Nurse Education Today 38 (2016) 36–41
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Nurse education and willingness to provide spiritual care Li-Fen Wu a,⁎, Hui-Chen Tseng b, Yu-Chen Liao c a b c
Department of Nursing, National Taichung University of Science and Technology, Taichung, Taiwan College of Nursing, University of Iowa, USA Department of Nursing, Taichung Veterans General Hospital, Taichung, Taiwan
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Article history: Accepted 3 January 2016 Keywords: Spiritual care Nurse education Continuing education Willingness
s u m m a r y Background: Spiritual care is a critical part of holistic care, and nurses require adequate preparation to address the spiritual needs of patients. However, nurses' willingness to provide such care has rarely been reported. Hence, nurses' education, and knowledge of spiritual care, as well as their willingness to provide it require further study. Methods: A convenience sample of 200 nurses participated in the study. Quantitative data were collected using a 21-item Spiritual Care Needs Inventory (content validity index = .87; Cronbach's alpha = .96). Results: The majority of participants were female (96.5%, n = 193) between 21 and 59 years old (mean = 35.1 years). Moreover, the majority of participants had a Bachelor's degree (74.0%, n = 148) and 1–36 years of clinical experience (mean = 12.13 years). Regarding religious beliefs, 63 (31.5%) had no religious belief, and 93 (46.5%) did not engage in any religious activity. Overall, the nurses were willing to provide spiritual care, although only 25 (12.5%) felt that they had received adequate education. Conclusion: The findings of this study indicate the need for further educational preparation in spiritual care for nurses. Specifically, additional teaching materials are required that are more directly related to spiritual care. Greater emphasis should be placed on different subject areas in school-based education, continuing education, and self-learning education according to the needs of nurses. Since spiritual care education needs policy support, in-depth discussions should take place regarding the approach and cultural environment for providing spiritual care in future nursing courses. Moreover, further studies should investigate barriers in providing spiritual nursing care to patients and whether they are the results of a lack of relevant knowledge or other factors. © 2016 Elsevier Ltd. All rights reserved.
Introduction
Background
Spiritual care is a critical area of holistic care and is generally considered as a part of the quality of care. Nurses require adequate preparation to address the spiritual needs of their patients (Timmins et al., 2015). Clinical nurses must attend to their patients day and night, and are responsible for maintaining holistic health and integrity of their patients. Holistic health involves patients' physical, psychological, social, and spiritual needs that are adequately met. Despite the requirement for nurses to provide spiritual care (Attard et al., 2014), relatively few studies have investigated nurses' willingness to provide such care and whether they have sufficient educational preparation if they choose to do so. Therefore, this study investigated clinical nurses' willingness to provide spiritual care and to examine whether the source of spiritual care education could affect their willingness.
The International Council of Nurses Code of Ethics for Nurses recognises the spiritual aspect of nursing care as a required duty of all nurses (International Council of Nurses, 2012). In addition, Florence Nightingale—the founder of modern nursing—emphasised the need for nurses to honour the psychological and spiritual aspects of patients to promote their health (Macrae, 2001). Because nurses are with patients throughout their daily practice, they are naturally in a position to safeguard their patients' wholeness and integrity (Chan, 2010). Nursing is a practice-based discipline that focuses on people; thus, caring for patients on a daily basis implies that spiritual care cannot be separated from caring for the person as a whole (Tanyi, 2002). Therefore, nurses have an active role in meeting the spiritual needs of their patients. Literature Review
⁎ Corresponding author at: 1, Ta-yu East Street, Taichung, Taiwan. E-mail address: [email protected] (L.-F. Wu).
http://dx.doi.org/10.1016/j.nedt.2016.01.001 0260-6917/© 2016 Elsevier Ltd. All rights reserved.
Rieg et al. (2006) emphasised that all people are spiritual beings with spiritual needs. Selman et al. (2007) conducted a literature review and proposed a model of spirituality comprising the following six
L.-F. Wu et al. / Nurse Education Today 38 (2016) 36–41
aspects: relationships; religious or nonreligious beliefs, practices, and experiences (e.g., faith in God); spiritual resources (e.g., meaning, purpose); outlook on life and self (e.g., hope, self-worth); outlook on death and dying (e.g., fears, death anxiety); and indicators of spiritual well-being (e.g., peace, feeling in control). Narayanasamy (2001) proposed the following eight spiritual needs: meaning and purpose; love and harmonious relationships; forgiveness; a source of hope and strength; trust; expression of personal beliefs and values; spiritual practices; expression of the concept of God or a deity; and creativity. Various spiritual concerns involved in nursing depend on personal expression of individual nurses to ensure that their provided care can meet patients' needs (van Leeuwen et al., 2006). McSherry and Jamieson (2011) conducted a large online survey on 4054 members of the Royal College of Nursing in the United Kingdom and the study revealed that the most crucial spiritual care needs, ranked according to frequency, were: (1) the need for a source of hope and strength, (2) the need to express personal beliefs and values, (3) the need for spiritual practice and expressions of the concept of God or a deity, and (4) the need for meaning and purpose. Narayanasamy and Owens (2001) studied 115 nurses in the United Kingdom and found that the concept of spirituality and the role of nurses in providing spiritual care were confusing to nurses. Wu et al. (2012) studied 239 senior nursing students from 22 schools in Taiwan and noted that they were uncertain about the primary principles of spiritual care, such as listening, spending time with patients, respecting patient privacy and dignity, maintaining religious practices, and delivering care with kindness and concern. Timmins et al. (2015) explored the extent to which spirituality and spiritual care concepts were included in core textbooks in nursing education. They concluded that such texts must be strengthened through consistently applying and including spirituality and spiritual care in relevant instructional material. Wu and Lin (2011) found that adequate education could have a positive impact on how spirituality and spiritual care are perceived. Spiritual care is a fundamental component of high-quality compassionate health care. Moreover, such practices are most effective only when they are recognised and reflected in the attitudes and actions of both patients and health care providers (Puchalski et al., 2014). McSherry and Jamieson (2011) argued that spiritual care is an integral and fundamental aspect of nursing care. Holistic nursing emphasises that spiritual care should not be overlooked (Brennan, 2013). In addition, spiritual care is concerned with the personal caring qualities and attributes of nurses, such as demonstrating care, compassion, cheerfulness, and kindness when communicating and interacting with patients, as well as respecting their privacy and dignity, and supporting them with their cultural and religious beliefs. Previous studies have shown that spiritual care enables patients to appreciate their life, achieve inner peace, and explore coping strategies that can help them overcome crisis situations (Kociszewski, 2003; Lundberg and Kerdonfag, 2010). Spiritual care is delivered through demonstrating care and respect, which can assist patients in regaining a sense of meaning and purpose in life, restoring their faith or trust, and finding hope, love, and forgiveness (Grant, 2004). Deal and Grassley (2012) posited that spiritual care includes various aspects of psychosocial nursing care, such as listening, demonstrating kindness, and treating patients with respect. It can also include organising assistance for patients from spiritual advisors (e.g., chaplains) or sharing spiritual practices (e.g., reading religious texts). Regarding the outcomes of providing spiritual care, Lundberg and Kerdonfag (2010) identified the three benefits of spiritual care as preventing disease, enhancing rapid recovery, and fostering composure. Spiritual care can be a source of strength and comfort for patients, and can alleviate their spiritual distress (Carson, 2011; Deal and Grassley, 2012). Nurses were also aware of the importance of liaising and collaborating with other health care professionals to support patients' spiritual care needs. McSherry et al. (2004) and Baldacchino (2008) also stated that cultural factors should be considered when providing spiritual care. Therefore,
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nurses must possess fundamental cultural knowledge related to providing spiritual care.
Methods Design and Sample The present study adopted a cross-sectional survey design, using convenience sampling, to solicit responses from eligible full-time registered nurses employed at a hospital in Taiwan. The study was explained to all nurses at various nursing department meetings. All on-duty registered nurses who took care of adult patients were invited to participate in the study. Questionnaires were distributed to eligible nurses and they were instructed to fill in the questionnaires and returned to the research assistant at their leisure. Based on a sample size estimation to obtain an effect size of 0.95, a minimum of 134 participants would be required (G Power Version 3.1) (Faul et al., 2009).
Table 1 Basic characteristics of the study participants (N = 200). Variable Age (years) 20–29 30–39 40–49 50–59 Mean ± SD (range) Clinical experience (years) 1–10 11–20 21–30 31–36 Mean ± SD (range) Gender Male Female Education level Associate's degree Bachelor's degree Master's degree Religious belief None Have a religion Buddhist Taoist Protestant or Catholic Folk beliefs and others Attending religious activities None Yes Regular Occasional Have attended a spiritual care course in nursing school Yes No Attended a spiritual care course in continuing education Yes No Source of spiritual care education (N = 193) School education Continuing education Self-learning education School and continuing education School and self-learning education Continuing and self-learning education School, continuing and self-learning education Have received adequate education Yes No
n (%) 83 (41.5) 43 (21.5) 55 (27.5) 19 (9.5) 35.1 ± 9.6 (21–59) 117 (58.5) 31 (15.5) 42 (21.0) 10 (5.0) 12.13 ± 10.02 (1–36) 7 (3.5) 193 (96.5) 15 (7.5) 148 (74.0) 37 (18.5) 63 (31.5) 137 (68.5) 20 (10.0) 39 (19.5) 13 (6.5) 65 (32.5) 93 (46.5) 107 (53.5) 21 (10.5) 86 (43.0) 139 (69.5) 61 (30.5) 136 (68.0) 64 (32.0) 11 (5.7) 65 (33.7) 7 (3.6) 43 (22.3) 1 (0.5) 36 (18.7) 30 (15.5) 25 (12.5) 175 (87.5)
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L.-F. Wu et al. / Nurse Education Today 38 (2016) 36–41
Table 2 Willingness of the participants to provide spiritual care (N = 200). Factor
Caring and respecting
Meaning and hope
Item of spiritual care needs inventory
Willingness n (%)
Listening, accompanying, and providing reassurance Providing interaction Respect for privacy and dignity Respect for religious and cultural beliefs Showing concern Building friendship and interpersonal relationship Spending time to discuss and explore fears, anxieties, and troubles Bringing courage Guidance to find inner peace Guidance to find confidence Guidance to live in the moment Guidance in gaining a sense of hope in life Guidance to find a place of worship or a church Bringing a sense of well-being Guidance to discover the meaning and purpose in life Allowing spiritual communication Eliminating a sense of guilt Guidance to connect with nature Guidance to use art and creativity for self-expression Guidance to find meaning when facing troubles in life Guidance in being at peace with the world Overall, I am willing to provide spiritual care
Instruments and Data Collection The questionnaire used in this study was designed to ascertain the basic characteristics of the participants and their willingness to provide specific aspects of spiritual care. The latter was measured based on a 21-item Spiritual Care Needs Inventory (SCNI) that was previously developed in a study consisted of 1351 adult acute care patients recruited from a medical centre in Taiwan. In the study, the item-level content validity index (CVI) for the SCNI was found to range from 0.82 to 1.00 with an instrument-level CVI of 0.87 and a Cronbach's alpha of 0.96. In addition, two factors emerged from a principal component analysis and they were labelled as: (1) Caring and Respecting and (2) Meaning and Hope (Wu et al., 2015). In the present study, the response categories in the previous patient's version of the SCNI were changed from “needs” (need, neutral, do not need) to a nurse's version measuring “willingness” (willing, don't know how to provide, unwilling). A Cronbach's alpha of 0.92 was observed in this nurses' version of the SCNI. Results from a pilot study indicated that the entire questionnaire could be completed within 15 min.
Ethical Considerations Participation in the study was voluntary. All participants were informed about the study's purpose and procedures by the researchers, and each participant signed a written consent form before responding to the questionnaire. Participants were assured that all information would be treated in strict confidence. Ethical approval for this study was obtained from the institutional review board of the study hospital (SE13008#1). To maintain the confidentiality of the data, no personally
Willing
Don't know how to provide
Unwilling
200 (100.0) 200 (100.0) 200 (100.0) 199 (99.5) 198 (99.0) 190 (95.0) 189 (94.5) 178 (89.0) 178 (89.0) 171 (85.5) 171 (85.5) 170 (85.0) 172 (86.0) 165 (82.5) 161 (80.5) 154 (77.0) 148 (74.0) 145 (72.5) 146 (73.0) 151 (75.5) 137 (68.5) 200 (100.0)
0 0 0 1 (0.5) 2 (1.0) 10 (5.0) 11 (5.5) 22 (11.0) 21 (10.5) 29 (14.5) 29 (14.5) 30 (15.0) 22 (11.0) 35 (17.5) 39 (19.5) 46 (23.0) 52 (26.0) 54 (27.0) 52 (26.0) 59 (24.5) 62 (31.0) 0
0 0 0 0 0 0 0 0 1 (0.5) 0 0 0 6 (3.0) 0 0 0 0 1 (0.5) 2 (1.0) 0 1 (0.5) 0
identifiable information was recorded on the questionnaires. All questionnaires and consent forms were retained in a secure location for a period of at least three years after the completion of the study. Data Analysis Data were analysed using SPSS Version 19.0 for Windows (SPSS, Inc., Chicago, IL, USA). The participants' basic characteristics were explored using descriptive statistics. A record of the participants' willingness to provide care was assessed according to the frequency and percentage of providing such care. Chi-square analyses were used to determine the differences in each item for each basic characteristic of the participants. The level of significance was set at .05. Results Characteristics of the Participants Of the 200 nurse participants recruited in the study, the majority were women (96.5%) (Table 1) and the mean age was 35.1 years with a range of 21–59 years. Three-quarters of the participants had a Bachelor's degree and the mean clinical experience was 12.1 years with a range of 1–36 years. Regarding religious beliefs, 31.5% had no religious beliefs and 46.5% did not engage in any religious activities. In addition, 69.5% had previously attended a spiritual care course in nursing school and 68.0% had previously attended a spiritual care course in continuing education. Seven categories were used to define the source of the nurses' education regarding the question “How were you educated to provide spiritual care to patients?”. About a third (33.7%) of the participants learnt how to provide spiritual care solely through
Table 3-1 Comparison between the nurse participants who had taken or not taken a spiritual care course in nursing school and their willingness to allow spiritual communication. Allowing spiritual communication, n (%)
Attended spiritual care courses in nursing school Yes No Total
Willing
Don't know how
115 (73.7) 41 (26.3) 156 (100.0)
24 (54.5) 20 (45.5) 44 (100.0)
Total n (%)
139 (68.0) 61 (32.0) 200 (100.0)
Degree of freedom
χ2
p
1
4.71
.030
L.-F. Wu et al. / Nurse Education Today 38 (2016) 36–41
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Table 3-2 Comparison between nurse participants who had taken or not taken a spiritual care course in continuing education and their willingness to guide patients to find confidence. Guidance to find confidence, n (%)
Took spiritual care courses in continuing education Yes No Total
Willing
Don't know how
122 (71.3) 49 (28.7) 171 (100.0)
14 (48.3) 15 (51.7) 29 (100.0)
continuing education, followed by a combination of school and continuing education (22.3%) and self-learning (3.6%). Only 12.5% of the participants felt that they had received adequate education on how to provide appropriate spiritual care. Willingness to Provide Spiritual Care Table 2 shows the two major factors covering a total of 21 different items representing the nurses' willingness to provide spiritual care: 7 items were placed under “Caring and Respecting” and 14 items were placed under “Meaning and Hope.” There were no nurses unwilling to provide spiritual care described by the items under the factor “Caring and Respecting,” and only a few nurses reported their unwillingness to provide spiritual care described by the items under the factor “Meaning and Hope” (0.5–3.0% in 5 items). Overall, the nurses were generally willing to provide spiritual care. For the 7 items under the component “Caring and Respecting,” a range of 0 to 11 nurses (0–5.5%) indicated that they did not know how to provide the relevant spiritual care. For the 14 items under the factor “Meaning and Hope,” a range of 21 to 62 nurses (10.5–31.0%) indicated that they did not know how to provide the relevant spiritual care. Moreover, under “Caring and Respecting”, all participants were willing to provide “Listening, accompanying, and providing reassurance,” “Providing interaction,” and “Respect for privacy and dignity”. Differences Between Nurses' Basic Characteristics, Source of Spiritual Care Education, and Items Covered Under Willingness to Provide Spiritual Care This study also investigated whether the nurses' willingness to provide spiritual care differed according to their basic characteristics. No statistically significant differences were observed in the following characteristics: age, clinical experience, gender, educational level, personal religion (including various religions, and whether they had a religion or not), frequency of engaging in religious activities, previously had attended spiritual care courses in classes in nursing school or continuing education, or the perception of having received adequate education. Only the source of education could account for the differences in some items. Table 3-1 shows that nurses who had attended spiritual care courses in nursing school were more willing to allow spiritual communication. Table 3-2 shows that nurses who had taken spiritual
Total n (%)
Degree of freedom
χ2
p
1
5.23
.022
136 (68.0) 64 (32.0) 200 (100.0)
care courses as a part of their continuing education were more willing to guide their patients to find confidence. Table 3-3 shows that 33.9% of the nurses believed that continuing education prepared them for providing spiritual care by teaching them how to respect their patients' religious and cultural beliefs. Table 3-4 shows that the willingness of guiding patients to find inner peace was significantly different depending on the source of spiritual care education. Discussion Results from our study indicated that nurses who had received relevant education were generally willing to provide spiritual care for their patients. The nurses' responses to the 21 items in the SCNI differed slightly. Nurses were less knowledgeable about how to provide the relevant spiritual care for the items covered under the factor “Meaning and Hope” compared with those under the factor “Caring and Respecting.” To provide adequate spiritual care in practice, future studies should investigate the development of education courses focusing on the items covered under “Meaning and Hope”. The participants' willingness to provide certain types of spiritual care also varied. All the nurses were willing to provide spiritual care related to the factor “Caring and Respecting” (i.e., “Listening, accompanying, and providing reassurance”, “Providing interaction”, and “Respect for privacy and dignity”). Conversely, some nurses were hesitant in providing spiritual care related to several items under the factor “Meaning and Hope”. One possible reason for this observation is that while the items under “Caring and Respecting” are relatively easy to incorporate into the daily practice of nursing, the majority of items under “Meaning and Hope” were highly subjective and multidimensional (Burkhart and Solari-Twadell, 2001; Tanyi, 2002; McSherry and Ross, 2002). In addition, willingness to provide spiritual care did not differ significantly according to gender, educational level, clinical experience, or religious affiliations. However, the willingness to provide spiritual care did relate to the subjective opinion of whether the nurses had received training in providing spiritual care. Wong and Yau (2009) claimed that practicing nurses were frequently confused about the nature of spiritual care, and yet their understanding of spiritual care could influence how they delivered it. Findings of the present study indicated that the nurses felt that they had not received adequate training to provide spiritual care. Some nurses stated that spiritual care was not included in their
Table 3-3 Differences in education preparation and nurses' willingness to respect patients' religious and cultural beliefs. Respect for religious and cultural beliefs, n (%) Willing Source of spiritual care education School education Continuing education Self-learning education School and continuing education School and self-learning education Continuing and self-learning education School, continuing and self-learning education
11 (5.7) 65 (33.9) 6 (3.1) 43 (22.4) 1 (0.5) 36 (18.8) 30 (15.6) 192 (100.0)
Total n (%)
Degree of freedom
χ2
p
6
26.7
b.001
Don't know how
0 0 1 (100.0) 0 0 0 0 1 (100.0)
11 (5.7) 65 (33.9) 7 (3.6) 43 (22.3) 1 (0.5) 36 (18.7) 30 (15.5) 193 (100.0)
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Table 3-4 Differences in education preparation and nurses' willingness to guide patients to find inner peace. Guidance to find inner peace, n (%)
Source of spiritual care education School education Continuing education Self-learning education School and continuing education School and self-learning education Continuing and self-learning education School, continuing and self-learning education
Willing
Don't know how
Unwilling
10 (5.9) 55 (32.4) 6 (3.5) 37 (21.8) 1 (0.6) 34 (20.0) 27 (15.9) 170 (100.0)
1 (4.5) 10 (45.5) 0 6 (27.3) 0 2 (9.1) 3 (13.6) 22 (100.0)
0 0 1 (100.0) 0 0 0 0 1 (100.0)
job description. Possible reasons for neglecting the spiritual dimensions of nursing care included increased workload, lack of time, feelings of inadequacy in delivering spiritual care, insufficient resources, and lack of knowledge (O'Brein, 2007; Baldacchino, 2008; Chan, 2010; McSherry and Jamieson, 2011). Research-based findings consistently suggested that nurses' knowledge and skills related to spiritual care were insufficient because of poor role preparation. Hence, there is a need for providing more educational preparation for nurses regarding spiritual care. Providing spiritual care requires the cooperation between a multidisciplinary team of professionals, in which nurses liaise with patients and provide direct or indirect care through appropriate services or referral to relevant resources. McSherry and Jamieson (2011) indicated that nurses felt that they were not solely responsible for providing spiritual care, but nurses, chaplains, patients, family and friends, and other health care professionals should all be responsible for providing spiritual care. Nevertheless, other studies found that giving spiritual care could be associated with an emotional cost (Deal and Grassley, 2012). Since our study showed that some nurses remained hesitant in providing spiritual care in certain circumstances, it is important to encourage the adoption of a patientcentred approach to spiritual care education to ensure that all health resources functions are in cohesion. Nurses should collaborate with other health care professionals and spiritual advisors to support their patients' spiritual needs. The majority of nurses in the present study who had received continuing education were willing to provide spiritual care. This is in agreement with the findings of Baldacchino (2011), in which the nurses noted that continuing education was a valuable educational resource because it could update their knowledge on spiritual care and elevate their spiritual awareness and approach to providing care. Moreover, they acknowledged their role as change agents in implementing holistic care in collaboration with a multidisciplinary team.
Conclusions Nurses' willingness or commitment to providing spiritual care plays a critical role as the first step in assisting patients in obtaining harmony in body, mind, and spirit as a mean to achieve desirable patient outcomes and enhancing care quality. Findings of this study indicated the need for further educational preparation in spiritual care for nurses. Specifically, additional teaching materials focusing on spiritual care are required. Greater emphasis should be placed on different subject areas in school-based education, continuing education, and self-learning education according to the needs of nurses. Since spiritual care education needs policy support, in-depth discussions should take place regarding the approach and cultural environment for providing spiritual care in future nursing courses. Moreover, future studies should investigate barriers in providing spiritual nursing care to patients and whether these barriers are the results of a lack of relevant knowledge or other factors.
Total n (%)
Degree of freedom
χ2
p
6
26.7
b.001
11 (5.7) 65 (33.7) 7 (3.6) 43 (22.3) 1 (0.5) 36 (18.8) 30 (15.5) 193 (100.0)
Relevance to Clinical Practice Findings of this study provided information on the nurses' willingness to provide spiritual care and related care in Taiwan. Although the study was conducted within a local context, it can provide valuable information for international and cross-cultural comparisons. Understanding nurses' willingness facilitates improvement in the delivery of spiritual care to patients. Knowledge preparedness in delivering spiritual care was a major concern amongst the clinical nurses who participated in this study. This aspect of nursing care has not been adequately addressed in programmes offered at both nursing schools and continuing education. Hence, nursing schools and hospitals should proactively provide assistance to clinical nurses to facilitate delivering the most suitable nursing care to patients. Patient-centred care should involve integrating all health resources to ensure that patients can receive holistic care, which in turn would enhance the overall quality of nursing care. Future studies should investigate barriers for nurses to provide spiritual nursing care and evaluate nurses' knowledge on spiritual care prior to their delivery of such services.
Acknowledgement This study was partially supported by a grant from the National Science Council (NSC 101-2314-B-025-002) and Taichung Veterans General Hospital/National Taichung University of Science and Technology (TCVGH-NTUST1048501). The authors sincerely thank all participating nurses and Malcolm Koo for helping to refine this manuscript.
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Nurse Education Today journal homepage: www.elsevier.com/nedt
Nurse education and willingness to provide spiritual care Li-Fen Wu a,⁎, Hui-Chen Tseng b, Yu-Chen Liao c a b c
Department of Nursing, National Taichung University of Science and Technology, Taichung, Taiwan College of Nursing, University of Iowa, USA Department of Nursing, Taichung Veterans General Hospital, Taichung, Taiwan
a r t i c l e
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Article history: Accepted 3 January 2016 Keywords: Spiritual care Nurse education Continuing education Willingness
s u m m a r y Background: Spiritual care is a critical part of holistic care, and nurses require adequate preparation to address the spiritual needs of patients. However, nurses' willingness to provide such care has rarely been reported. Hence, nurses' education, and knowledge of spiritual care, as well as their willingness to provide it require further study. Methods: A convenience sample of 200 nurses participated in the study. Quantitative data were collected using a 21-item Spiritual Care Needs Inventory (content validity index = .87; Cronbach's alpha = .96). Results: The majority of participants were female (96.5%, n = 193) between 21 and 59 years old (mean = 35.1 years). Moreover, the majority of participants had a Bachelor's degree (74.0%, n = 148) and 1–36 years of clinical experience (mean = 12.13 years). Regarding religious beliefs, 63 (31.5%) had no religious belief, and 93 (46.5%) did not engage in any religious activity. Overall, the nurses were willing to provide spiritual care, although only 25 (12.5%) felt that they had received adequate education. Conclusion: The findings of this study indicate the need for further educational preparation in spiritual care for nurses. Specifically, additional teaching materials are required that are more directly related to spiritual care. Greater emphasis should be placed on different subject areas in school-based education, continuing education, and self-learning education according to the needs of nurses. Since spiritual care education needs policy support, in-depth discussions should take place regarding the approach and cultural environment for providing spiritual care in future nursing courses. Moreover, further studies should investigate barriers in providing spiritual nursing care to patients and whether they are the results of a lack of relevant knowledge or other factors. © 2016 Elsevier Ltd. All rights reserved.
Introduction
Background
Spiritual care is a critical area of holistic care and is generally considered as a part of the quality of care. Nurses require adequate preparation to address the spiritual needs of their patients (Timmins et al., 2015). Clinical nurses must attend to their patients day and night, and are responsible for maintaining holistic health and integrity of their patients. Holistic health involves patients' physical, psychological, social, and spiritual needs that are adequately met. Despite the requirement for nurses to provide spiritual care (Attard et al., 2014), relatively few studies have investigated nurses' willingness to provide such care and whether they have sufficient educational preparation if they choose to do so. Therefore, this study investigated clinical nurses' willingness to provide spiritual care and to examine whether the source of spiritual care education could affect their willingness.
The International Council of Nurses Code of Ethics for Nurses recognises the spiritual aspect of nursing care as a required duty of all nurses (International Council of Nurses, 2012). In addition, Florence Nightingale—the founder of modern nursing—emphasised the need for nurses to honour the psychological and spiritual aspects of patients to promote their health (Macrae, 2001). Because nurses are with patients throughout their daily practice, they are naturally in a position to safeguard their patients' wholeness and integrity (Chan, 2010). Nursing is a practice-based discipline that focuses on people; thus, caring for patients on a daily basis implies that spiritual care cannot be separated from caring for the person as a whole (Tanyi, 2002). Therefore, nurses have an active role in meeting the spiritual needs of their patients. Literature Review
⁎ Corresponding author at: 1, Ta-yu East Street, Taichung, Taiwan. E-mail address: [email protected] (L.-F. Wu).
http://dx.doi.org/10.1016/j.nedt.2016.01.001 0260-6917/© 2016 Elsevier Ltd. All rights reserved.
Rieg et al. (2006) emphasised that all people are spiritual beings with spiritual needs. Selman et al. (2007) conducted a literature review and proposed a model of spirituality comprising the following six
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aspects: relationships; religious or nonreligious beliefs, practices, and experiences (e.g., faith in God); spiritual resources (e.g., meaning, purpose); outlook on life and self (e.g., hope, self-worth); outlook on death and dying (e.g., fears, death anxiety); and indicators of spiritual well-being (e.g., peace, feeling in control). Narayanasamy (2001) proposed the following eight spiritual needs: meaning and purpose; love and harmonious relationships; forgiveness; a source of hope and strength; trust; expression of personal beliefs and values; spiritual practices; expression of the concept of God or a deity; and creativity. Various spiritual concerns involved in nursing depend on personal expression of individual nurses to ensure that their provided care can meet patients' needs (van Leeuwen et al., 2006). McSherry and Jamieson (2011) conducted a large online survey on 4054 members of the Royal College of Nursing in the United Kingdom and the study revealed that the most crucial spiritual care needs, ranked according to frequency, were: (1) the need for a source of hope and strength, (2) the need to express personal beliefs and values, (3) the need for spiritual practice and expressions of the concept of God or a deity, and (4) the need for meaning and purpose. Narayanasamy and Owens (2001) studied 115 nurses in the United Kingdom and found that the concept of spirituality and the role of nurses in providing spiritual care were confusing to nurses. Wu et al. (2012) studied 239 senior nursing students from 22 schools in Taiwan and noted that they were uncertain about the primary principles of spiritual care, such as listening, spending time with patients, respecting patient privacy and dignity, maintaining religious practices, and delivering care with kindness and concern. Timmins et al. (2015) explored the extent to which spirituality and spiritual care concepts were included in core textbooks in nursing education. They concluded that such texts must be strengthened through consistently applying and including spirituality and spiritual care in relevant instructional material. Wu and Lin (2011) found that adequate education could have a positive impact on how spirituality and spiritual care are perceived. Spiritual care is a fundamental component of high-quality compassionate health care. Moreover, such practices are most effective only when they are recognised and reflected in the attitudes and actions of both patients and health care providers (Puchalski et al., 2014). McSherry and Jamieson (2011) argued that spiritual care is an integral and fundamental aspect of nursing care. Holistic nursing emphasises that spiritual care should not be overlooked (Brennan, 2013). In addition, spiritual care is concerned with the personal caring qualities and attributes of nurses, such as demonstrating care, compassion, cheerfulness, and kindness when communicating and interacting with patients, as well as respecting their privacy and dignity, and supporting them with their cultural and religious beliefs. Previous studies have shown that spiritual care enables patients to appreciate their life, achieve inner peace, and explore coping strategies that can help them overcome crisis situations (Kociszewski, 2003; Lundberg and Kerdonfag, 2010). Spiritual care is delivered through demonstrating care and respect, which can assist patients in regaining a sense of meaning and purpose in life, restoring their faith or trust, and finding hope, love, and forgiveness (Grant, 2004). Deal and Grassley (2012) posited that spiritual care includes various aspects of psychosocial nursing care, such as listening, demonstrating kindness, and treating patients with respect. It can also include organising assistance for patients from spiritual advisors (e.g., chaplains) or sharing spiritual practices (e.g., reading religious texts). Regarding the outcomes of providing spiritual care, Lundberg and Kerdonfag (2010) identified the three benefits of spiritual care as preventing disease, enhancing rapid recovery, and fostering composure. Spiritual care can be a source of strength and comfort for patients, and can alleviate their spiritual distress (Carson, 2011; Deal and Grassley, 2012). Nurses were also aware of the importance of liaising and collaborating with other health care professionals to support patients' spiritual care needs. McSherry et al. (2004) and Baldacchino (2008) also stated that cultural factors should be considered when providing spiritual care. Therefore,
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nurses must possess fundamental cultural knowledge related to providing spiritual care.
Methods Design and Sample The present study adopted a cross-sectional survey design, using convenience sampling, to solicit responses from eligible full-time registered nurses employed at a hospital in Taiwan. The study was explained to all nurses at various nursing department meetings. All on-duty registered nurses who took care of adult patients were invited to participate in the study. Questionnaires were distributed to eligible nurses and they were instructed to fill in the questionnaires and returned to the research assistant at their leisure. Based on a sample size estimation to obtain an effect size of 0.95, a minimum of 134 participants would be required (G Power Version 3.1) (Faul et al., 2009).
Table 1 Basic characteristics of the study participants (N = 200). Variable Age (years) 20–29 30–39 40–49 50–59 Mean ± SD (range) Clinical experience (years) 1–10 11–20 21–30 31–36 Mean ± SD (range) Gender Male Female Education level Associate's degree Bachelor's degree Master's degree Religious belief None Have a religion Buddhist Taoist Protestant or Catholic Folk beliefs and others Attending religious activities None Yes Regular Occasional Have attended a spiritual care course in nursing school Yes No Attended a spiritual care course in continuing education Yes No Source of spiritual care education (N = 193) School education Continuing education Self-learning education School and continuing education School and self-learning education Continuing and self-learning education School, continuing and self-learning education Have received adequate education Yes No
n (%) 83 (41.5) 43 (21.5) 55 (27.5) 19 (9.5) 35.1 ± 9.6 (21–59) 117 (58.5) 31 (15.5) 42 (21.0) 10 (5.0) 12.13 ± 10.02 (1–36) 7 (3.5) 193 (96.5) 15 (7.5) 148 (74.0) 37 (18.5) 63 (31.5) 137 (68.5) 20 (10.0) 39 (19.5) 13 (6.5) 65 (32.5) 93 (46.5) 107 (53.5) 21 (10.5) 86 (43.0) 139 (69.5) 61 (30.5) 136 (68.0) 64 (32.0) 11 (5.7) 65 (33.7) 7 (3.6) 43 (22.3) 1 (0.5) 36 (18.7) 30 (15.5) 25 (12.5) 175 (87.5)
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Table 2 Willingness of the participants to provide spiritual care (N = 200). Factor
Caring and respecting
Meaning and hope
Item of spiritual care needs inventory
Willingness n (%)
Listening, accompanying, and providing reassurance Providing interaction Respect for privacy and dignity Respect for religious and cultural beliefs Showing concern Building friendship and interpersonal relationship Spending time to discuss and explore fears, anxieties, and troubles Bringing courage Guidance to find inner peace Guidance to find confidence Guidance to live in the moment Guidance in gaining a sense of hope in life Guidance to find a place of worship or a church Bringing a sense of well-being Guidance to discover the meaning and purpose in life Allowing spiritual communication Eliminating a sense of guilt Guidance to connect with nature Guidance to use art and creativity for self-expression Guidance to find meaning when facing troubles in life Guidance in being at peace with the world Overall, I am willing to provide spiritual care
Instruments and Data Collection The questionnaire used in this study was designed to ascertain the basic characteristics of the participants and their willingness to provide specific aspects of spiritual care. The latter was measured based on a 21-item Spiritual Care Needs Inventory (SCNI) that was previously developed in a study consisted of 1351 adult acute care patients recruited from a medical centre in Taiwan. In the study, the item-level content validity index (CVI) for the SCNI was found to range from 0.82 to 1.00 with an instrument-level CVI of 0.87 and a Cronbach's alpha of 0.96. In addition, two factors emerged from a principal component analysis and they were labelled as: (1) Caring and Respecting and (2) Meaning and Hope (Wu et al., 2015). In the present study, the response categories in the previous patient's version of the SCNI were changed from “needs” (need, neutral, do not need) to a nurse's version measuring “willingness” (willing, don't know how to provide, unwilling). A Cronbach's alpha of 0.92 was observed in this nurses' version of the SCNI. Results from a pilot study indicated that the entire questionnaire could be completed within 15 min.
Ethical Considerations Participation in the study was voluntary. All participants were informed about the study's purpose and procedures by the researchers, and each participant signed a written consent form before responding to the questionnaire. Participants were assured that all information would be treated in strict confidence. Ethical approval for this study was obtained from the institutional review board of the study hospital (SE13008#1). To maintain the confidentiality of the data, no personally
Willing
Don't know how to provide
Unwilling
200 (100.0) 200 (100.0) 200 (100.0) 199 (99.5) 198 (99.0) 190 (95.0) 189 (94.5) 178 (89.0) 178 (89.0) 171 (85.5) 171 (85.5) 170 (85.0) 172 (86.0) 165 (82.5) 161 (80.5) 154 (77.0) 148 (74.0) 145 (72.5) 146 (73.0) 151 (75.5) 137 (68.5) 200 (100.0)
0 0 0 1 (0.5) 2 (1.0) 10 (5.0) 11 (5.5) 22 (11.0) 21 (10.5) 29 (14.5) 29 (14.5) 30 (15.0) 22 (11.0) 35 (17.5) 39 (19.5) 46 (23.0) 52 (26.0) 54 (27.0) 52 (26.0) 59 (24.5) 62 (31.0) 0
0 0 0 0 0 0 0 0 1 (0.5) 0 0 0 6 (3.0) 0 0 0 0 1 (0.5) 2 (1.0) 0 1 (0.5) 0
identifiable information was recorded on the questionnaires. All questionnaires and consent forms were retained in a secure location for a period of at least three years after the completion of the study. Data Analysis Data were analysed using SPSS Version 19.0 for Windows (SPSS, Inc., Chicago, IL, USA). The participants' basic characteristics were explored using descriptive statistics. A record of the participants' willingness to provide care was assessed according to the frequency and percentage of providing such care. Chi-square analyses were used to determine the differences in each item for each basic characteristic of the participants. The level of significance was set at .05. Results Characteristics of the Participants Of the 200 nurse participants recruited in the study, the majority were women (96.5%) (Table 1) and the mean age was 35.1 years with a range of 21–59 years. Three-quarters of the participants had a Bachelor's degree and the mean clinical experience was 12.1 years with a range of 1–36 years. Regarding religious beliefs, 31.5% had no religious beliefs and 46.5% did not engage in any religious activities. In addition, 69.5% had previously attended a spiritual care course in nursing school and 68.0% had previously attended a spiritual care course in continuing education. Seven categories were used to define the source of the nurses' education regarding the question “How were you educated to provide spiritual care to patients?”. About a third (33.7%) of the participants learnt how to provide spiritual care solely through
Table 3-1 Comparison between the nurse participants who had taken or not taken a spiritual care course in nursing school and their willingness to allow spiritual communication. Allowing spiritual communication, n (%)
Attended spiritual care courses in nursing school Yes No Total
Willing
Don't know how
115 (73.7) 41 (26.3) 156 (100.0)
24 (54.5) 20 (45.5) 44 (100.0)
Total n (%)
139 (68.0) 61 (32.0) 200 (100.0)
Degree of freedom
χ2
p
1
4.71
.030
L.-F. Wu et al. / Nurse Education Today 38 (2016) 36–41
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Table 3-2 Comparison between nurse participants who had taken or not taken a spiritual care course in continuing education and their willingness to guide patients to find confidence. Guidance to find confidence, n (%)
Took spiritual care courses in continuing education Yes No Total
Willing
Don't know how
122 (71.3) 49 (28.7) 171 (100.0)
14 (48.3) 15 (51.7) 29 (100.0)
continuing education, followed by a combination of school and continuing education (22.3%) and self-learning (3.6%). Only 12.5% of the participants felt that they had received adequate education on how to provide appropriate spiritual care. Willingness to Provide Spiritual Care Table 2 shows the two major factors covering a total of 21 different items representing the nurses' willingness to provide spiritual care: 7 items were placed under “Caring and Respecting” and 14 items were placed under “Meaning and Hope.” There were no nurses unwilling to provide spiritual care described by the items under the factor “Caring and Respecting,” and only a few nurses reported their unwillingness to provide spiritual care described by the items under the factor “Meaning and Hope” (0.5–3.0% in 5 items). Overall, the nurses were generally willing to provide spiritual care. For the 7 items under the component “Caring and Respecting,” a range of 0 to 11 nurses (0–5.5%) indicated that they did not know how to provide the relevant spiritual care. For the 14 items under the factor “Meaning and Hope,” a range of 21 to 62 nurses (10.5–31.0%) indicated that they did not know how to provide the relevant spiritual care. Moreover, under “Caring and Respecting”, all participants were willing to provide “Listening, accompanying, and providing reassurance,” “Providing interaction,” and “Respect for privacy and dignity”. Differences Between Nurses' Basic Characteristics, Source of Spiritual Care Education, and Items Covered Under Willingness to Provide Spiritual Care This study also investigated whether the nurses' willingness to provide spiritual care differed according to their basic characteristics. No statistically significant differences were observed in the following characteristics: age, clinical experience, gender, educational level, personal religion (including various religions, and whether they had a religion or not), frequency of engaging in religious activities, previously had attended spiritual care courses in classes in nursing school or continuing education, or the perception of having received adequate education. Only the source of education could account for the differences in some items. Table 3-1 shows that nurses who had attended spiritual care courses in nursing school were more willing to allow spiritual communication. Table 3-2 shows that nurses who had taken spiritual
Total n (%)
Degree of freedom
χ2
p
1
5.23
.022
136 (68.0) 64 (32.0) 200 (100.0)
care courses as a part of their continuing education were more willing to guide their patients to find confidence. Table 3-3 shows that 33.9% of the nurses believed that continuing education prepared them for providing spiritual care by teaching them how to respect their patients' religious and cultural beliefs. Table 3-4 shows that the willingness of guiding patients to find inner peace was significantly different depending on the source of spiritual care education. Discussion Results from our study indicated that nurses who had received relevant education were generally willing to provide spiritual care for their patients. The nurses' responses to the 21 items in the SCNI differed slightly. Nurses were less knowledgeable about how to provide the relevant spiritual care for the items covered under the factor “Meaning and Hope” compared with those under the factor “Caring and Respecting.” To provide adequate spiritual care in practice, future studies should investigate the development of education courses focusing on the items covered under “Meaning and Hope”. The participants' willingness to provide certain types of spiritual care also varied. All the nurses were willing to provide spiritual care related to the factor “Caring and Respecting” (i.e., “Listening, accompanying, and providing reassurance”, “Providing interaction”, and “Respect for privacy and dignity”). Conversely, some nurses were hesitant in providing spiritual care related to several items under the factor “Meaning and Hope”. One possible reason for this observation is that while the items under “Caring and Respecting” are relatively easy to incorporate into the daily practice of nursing, the majority of items under “Meaning and Hope” were highly subjective and multidimensional (Burkhart and Solari-Twadell, 2001; Tanyi, 2002; McSherry and Ross, 2002). In addition, willingness to provide spiritual care did not differ significantly according to gender, educational level, clinical experience, or religious affiliations. However, the willingness to provide spiritual care did relate to the subjective opinion of whether the nurses had received training in providing spiritual care. Wong and Yau (2009) claimed that practicing nurses were frequently confused about the nature of spiritual care, and yet their understanding of spiritual care could influence how they delivered it. Findings of the present study indicated that the nurses felt that they had not received adequate training to provide spiritual care. Some nurses stated that spiritual care was not included in their
Table 3-3 Differences in education preparation and nurses' willingness to respect patients' religious and cultural beliefs. Respect for religious and cultural beliefs, n (%) Willing Source of spiritual care education School education Continuing education Self-learning education School and continuing education School and self-learning education Continuing and self-learning education School, continuing and self-learning education
11 (5.7) 65 (33.9) 6 (3.1) 43 (22.4) 1 (0.5) 36 (18.8) 30 (15.6) 192 (100.0)
Total n (%)
Degree of freedom
χ2
p
6
26.7
b.001
Don't know how
0 0 1 (100.0) 0 0 0 0 1 (100.0)
11 (5.7) 65 (33.9) 7 (3.6) 43 (22.3) 1 (0.5) 36 (18.7) 30 (15.5) 193 (100.0)
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Table 3-4 Differences in education preparation and nurses' willingness to guide patients to find inner peace. Guidance to find inner peace, n (%)
Source of spiritual care education School education Continuing education Self-learning education School and continuing education School and self-learning education Continuing and self-learning education School, continuing and self-learning education
Willing
Don't know how
Unwilling
10 (5.9) 55 (32.4) 6 (3.5) 37 (21.8) 1 (0.6) 34 (20.0) 27 (15.9) 170 (100.0)
1 (4.5) 10 (45.5) 0 6 (27.3) 0 2 (9.1) 3 (13.6) 22 (100.0)
0 0 1 (100.0) 0 0 0 0 1 (100.0)
job description. Possible reasons for neglecting the spiritual dimensions of nursing care included increased workload, lack of time, feelings of inadequacy in delivering spiritual care, insufficient resources, and lack of knowledge (O'Brein, 2007; Baldacchino, 2008; Chan, 2010; McSherry and Jamieson, 2011). Research-based findings consistently suggested that nurses' knowledge and skills related to spiritual care were insufficient because of poor role preparation. Hence, there is a need for providing more educational preparation for nurses regarding spiritual care. Providing spiritual care requires the cooperation between a multidisciplinary team of professionals, in which nurses liaise with patients and provide direct or indirect care through appropriate services or referral to relevant resources. McSherry and Jamieson (2011) indicated that nurses felt that they were not solely responsible for providing spiritual care, but nurses, chaplains, patients, family and friends, and other health care professionals should all be responsible for providing spiritual care. Nevertheless, other studies found that giving spiritual care could be associated with an emotional cost (Deal and Grassley, 2012). Since our study showed that some nurses remained hesitant in providing spiritual care in certain circumstances, it is important to encourage the adoption of a patientcentred approach to spiritual care education to ensure that all health resources functions are in cohesion. Nurses should collaborate with other health care professionals and spiritual advisors to support their patients' spiritual needs. The majority of nurses in the present study who had received continuing education were willing to provide spiritual care. This is in agreement with the findings of Baldacchino (2011), in which the nurses noted that continuing education was a valuable educational resource because it could update their knowledge on spiritual care and elevate their spiritual awareness and approach to providing care. Moreover, they acknowledged their role as change agents in implementing holistic care in collaboration with a multidisciplinary team.
Conclusions Nurses' willingness or commitment to providing spiritual care plays a critical role as the first step in assisting patients in obtaining harmony in body, mind, and spirit as a mean to achieve desirable patient outcomes and enhancing care quality. Findings of this study indicated the need for further educational preparation in spiritual care for nurses. Specifically, additional teaching materials focusing on spiritual care are required. Greater emphasis should be placed on different subject areas in school-based education, continuing education, and self-learning education according to the needs of nurses. Since spiritual care education needs policy support, in-depth discussions should take place regarding the approach and cultural environment for providing spiritual care in future nursing courses. Moreover, future studies should investigate barriers in providing spiritual nursing care to patients and whether these barriers are the results of a lack of relevant knowledge or other factors.
Total n (%)
Degree of freedom
χ2
p
6
26.7
b.001
11 (5.7) 65 (33.7) 7 (3.6) 43 (22.3) 1 (0.5) 36 (18.8) 30 (15.5) 193 (100.0)
Relevance to Clinical Practice Findings of this study provided information on the nurses' willingness to provide spiritual care and related care in Taiwan. Although the study was conducted within a local context, it can provide valuable information for international and cross-cultural comparisons. Understanding nurses' willingness facilitates improvement in the delivery of spiritual care to patients. Knowledge preparedness in delivering spiritual care was a major concern amongst the clinical nurses who participated in this study. This aspect of nursing care has not been adequately addressed in programmes offered at both nursing schools and continuing education. Hence, nursing schools and hospitals should proactively provide assistance to clinical nurses to facilitate delivering the most suitable nursing care to patients. Patient-centred care should involve integrating all health resources to ensure that patients can receive holistic care, which in turn would enhance the overall quality of nursing care. Future studies should investigate barriers for nurses to provide spiritual nursing care and evaluate nurses' knowledge on spiritual care prior to their delivery of such services.
Acknowledgement This study was partially supported by a grant from the National Science Council (NSC 101-2314-B-025-002) and Taichung Veterans General Hospital/National Taichung University of Science and Technology (TCVGH-NTUST1048501). The authors sincerely thank all participating nurses and Malcolm Koo for helping to refine this manuscript.
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