confidence and trust with the patient. Our reflection is that love as a reuniting force (Tillich, 1954) should be present in all caring relationships.

The Relevance for Clinical Practice

We would like to highlight how the power of love can provide a confirmation of the individuals’ worth in clinical practice; however, love should include both giving and receiving. Family members supporting patients in palliative care reported about deepened relationships and increased awareness about life values (Sand et al., 2010). Acts of goodness and compassion may provide a sense of dignity, growth, and an inner feeling of joy or pleasure because one feels like a “better” human being (Arman & Rehnsfeldt, 2006). Spirituality may manifest itself and grow when the patients experience both receiving and giving love, as found in fulfillment of duties and in service to others or a God (Råholm & Eriksson, 2001). To maintain human dignity, one important duty in life is to be able to serve or to be there for another human being (Eriksson, 2001). Compassionate care is in the light of our own research, rooted in dignity in terms of being “valuable” meaning that the patient experience being of importance for others, and that others show that the patient does mean something for them. Thus, we suggest that Love in connectedness in caring for the patient is about relationships built on mutual love. This is part of the very foundation of loving care, that there is a reciprocity in the relationship between the patient and the caregiver (Rykkje et al., 2011). Staff must be involved so that love reunites by enabling the patient to both give and receive compassionate care. Hence, the caregiver must make room so that the patient can also give others loving care, and not just be a care recipient.

According to Eriksson (1997), professional caregivers should be able to recognize and meet the individual patient’s spiritual needs. Therefore, health professionals must have knowledge about spirituality and awareness for the spiritual dimension in life. Caring for the whole human being presupposes that we understand and confirm the patient’s spirituality (Lindström et al., 2010). To care for the patient’s spirit is important to maintain human dignity, and therefore, it may be viewed as an ethical obligation. We would like to portray spiritual care as to listening to the patient in caring relationships of true presence, and trying to understand the situation from the patients’ point of view. Compassionate care, just being there, and confirming the patients’ dignity (Råholm & Lindholm, 1999) may foster the patients’ spiritual development and enable them to feel whole as human beings (Lindström et al., 2010).

Closing Reflections

Tillich puts forward that love is unity, and as such, it is the moving power of life. We find that both connectedness and love are key concepts in caring for the patient. Connectedness is found to be central in spirituality, and the literature supports that love understood as compassion is relational and thus fundamental in connectedness. Bringing these concepts together in the category Love in connectedness has provided a deeper understanding of how love is a life-giving force in spirituality. We also view Love in connectedness as a resource in the patients’ becoming in health, and in the maintenance of human dignity.

Footnotes

Authors’ Note

The first author conducted the search for articles. All authors contributed to the study design, selection of articles, analysis, drafting, and critical revisions of the article.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research and/or authorship of this article.

Author Biographies

Linda Rykkje, RN, PhD, Associate professor with Stord/Haugesund University College, Department of Nursing. Her research interests include spiritual care, dignity, and well-being for older people, as well as practice development.

Katie Eriksson, RN, PhD, Professor emeritus in Caring Science, Honorary doctor in Public health in Gothenburg, and Honorary doctor in Nursing in University of Karlstad.

Maj-Britt Råholm, RN, PhD, Professor at Sogn og Fjordane University College, Faculty of Health Studies. Her research interests include dignity in nursing home sector, ethics, nursing leadership, nursing education, competence development, research in theory of science (the concept of abduction), hermeneutics

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