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The efficacy of integrating spirituality into undergraduate nursing curricula Meryem Yilmaz and Hesna Gurler Nurs Ethics published online 18 March 2014 DOI: 10.1177/0969733014521096 The online version of this article can be found at: http://nej.sagepub.com/content/early/2014/03/18/0969733014521096
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Article
The efficacy of integrating spirituality into undergraduate nursing curricula
Nursing Ethics 1–17 ª The Author(s) 2014 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733014521096 nej.sagepub.com
Meryem Yilmaz and Hesna Gurler Cumhuriyet University, Turkey
Abstract Background: Attention to patients’ spirituality, as a moral obligation of care, is now widely accepted in nursing practice. However, until recently, many nursing programs have paid little attention to spirituality. Objective: The objective of this study was to identify the impact of two different curricula, used to teach undergraduate nursing students, on increasing nursing student awareness of spirituality in the care of patients. Research design: A quasi-experimental post-intervention two-group design was conducted in 2009– 2010 and 2010–2011 academic years. Participants and research context: The study included a total of 130 volunteer senior-year students. The students were assigned as ‘‘the intervention group/integrated system’’ that were informed about spirituality or as ‘‘the control group/traditional system’’ that received no information on spirituality. Data were collected via a personal information form and the Spirituality and Spiritual Care Rating Scale was used to assess responses. The study was conducted at the Department of Nursing of the Faculty of Health Sciences, Cumhuriyet University, in Central Anatolia/Turkey. Ethical considerations: Permission to conduct the study at the nursing school was obtained from the schools’ management teams. The rights of the participants were protected in this study by obtaining informed consent. Findings: The results revealed that the intervention group had a higher mean score on the Spirituality and Spiritual Care Rating Scale than did the control group. The students in the intervention group defined the terms of spirituality and spiritual care more accurately than did the control group students. Discussion: Nurses are professionally and ethically responsible for providing spiritual care. Nurses’ competence in meeting the spiritual needs of their patients should be improved by undergraduate education on spiritual care. Nursing scholars reported a significant difference in the knowledge and attitudes toward spirituality of nursing students as a result of the integration of spirituality into the undergraduate nursing curriculum. Conclusion: Spirituality should be more widely included in nursing education. Keywords Nursing education, spiritual care, spirituality, teaching spirituality
Corresponding author: Meryem Yilmaz, Department of Nursing, Faculty of Health Sciences, Cumhuriyet University, 58140 Sivas, Turkey. Email: [email protected]
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Introduction Although the nursing profession has its roots in spirituality,1 the spiritual dimension of holistic nursing is an area that has been neglected during both nursing education2 and the practice of nursing.3 In the 19th century, Florence Nightingale taught that spiritual education and development were important in the training of nurses.4 In addition, the World Health Organization (WHO) reported in 1998 that a spiritual dimension should be added to the physical, mental, and social dimensions of health; they modified the definition of health as follows: ‘‘Health is a dynamic state of complete physical, mental, spiritual, and social wellbeing and not merely the absence of disease or infirmity.’’5 The International Council of the Nurses’ Code of Ethics for Nurses6 recognizes that the need for nursing care is universal and states that professional nurses are responsible for promoting an environment in which the human rights, values, customs, and spiritual beliefs of the individual, family, and community are respected.6 Contemporary nursing theory supports holistic nursing care that includes attention to the spiritual dimension,7 and the nursing literature reports on the need to educate nursing students with regard to spiritual care; the assessment of the impact of such education is widely recognized.2,8–11 However, until recently, many nursing programs’ spirituality has received far less attention.12 Meyer13 reported that less than 6% of nursing curricula included topics on spirituality. In countries such as the United Kingdom and the United States, accreditation for nursing programs includes assessment and care of the spiritual dimension.13 Studies have been carried out to measure the outcomes of such teaching programs.4,9,14,15 However, there is evidence that suggests that there is no consensus on a universally recognized training program that includes the spiritual domain as part of the nursing curriculum.15,16 There continues to be debate in the literature regarding spiritual care in nursing education, on the teaching content as well as the methods11,17–19 and organization of curricula.15,20 There has been limited research examining the format of how this education should be carried out.11
Background Nurses are professionally and ethically responsible for providing spiritual care.21 Spirituality in patient care is acknowledged in the ethical codes guiding standards of practice, conduct, and behavior.22 Attention to patients’ spirituality as a moral obligation of care is now widely accepted as part of nursing.23 However, the ethical obligation of nurses for providing sufficient knowledge as well as discussion of attitudes and awareness related to the concept of spirituality, during undergraduate education, has been neglected and requires greater recognition. Pesut23 stated that ‘‘ethical universalism consists of principles such as those contained in professional codes of ethics or those embraced by particular spiritual traditions.’’ Spirituality began to appear in the late 1970s. However, little attention has been given to the spiritual development of nurses and nursing students. According to the results of studies by scholars in nursing, integrating the concept of spirituality into the undergraduate nursing curriculum increases the knowledge, attitudes, and awareness associated with spirituality of nursing students.8–11,24 However, spirituality has not kept pace and has not consistently been integrated into the undergraduate nursing curricula. In a study reported by Lemmer,15 nursing teaching plans were investigated; spiritual education was found to be lacking in the majority of universities surveyed. A few nursing faculties could define their approach to spirituality and had enough knowledge to teach nursing students about spiritual knowledge and interventions. Pesut24 emphasized that the training of spiritual care is more complex than physical care; this is due to the broad, abstract, value-laden, and multidimensional construct of spirituality. Therefore, it is not easy for nursing students to understand; it is difficult to teach nursing students about the spiritual needs of patients.25 Pesut24 reported that barriers to integrating spiritual care into the curriculum might include the complexity of defining the concept of spirituality within a multicultural society with secular values and materialism. In addition, many nursing programs have resource limitations and lack models to follow, prepared faculty, and 2
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accountability with regard to this topic. Hence, it is necessary to find the appropriate way to teach them so that they can understand the concept of spirituality, including its definition as well as learning how to incorporate this into patient care.17,24 There has been some effort to incorporate the concept of spirituality into nursing curricula by nursing scholars.11,18 Some investigators have recommended that students learn spiritual care through models, such as case studies; exemplary care plans;17 art gallery visits;19 role-playing activities; brainstorming, participatory, and student-centered methods;26 writing in journals and sharing the journal entries in the classroom;27 nursing process,28 and multiple teaching methods have been suggested.11 Narayanasamy17 developed the Actioning Spirituality and Spiritual Care Education and Training (ASSET) model in 1999, a problem-based approach. The ASSET model incorporates the triad of structural content, the learning process, and educational outcomes. The American Nurses Association (ANA) professional standards committee has suggested that holistic care be included in the nursing curricula.25 In Turkey, the 4-year nursing education program is based on a holistic nursing model: ‘‘The human is a whole that has bio-psychosocial dimensions.’’ The patient’s physical, social, and psychological dimensions are emphasized during the education of nursing students using this perspective. But the spiritual dimension has commonly been neglected in the nursing curricula of programs in Turkey. Spirituality is a concept that only recently started to be discussed in the fields of alternative medicine and nursing, in Turkey. Although the concept has been taught for a few years, in Turkey, as a separate course at some schools, changes in the field with regard to the application of these concepts have been insufficient. Recently, research in the area of spiritual care has increased, but a very limited number of studies have been published about issues related to spirituality and spiritual care, in the field of nursing, in Turkey.29–33 The Republic of Turkey is a secular country; there are many ethnic groups with a variety of rituals and practices as well as many different beliefs. However, the individuals in this society all share Islam as a common religion. In Turkey, spirituality and religion are certainly an important aspect of life for many; the word spirituality is associated with religion for the majority of the population. In Islamic communities, this is due to cultural beliefs and practices, religious and personal values, and religious dimensions of spirituality such as prayer and belief in God/Allah, or a higher power. There is no scientific study, conducted in Turkey, on this subject in the general population. However, the word spirituality was associated with religion, in our study on nurses31 and our observations. No prior study has been performed to determine the level of knowledge and practice of nursing students regarding spirituality and spiritual care, and the impact of systematically adding spirituality into the nursing curriculum in Turkey. This article describes the integration of spirituality into a baccalaureate nursing program, using Gordon’s Functional Health Patterns (FHPs). The FHP is a model devised by Marjory Gordon. There are 11 pattern areas: health perception–health management, nutrition–metabolic, elimination, activity–exercise, sleep–rest, cognitive–perceptual, selfperception–self-concept, role–relationship, sexuality–reproductive, coping–stress tolerance, and value– belief. Each pattern is an expression of bio-psychosocial integration, thus no one pattern can be understood without knowledge of the other patterns. The FHPs are influenced by biological, developmental, cultural, social, and spiritual factors. The FHPs provide an easily learned framework of assessment and critical thinking for the development of clinical judgment. In Gordon’s34 framework, spirituality is found within the pattern of values and beliefs. It describes patterns of values, goals, and beliefs (including spiritual beliefs) that guide choices and decisions.
The integrated curriculum The management at faculty redesigned the 4-year undergraduate curriculum. After reviewing other curricula from both national and international nursing schools, an integrated curriculum program was established, and the FHPs were chosen to guide the process. The concept of spirituality was incorporated as a 3
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separate subject into the curriculum. In this program, brainstorming, small group discussions, patient casestudy analysis, and students’ observations on the subject were used as interactive methods. The students played a more active role.
The traditional curriculum The concept of spirituality was not incorporated as a separate subject into the curriculum. The message that a patient is a whole with his or her values and beliefs (as a religion) was emphasized in the nursing education. The courses in this program were often carried out in the classroom or a clinic, and the educators played an active role. In this program, there were no case studies or small discussion groups.
Objectives The objectives of this study were as follows: (a) to identify the impact on the level of knowledge and practice, among senior nursing students, of spirituality, added to the integrated nursing curriculum and (b) to compare the integrated curriculum with the traditional nursing curriculum.
Methods Research design This was a quasi-experimental intervention study. The study was carried out to measure the efficacy of integration of spirituality into the curriculum with regard to senior nursing students’ knowledge of spirituality and spiritual care. In this study, two groups were evaluated: the control group and the intervention group. The students in the control group were taught with the traditional curriculum, and the students in the intervention group were taught with an integrated curriculum according to the FHPs.
Participants and research context In this study, ‘‘a simple random sampling method’’ was used. The students were assigned as ‘‘the intervention group/integrated system’’ that were informed about spirituality or as ‘‘the control group/traditional system’’ that received no information on spirituality. The traditional and integrated education systems had a total of 156 students in the final year. The study included a total of 130 volunteer senior-year students, including 72 out of 75 students (96%) and 58 out of 81 students (77.6%); these students participated in the study as the control group and the intervention group, respectively. The students who were absent at the time of data collection were not included in the study. The participants were similar in terms of age, gender, culture, and beliefs. All the participants were women. The religious affiliation of the participants reflects the religious affiliation of the Turkey population. The study was conducted at the Department of Nursing of the Faculty of Health Sciences (NHSF), Cumhuriyet University, in Central Anatolia/Turkey.
Instruments Personal information form. This was prepared by researchers and consisted of 12 questions on age, knowledge on spirituality, knowledge received about spirituality, ways to receive knowledge, the adequacy of the knowledge, the reading of scientific publications, practices concerning spirituality in clinics, practices 4
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Questions 1. Age 2. Have you ever received knowledge about spirituality? 3. Where did you receive the knowledge? 4. Have you received enough knowledge related to spirituality? 5. Do you know the concept of spirituality? 6. Have you ever read scientific publications related to spirituality? 7. Have you implemented spirituality care in clinical practice? 8. What have you done about spiritual care? 9. Do nurses provide holistic care in clinical practice? 10. Do nurses pay attention to patients’ spiritual needs in clinical practice? 11.What is the meaning of spirituality? 12.What is spiritual care?
Figure 1. Personal information form (PIF).
concerning spiritual care, whether nurses deliver holistic care in clinical practice, and the definitions of spirituality and spiritual care (see Figure 1). The Spirituality and Spiritual Care Rating Scale. This scale was developed by McSherry, Draper, and Kendrick in 2002 and consists of 17 items. It includes a 5-point Likert scale, with subscales of spirituality and spiritual care (6, 7, 8, 9, 11, 12, and 14), religiosity (4, 5, 13, and 16), and personalized care (1, 2, and 10). In all, 13 items were scored from 1 ‘‘strongly disagree’’ to 5 ‘‘strongly agree,’’ and 4 items were scored in the reverse order. A mean total score of 5 showed a high level of perceived spirituality and spiritual care. In general, higher scores indicate a higher level of perception of spirituality or provision of spiritual care.35 The Turkish version of the Spirituality and Spiritual Care Rating Scale (SSCRS) was used in this study. Ergu¨l and Bayık Temel30 determined the validity and reliability of the Turkish version of the scale. The Cronbach’s alpha, on the Turkish version of the scale, was 0.76.
Data collection The data were collected at the end of the spring semester of the 2009–2010 (control group) and 2010–2011 (intervention group) academic years. There was no pretesting done or assessment at any other time during the curriculum. The data collection forms mentioned below were distributed to the students who agreed to participate in the study. Students independently completed the forms in their classrooms under the supervision of researchers. It took approximately 30 min for the students to complete the forms. 5
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Ethical considerations Permission to conduct the study at the nursing school was obtained from the schools’ management teams (there was no Institutional Ethics Board). The rights of the participants were protected in this study by obtaining informed consent, as participants were given full information about the study, as to what the requirements, purpose, and benefits were. Respect for confidentiality and anonymity was maintained by ensuring that information given by the participants was kept private. Protecting the right to withdraw from the study was enforced by informing the participants that they could refuse to participate at any time during the research process.
Procedure The students in the intervention group received information about spirituality, and the students in the control group did not (see Figure 2). During the first 2 years of the program integration, spirituality was taught to students. In the first year, 3 h were used to teach patterns of values and beliefs according to the FHPs. The course included small group discussions, which were guided for 1 h by questions prepared by the first researcher. Students were gathered in a classroom after the group discussion. The first researcher gave a 2-h theoretical lecture to the students on spirituality using PowerPoint presentations. During the second year, the importance of spirituality in adulthood and at advanced ages was taught using PowerPoint presentations (see Figure 3). During the third year, real patient scenarios were prepared after discussions by both the researchers and faculty members according to all 11 areas of the FHPs, which were taught to groups of 15–18 students. The nursing diagnosis of spiritual distress and nursing interventions were discussed according to the data on patterns of values and beliefs. Two patient scenarios (breast cancer and heart surgery) were discussed. The scenarios were developed based on the data collected from actual patients. Illness can challenge one’s personal system of meaning. Scenarios were chosen that could confuse meaning and purpose in life at times of crisis and life-threatening illness/potentially leading to death, such as patients who had cancer or required heart surgery. During the discussions, no PowerPoint presentations were used. In addition to the scenarios, concepts were discussed with a patient care plan configured according to the FHPs during 8 weeks of clinical practice. Students in their senior year had a year-round internship with two semesters of 15 weeks each; they discussed concepts as they related to patient care plans that were then applied in the clinical settings with patients. The curriculum did not include any additional programs that are associated with this topic, which might have influenced student learning. The questionnaires were administered once for both the intervention and control groups after the programs were completed, during the final examination week.
Data analysis All questionnaires were coded. SPSS version 14.0 was used for all analyses. The quantitative data collected from the personal information form (PIF) were analyzed using descriptive statistics using proportion, frequency, and chi-square analyses. The results of the SSCRS are reported as means (+ standard deviation (SD)) and the independent t tests were used to determine the SSCRS score differences among study participants. The qualitative responses on the PIF were then coded and later analyzed using descriptive statistics, proportions, and frequency of spiritual care practices and definitions of spirituality and spiritual care were noted. 6
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Department of Nursing, Health Institute, Cumhuriyet University
Control Group (N = 72)
1st year Bio-psychosocial care; in the 2nd, 3rd and 4th years, there was no teaching on spirituality concepts
Intervention Group (N = 58)
1st year and 2nd year 1. Small group discussion (15-18 students) on spirituality 2. PowerPoint presentation on spirituality
3rd year 1. Small group discussion in written cases of patients (15-18 students) 2. Discussion on patient care plan prepared according to FHPs during eight-week practice at clinics
4th year Discussion on patient care plan prepared according to FHPs during internship Figure 2. The concept of spirituality in the curricula. FHP: functional health pattern.
Findings Characteristics of the sample The total response rate was 85% (N ¼ 130); 77.6% (n ¼ 58) of the students in the intervention group and 96% (n ¼ 72) in the control group completed the questionnaires, and 156 students completed the nursing programs; these students participated in the study as or the intervention group, respectively; all the students were females and none was married. The mean age was 21.8 years (SD ¼ 0.95 years); for the intervention group the mean age was 22.1 years (SD ¼ 0.97 years), and for the control group it was 21.8 years (SD ¼ 1.47 years). Other characteristics of the study participants are summarized in Table 1; about 95% of the students 7
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First year
Small group discussion about questions:
1h
What is holism? What is holistic care? What are values? What is belief? What are spirituality concepts? What is religion? What is the difference between religion and spirituality? What are the reasons to emerge regarding spirituality concepts? PowerPoint presentation on spirituality concept (related to
2h
the above questions) Second year 2h
What is spiritual distress? What are the indicators of spiritual distress? What are verbal statements of persons in spiritual distress?
Third year
Discussion of patient scenarios (breast cancer and heart surgery)
8+8 = 16 h
and in clinical practice and patient care plan by FSO discussion of spiritual distress Year-round internship
Fourth year
Patient care planning/spiritual distress
Figure 3. Course program related to spirituality (intervention group).
in the intervention group and 54.2% of the students in the control group stated that they had knowledge about spirituality. A total of 76.9% of the students in the control group and 98.1% of the students in the intervention group remarked that the knowledge was adequate, and 37.5% of the students in the control group and 67.2% in the intervention group reported that they read scientific publications related to spirituality. Most of the students (93.1% in the control group and 84.5% in the intervention group) pointed out that the nurses in clinics did not offer holistic care and did not attend to the spiritual needs of patients. There were significant differences in receiving information about spirituality and the implementation of spiritual care between the control group and the intervention group (Table 1).
Posttest scores of SSCRS Table 2 shows the means and SD posttest scores of the SSCRS; for the intervention group (M ¼ 56.34, SD ¼ 5.47), this was higher than the control group (M ¼ 53.81, SD ¼ 4.37). The mean score on the subscale of ‘‘spirituality and spiritual care’’ was 25.09 (SD ¼ 2.78) in the control group, while it was 27.10 (SD ¼ 3.69) in the intervention group. For the subscale of ‘‘religiosity,’’ the control group scored 8
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Table 1. Posttest scores of status and ways of receiving knowledge, observations, and practices related to spirituality. Students’ responses Knowledge about spirituality Yes No Where receiving knowledge Undergraduate education No undergraduate educationb Adequate knowledge received Adequate Not adequate Reading scientific publication related to spirituality Yes No Implementing spirituality care in clinical practice Yes No Nurses Offered holistic care Did not offer holistic care Nurses Gave attention to patients’ spiritual needs Did not give attention to patients’ spiritual needs Total
Control group n (%)
Intervention group n (%)
Test
39 (54.2) 33 (45.8)
55 (94.8) 3a (5.2)
w2 ¼ 25.52 p ¼ .000
0 (0.0) 39 (100.0)
55 (100.0) 0 (0.0)
w2 ¼ 94.00 p ¼ .002
30 (76.9) 9 (23.1)
54 (98.1) 1 (1.9)
w2 ¼ 46.56 p ¼ .000
27 (37.5) 45 (62.5)
39 (67.2) 19 (32.8)
w2 ¼ 11.36 p ¼ .001
45 (62.5) 27 (37.5)
50 (86.2) 8 (13.8)
w2 ¼ 9.17 p ¼ .002
5 (6.9) 67 (93.1)
10 (15.5) 48 (84.5)
w2 ¼ 3.337 p ¼ .068
8 (11.2) 64 (88.8) 72 (100.0)
4 (6.9) 54 (93.1) 58 (100.0)
w2 ¼ 0.681 p ¼ .409
a
Discontinuous. Congresses and symposia, written, verbal media, and family.
b
12.26 (SD ¼ 2.44), and the intervention group scored 10.72 (SD ¼ 2.45). The mean scores of both groups for the subscale of ‘‘personalized care’’ were similar (M ¼ 14.43, SD ¼ 2.14; M ¼ 14.34, SD ¼ 1.80, respectively). There was a significant difference between groups in the mean scores on the scale and on all subscales, except for personalized care.
Posttest scores of spiritual care practices of the students during clinical practice As shown in Table 3, a total of 84.4% of the control group and 40.0% of the intervention group noted that they prepared a proper environment for patients to pray, say Salat/prayer, and read the Qur’an (the sacred book of Islam); 64.0% of the intervention group students had diagnosed ‘‘spiritual distress’’ and performed appropriate interventions. None of the students in the control group diagnosed ‘‘spiritual distress.’’
Posttest scores of descriptions of spirituality and spiritual care Table 4 presents posttest scores the definitions for spirituality and spiritual care of the students in both groups. A total of 24.9% of the students in the control group and 31.3% of the students in the intervention group described spirituality as ‘‘the inner world that generates a purpose in life with regard to an individual’s values and beliefs,’’ 20.7% of the students in the control group and 27.7% of the students in the intervention group described it as ‘‘the meaning of life,’’ and 18.1% of the students in the control group and 9
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Table 2. Posttest scores of Spirituality and Spiritual Care Rating Scale (SSCRS) mean. SSCRS scores
N
General Control group 72 Intervention group 58 Total 130 Subscales Spirituality and spiritual care Control group 72 Intervention group 58 Total 130 Religiosity Control group 72 Intervention group 58 Total 130 Personalized care Control group 72 Intervention group 58 Total 130
Mean
SD
Minimum
Maximum
Test
53.8194 56.3448 54.9462
4.37125 5.47258 5.03370
42.00 45.00 42.00
68.00 69.00 69.00
t ¼ 2.926 p ¼ .004
25.0972 27.1034 25.9923
2.78911 3.69300 3.36304
17.00 14.00 14.00
31.00 35.00 35.00
t ¼ 3.425 p ¼ .001
12.2639 10.7241 11.5769
2.44945 2.45516 2.56048
6.00 5.00 5.00
18.00 15.00 18.00
t ¼ 3.558 p ¼ .001
14.3472 14.4310 14.3846
1.80890 2.14486 1.95842
11.00 9.00 9.00
19.00 20.00 20.00
t ¼ 0.237 p ¼ .809
SD: standard deviation.
Table 3. Posttest scores of spiritual care practices of the students during clinical practice.
Practices of spiritual carea Respecting individuals’ values and beliefs Being merry/compassionate Respecting individuals’ privacy Encourage patients to pray/say Salat and read Qur’an Diagnosing spiritual distress and conducting interventions for the nursing diagnosis Ensuring everyone shares his or her feelings Allowing patients’ relatives to visit them
Control group (n ¼ 45) n (%)
Intervention group (n ¼ 50) n (%)
9 (20.0) 4 (8.9) 12 (26.7) 38 (84.4) 0 (0.0)
14 (28.0) 4 (8.0) 9 (18.0) 20 (40.0) 32 (64.0)
8 (17.8) 8 (17.8)
11 (22.0) 2 (4.0)
a
Multiple answers were given.
54.5% of the students in the intervention group defined spiritual care as ‘‘care that respects an individual’s values and beliefs.’’
Discussion Incorporating the concept of spiritual care into nursing curricula improves the preparation of nurses to address the spiritual needs of patients. However, more organized discussions are needed about where and how spirituality should be incorporated into nursing education.9 While some nursing researchers have emphasized that teaching the concept of spirituality should focus on an integrated training model,26,36 others have supported the traditional educational model.24 The proposed integration model was developed to include concepts of spirituality in the subjects taught throughout the training process. Teaching spirituality 10
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Table 4. Posttest scores of descriptions of spirituality and spiritual care.
Descriptions of the studentsa What is spirituality? Inner world that generates a purpose in life toward individuals’ values and beliefs Strength that brings hope in life Meaning of life A term including religious practices/relations with Allah A concept that includes religion but is broader than religion Ignored topic in clinical practice Very important concept in human’s life Psychological comfort Love Missed What is spiritual care? Care that respects individuals’ values and beliefs Care considering ethical principles Apply religious practices that relax individuals Provide a peaceful environment for individuals Prevent experiences of spiritual distress Ensure sharing their feelings Empathy Provide holistic care Emotional support Missed
Control group n (%)
Intervention group n (%)
18 (24.9) 3 (4.1) 15 (20.7) 14 (19.4) 1 (1.4) 0 0 12 (16.6) 0 9 (12.5)
24 (31.3) 14 (22.9) 17 (27.7) 4 (6.9) 1 (1.7) 1 (1.7) 2 (3.4) 4 (6.9) 2 (3.4) 4 (6.9)
13 (18.1) 0 6 (8.3) 2 (2.7) 0 10 (13.8) 5 (6.9) 30 (41.6) 13 (18.1) 9 (12.5)
34 (54.5) 1 (1.7) 2 (3.4) 4 (6.9) 3 (4.2) 3 (4.2) 0 10 (13.8) 2 (3.4) 4 (6.9)
a
Multiple answers were given.
in a single module or course might not be adequate. In this context, several researchers have recommended that teaching spirituality is more effective when the faculty loosely defines spirituality, identifies specific topics to be taught, and uses real-life teaching strategies that assist nurses in developing diagnoses concerning spiritual strengths, distress, or despair.26,37 Wallace et al.10 developed a curriculum for teaching spirituality to nurses and integrated it into 13 different nursing curricula; they reported that the spiritual knowledge and attitudes of 34 senior nursing students improved significantly after the students received the integrated curriculum. The findings of this study showed significant differences between the general SSCRS scores of senior undergraduate nursing students in the two groups studied (F ¼ 8.559, p ¼ .004). The differences observed might have been due to the integration of spirituality into the curriculum. More specifically, the differences might have been due to spirituality being defined more clearly in the intervention group of students, patient scenarios being used in the classroom, and the patient care plans discussed with faculty members in the clinical setting. Spirituality was not discussed in classrooms or on the clinical rotations of the students in the control group. The use of patient scenarios for teaching is a useful student-centered approach to learning that allows students to solve real or simulated problems in a safe classroom environment. The patient scenarios give students the opportunity to think and reflect over an experience before being confronted with it in real time. In addition, such an approach might help students become critical thinkers and practitioners. The discussions might help the students increase their self-awareness and knowledge about the spiritual dimension of patients using the FHPs. However, although useful, such discussions are insufficient. Researchers have suggested that the necessary knowledge, skills, and principles of spiritual care can be 11
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achieved using case studies.35 Wallace et al.10 showed a significant difference in the knowledge and attitudes toward spirituality among senior-level nursing students as a result of the integration of spirituality into the undergraduate nursing curriculum. Lovanio and Wallace8 found that the spiritual attitudes and knowledge of undergraduate nursing students were significantly different when spiritual education was included in a course. Baldacchino11 suggested that the practice of self-reflection, consideration of case studies, and small group discussion were useful non-traditional methods for nursing teachers to improve nursing students’ understanding of spiritual care and provided them with the understanding of holistic care. Taylor et al.14 used a quasi-experimental study that identified significant improvement in the spiritual care attitudes, abilities, experiences, and knowledge of nursing students and nurses after using self-learning spiritual education materials. Other studies reported that providing spirituality and spiritual care education to nursing students increased their knowledge and attitudes.9,24 The findings of this study showed that there was no significant difference in the scores on the subdimension of personal care on the SSCRS between the two groups. This outcome might have been due to the similar teaching methods, regarding the personal care of patients, in the curricula used for both groups, and perhaps the emphasis on the importance of bio-psychosocial and holistic care. In this study, while the posttest scores on the SSCRS for spirituality and spiritual care were higher in the intervention group of students, the scores on the SSCRS for the religious sub-dimension were higher in the control group of students (see Table 2). These findings suggest that the control group was more attentive to the religious need/observances than the intervention group. This finding could be due to the fact that participants in the control group did not view spirituality as something separate from religious belief and religious practice. In addition, the concept of spirituality and the word/concept of religion are frequently used interchangeably in our culture. The complexity of the concept of spirituality may have contributed to this outcome; participants might have preferred to use the ‘‘religious domain’’ when this topic was brought up instead of spirituality. In addition, the definition of spirituality might not have been loosely defined, in the control group. Although holistic care was included in the curriculum of the control group of students, spirituality was not incorporated into the curriculum. In this group, holistic care was defined as physical, mental, and social or bio-psychosocial care, not spiritual care. Spiritual care is different from bio-psychosocial care and emotional support even though spiritual distress is often made manifest by emotions. North American Nursing Diagnosis Association’s (NANDA)38 defining characteristics of spiritual distress were included, without religious/cultural ties. It is defined as the impaired ability to experience and integrate meaning and purpose in life through connectedness with the self, others, art, music, literature, nature, and/or a God/or power greater than oneself.39 The students in the control group learned about spirituality, in their community and on the Internet, as religious values and beliefs and by enculturation. Thus, for the control group of students, spirituality was more closely related to religiosity. In addition, in Turkey, spirituality is viewed synonymously with formal religion, often described in terms of religious beliefs, and practices and many people express and experience their spirituality within the context of religion. Religion can serve as a vehicle for expressing spirituality through a framework of values, beliefs, and ritual practices.40 Religions provide a set of beliefs about a God or supernatural powers upon which practices are based. Spirituality is a concept much broader than religion.41 Spirituality is characterized by faith, a search for meaning and purpose in life, a sense of connection with others, and a transcendence of self, resulting in a sense of inner peace and well-being.41 Burkhardt42 described it as inner strength, meaning and purpose, and harmonious interconnectedness. Coyle43 later described it as a belief in God or higher power, religious practices, and personal values. It is difficult for nursing students to understand the distinction between religion and spirituality. Wallace et al.10 reported that nursing curricula should enable students to understand spirituality in a broader context, one that goes beyond religious beliefs. In addition, nursing students should be taught differences between religion and spirituality as well as what they have in common. Moreover, Pesut24 suggested effective 12
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methods for resolving the difficulties in understanding these concepts, such as providing sufficient training and reading on the topics. However, in this study only a very limited number of publications for the students regarding spirituality, in the field of nursing, were found to be available in Turkish; this resulted in the level of reading scientific publications being less than desired, even among the students in the intervention group (67.2%), who were continually encouraged by teachers to look for resources and read more publications on the topic. In this study, the students reported that nurses in the clinical settings did not provide holistic care to their patients and did not care for the spiritual needs of their patients (see Table 1). In a previous study,20 the most common obstacles reported, preventing nurses from giving spiritual care to their patients, was the lack of time and education on the topic. In a study carried out in Turkey, spirituality (73%) and spiritual care (93.4%) were not defined by the majority of nurses; however, most of them (83.2%) reported that education was necessary to identify spiritual dimensions and that their education with regard to spirituality was insufficient.31 In another study, Turkish nurses’ perception of spirituality and spiritual care was reported to be insufficient.33 It implies that the majority of nurses may not be familiar with the concepts of spirituality and spiritual care. They do not seem to consider spirituality and spiritual care to be something separate specific nursing but something integral to the art and science of nursing. In a study reported by Narayanasamy,44 although nurses were aware of the spiritual needs of patients, they found that these needs were poorly met. Nurses’ competence in meeting the spiritual needs of their patients should be improved by education on spiritual care. However, the spiritual needs of patients must be seen in the context of service requirements and the successful business outcomes of a given clinical setting. Currently, the attitudes of nurses contribute to an emphasis on providing physical care to patients rather than spiritual care.45 As nursing has become more oriented toward task accomplishment, the spiritual dimension of care has been neglected, and this has threatened the concept of holistic care. This is because the spiritual dimension has not been considered to be relevant to patient care.26 However, if nurses are expected to provide holistic nursing care, then nurse educators must address all dimensions of holistic nursing throughout undergraduate curricula. Spiritual nursing care is increasingly being cited in the nursing literature as a fundamental ethical obligation. This obligation is based on the argument that nurses provide holistic care, spirituality is a universal dimension of the person, and so nurses should care for the spiritual dimension.46 In addition, among professional healthcare disciplines, the role of spirituality in patient care is acknowledged in ethical codes, guiding standards of practice, conduct, and behavior.22 It is believed that spirituality is the cornerstone of nursing practice and that addressing spiritual care needs and preferences in patient care practice is both a moral and ethical obligation.47 Some nursing models, which include spirituality in their theory, such as Roper et al.’s model and Neuman’s systems model, can be applied to incorporate spirituality into nursing curricula.48 Moreover, additional research is needed to articulate how spirituality can best be taught in both the classroom and during clinical practice. The challenge is for students to clearly understand the importance of spirituality in relationship to the delivery of nursing care in the clinical setting.4 In addition, Salmon et al.4 have stressed the importance of student learning in real-life situations. Nursing scholars9,26 have emphasized that the clinical environment provides rich experiences for students to discover spiritual dimensions, and that the nurses working in clinical areas should be role models for students. However, the medical literature shows that healthcare professions neglect spiritual care.7 Baldacchino49 reported that ‘‘since spiritual care is not being given the merited attention, learning the spiritual dimension in care through role models appears to be impracticable.’’ Therefore, learning about the spiritual dimension from role models in the clinical setting is hard to achieve. Thus, the fact that nurses do not provide holistic care or that they fail to pay attention to the spiritual needs of their patients limits the ability of nursing students to develop the skills needed for providing spiritual care. The practice of nursing can be used to demonstrate how spirituality could be incorporated into the patient’s plan of care. This will involve identifying the patient’s spiritual needs through conducting a spiritual assessment, planning, and implementing the appropriate interventions 13
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to help patients meet their needs and evaluating to what extent these interventions have been successful.28 Moreover, in this study, discussions on the concept of spirituality, patient care planning, and in various clinical areas increased the students’ understanding of the concept of spirituality. The results of this survey demonstrated that students in both the intervention and the control groups could prepare a proper environment for patients to pray/say Salat and read the Qur’an; they usually cite religious practices as forms of spiritual care in clinical practice. Spiritual care practices were not as common in the control group compared to the intervention group. This might have been due to the understanding of spirituality by students who developed from their religious teachings, personal beliefs, and their worldviews. The students likely had a well-developed cultural standpoint and their upbringing likely informed them to perceive spirituality as rooted in religion rather than developing a more humanistic perspective, or vice versa.50 In Turkey, both spirituality and religiosity are features of cultural identity and praying is widely used as a therapeutic tool by Turkish citizens. Meraviglia51 reported that ‘‘Prayer is an indicator of the defining attribute of connectedness with God and meaning in life is an outcome of spirituality.’’ In this study, when examining the answers given by the students to the question What is spirituality and spiritual care? the intervention group students defined the terms of spirituality and spiritual care referred more commonly to the meaning and purpose of life when compared to the control group students, but there responses were not satisfactory in intervention group. These findings suggest that students in the intervention group require further education on the topic of spirituality. The definition of spirituality is not easy for an undergraduate student to understand because of the subjectivity and abstract nature of this concept. Golberg52 notes that the understanding of the word spirituality is complicated by the fact that the word is an abstract noun, whereas the word spirit is a concrete noun. Golberg also describes the concept of spirituality as a quality within where the concrete spirit exists. Teaching about spirituality and spiritual care begins with a broad, universal, all inclusive definition of the concept spirituality. The lack of spiritual education in nursing programs may be the reason for the hesitancy to assess the spiritual needs and promote the spiritual health of patients in clinical practice.
Limitations There were several limitations of this study. The sample size, although adequate for examining the integration of the spiritual domain into the undergraduate nursing curriculum, limits generalization of the results. However, the findings can be generalized to similar cultural groups. In this study, all the students were female. The plan is to include males in future studies.
Conclusion This is the first study in Turkey to compare and evaluate a traditional undergraduate nursing curriculum with a curriculum that integrated spiritual care into the education of undergraduate nursing students. FHPs were used for the first time to integrate the spiritual domain into the curriculum. The findings from this study suggest that using interactive methods and integration of spirituality into the undergraduate nursing curriculum increased the students’ spiritual knowledge and attitudes. Gordon’s FHPs provide a holistic structure, which allows for the integration of the spiritual domain into the undergraduate nursing curriculum. The inclusion of spirituality into nursing education should be practiced more widely. In the future, data from pretest/posttest studies and analysis of students’ personal spirituality may add to improved understanding in this area of research. 14
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Relevance to clinical practice A holistic approach to patient care should include the care of a patient’s spiritual needs as well as their physical needs. Because spirituality is a moral obligation of care. This study provides data that support the recommendation that spirituality should be integrated into baccalaureate nursing programs in order to prepare student nurses to meet the spiritual needs of patients. Acknowledgments The authors would like to thank the students who participated in the study. Conflict of interest The authors declare that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-forprofit sectors. References 1. Narayanasamy A and Owens J. A critical incident study of nurses’ responses to the spiritual needs of their patients. J Adv Nurs 2001; 33(4): 446–455. 2. Pesut B. Developing spirituality in the curriculum: worldviews, intrapersonal connectedness, interpersonal connectedness. Nurs Educ Perspect 2003; 24(6): 290–294. 3. Tiew LH, Creedy DK and Chan MF. Student nurses’ perspectives of spirituality and spiritual care. Nurse Educ Today 2013; 33(6): 574–579. 4. Salmon B, Bruick-Sorge C, Beckman SJ, et al. The evolution of student nurses’ concepts of spirituality. Holist Nurs Pract 2010; 24: 73–78. 5. Nagase M. Does a multi-dimensional concept of health include spirituality? Analysis of Japan Health Science Council’s Discussions on WHO’s ‘‘Definition of Health’’ (1998). Int J Appl Soc 2012; 2(6): 71–77. 6. International Council of Nurses. The ICN Code of Ethics for Nurses, http://www.icn.ch/images/stories/documents/ about/icncode_english.pdf (2012, accessed 25 November 2013). 7. McEwen M. Spiritual nursing care. Holist Nurs Pract 2005; 19: 161–168. 8. Lovanio K and Wallace M. Promoting spiritual knowledge and attitudes: a student nurse education project. Holist Nurs Pract 2007; 21: 42–47. 9. Van Leeuwen R, Tiesinga LJ, Middel B, et al. The effectiveness of an educational programme for nursing students on developing competence in the provision of spiritual care. J Clin Nurs 2008; 17: 2768–2781. 10. Wallace M, Campbell S, Grossman SC, et al. Integrating spirituality into undergraduate nursing curricula. Int J Nurs Educ Scholarsh 2008; 5: 1–13. 11. Baldacchino DR. Teaching on spiritual dimension in care to undergraduate nursing students: the content and teaching methods. Nurse Educ Today 2008; 28: 550–562. 12. Keefe S. Infusing spirituality into health education. New Engl Adv Nurse 2005; 9: 41–42. 13. Meyer JE. New paradigm research in practice: the trials and tribulations of action research. J Adv Nurs 2003; 18: 1066–1072. 14. Taylor EJ, Mamier I, Bahjri K, et al. Efficacy of a self-study programme to teach spiritual care. J Clin Nurs 2008; 18: 1131–1140. 15. Lemmer C. Teaching the spiritual dimension of nursing care: a survey of US baccalaureate nursing programs. J Nurs Educ 2002; 41: 482–490. 15
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16. Cone PH and Giske T. Teaching spiritual care—a grounded theory study among undergraduate nursing educators. J Clin Nurs 2013; 22(13–14): 1951–1960. 17. Narayanasamy A. ASSET: a model for actioning spirituality and spiritual care education and training in nursing. Nurse Educ Today 1999; 36: 117–125. 18. Shih F, Gau M, Mao H, et al. Empirical validation of a teaching course on spiritual care in Taiwan. J Adv Nurs 2001; 36: 333–346. 19. Money B and Timmins F. Spirituality as a universal concept: student experience of learning about spirituality through the medium of art. Nurse Educ Pract 2007; 7: 275–284. 20. Ross L. Spiritual care in nursing: an overview of the research to date. J Clin Nurs 2006; 15: 852–862. 21. Wright KB. Clinical scholarship: professional, ethical, and legal implications for spiritual care in nursing image. J Nurs Scholarsh 1998; 30: 81–83. 22. Sessanna L, Finnell DS, Underhill M, et al. Measures assessing spirituality as more than religiosity: a methodological review of nursing and health-related literature. J Adv Nurs 2011; 67(8): 1677–1694. 23. Pesut B. Incorporating patients’ spirituality into care using Gadow’s Ethical Framework. Nurs Ethics 2009; 16(4): 418–428. 24. Pesut B. The development of nursing students’ spirituality and spiritual care giving. Nurse Educ Today 2002; 22: 128–135. 25. Beckman S, Boxley-Harges S, Bruick-Sorge C, et al. Five strategies that heighten nurses’ awareness of spirituality to impact client care. Holist Nurs Pract 2007; 21: 135–139. 26. Greenstreet WM. Teaching spirituality in nursing: a literature review. Nurse Educ Today 1999; 19: 649–658. 27. Bush T. Journaling and the teaching of spirituality. Nurse Educ Today 1999; 19: 20–28. 28. Ross L. Teaching spiritual care to nurses. Nurse Educ Today 1996; 16: 38–43. 29. Khorshid L and Gu¨rol Arslan G. Hems¸ irelik ve spritu¨el bakım [Nursing and spiritual care]. Ege U¨niversitesi Hems¸ irelik Yu¨ksek Okulu Dergisi [Ege Univ J Nurs High School] 2006; 22: 233–243 (in Turkish). 30. Ergu¨l S¸ and Bayık Temel A. Maneviyat ve manevi bakım dereceleme o¨lc¸eg˘inin Tu¨rkc¸e formunun gec¸erlilik ve gu¨venirlilig˘i [Validity and reliability of ‘‘Spirituality and Spiritual Care Rating Scale’’ Turkish version]. Ege U¨niversitesi Hems¸ irelik Yu¨ksek Okulu Dergisi [Ege Univ J Nurs High School] 2007; 23: 75–87 (in Turkish). 31. Yilmaz M and Okyay N. Hems¸ irelerin maneviyat ve manevi bakima ilis¸ kin go¨ru¨s¸ leri [Views related to spiritual care and spirituality of nurses]. Hems¸ irelikte Aras¸ tırma ve Gelis¸ tirme Dergisi -HEMAR-G [J Nurs Res Dev] 2009; 11: 41–52 (in Turkish). 32. Yilmaz M. A dimension of holistic care: spirituality, nature and relationship with nursing. J Anatol Nurs Health Sci 2011; 14(2): 61–70. 33. Ozbasaran F, Ergul S, Bayik Temel A, et al. Turkish nurses’ perceptions of spirituality and spiritual care. J Clin Nurs 2011; 20: 3102–3110. 34. Gordon M. Functional health patterns, nursing diagnosis process and application. New York: McGraw-Hill, 1982. 35. McSherry W, Draper P and Kendrick D. The construct validity of rating scale designated to assess spirituality and spiritual care. Int J Nurs Stud 2002; 39: 723–734. 36. Hoffert D, Henshaw C and Mvududu N. Enhancing the ability of nursing students to perform a spiritual assessment. Nurse Educ 2007; 32: 66–72. 37. Cavendish R, Luise B, Russo D, et al. Spiritual perspectives of nurses in the United States relevant for education and practice. West J Nurs Res 2004; 26: 196–212. 38. NANDA International. Nursing diagnoses: definitions and classification. Philadelphia: NANDA International, 2005–2006. 39. Caldeira S, Carvalho EC and Vieira M. Spiritual distress—proposing a new definition and defining characteristics. Int J Nurs Knowl 2013; 24(2): 77–84. 40. Callister LC, Bond AE, Matsumura G, et al. Threading spirituality throughout nursing education. Holist Nurs Pract 2004; 18(3): 160–166. 16
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41. Delgado C. A discussion of the concept of spirituality. Nurs Sci Q 2005; 8: 157–162. 42. Burkhardt M. Spirituality: an analysis of the concept. Holist Nurs Pract 1989; 3: 69–77. 43. Coyle J. Spirituality and health: towards a framework for exploring the relationship between spirituality and health. J Adv Nurs 2002; 37: 589–597. 44. Narayanasamy A. Nurses awareness and preparedness in meeting their patients’ spiritual needs. Nurse Educ Today 1993; 13: 196–201. 45. Carr T. Mapping the processes and qualities of spiritual nursing care. Qual Health Res 2008; 18(5): 686–700. 46. Pesut B. Fundamental or foundational obligation? Problematizing the ethical call to spiritual care in nursing. ANS Adv Nurs Sci 2006; 29(2): 125–133. 47. Delaney C. The Spirituality Scale: development and psychometric testing of a holistic instrument to assess the human spiritual domain. J Holist Nurs 2005; 23(2): 145–167. 48. Baldacchino DR. Nursing competencies for spiritual care. J Clin Nurs 2006; 15: 885–896. 49. Baldacchino DR. Teaching on spiritual care: the perceived impact on qualified nurses. Nurse Educ Pract 2011; 11: 47–53. 50. Paley J. Spirituality and secularization: nursing and the sociology of religion. J Clin Nurs 2009; 17: 175–186. 51. Meraviglia MG.Critical analysis of spirituality and its empirical indicators. Prayer and meaning in life. J Holist Nurs 1999; 17(1): 18–33. 52. Golberg B. Connection: an exploration of spirituality in nursing care. J Adv Nurs 1998; 27: 836–842.
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The efficacy of integrating spirituality into undergraduate nursing curricula Meryem Yilmaz and Hesna Gurler Nurs Ethics published online 18 March 2014 DOI: 10.1177/0969733014521096 The online version of this article can be found at: http://nej.sagepub.com/content/early/2014/03/18/0969733014521096
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Article
The efficacy of integrating spirituality into undergraduate nursing curricula
Nursing Ethics 1–17 ª The Author(s) 2014 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733014521096 nej.sagepub.com
Meryem Yilmaz and Hesna Gurler Cumhuriyet University, Turkey
Abstract Background: Attention to patients’ spirituality, as a moral obligation of care, is now widely accepted in nursing practice. However, until recently, many nursing programs have paid little attention to spirituality. Objective: The objective of this study was to identify the impact of two different curricula, used to teach undergraduate nursing students, on increasing nursing student awareness of spirituality in the care of patients. Research design: A quasi-experimental post-intervention two-group design was conducted in 2009– 2010 and 2010–2011 academic years. Participants and research context: The study included a total of 130 volunteer senior-year students. The students were assigned as ‘‘the intervention group/integrated system’’ that were informed about spirituality or as ‘‘the control group/traditional system’’ that received no information on spirituality. Data were collected via a personal information form and the Spirituality and Spiritual Care Rating Scale was used to assess responses. The study was conducted at the Department of Nursing of the Faculty of Health Sciences, Cumhuriyet University, in Central Anatolia/Turkey. Ethical considerations: Permission to conduct the study at the nursing school was obtained from the schools’ management teams. The rights of the participants were protected in this study by obtaining informed consent. Findings: The results revealed that the intervention group had a higher mean score on the Spirituality and Spiritual Care Rating Scale than did the control group. The students in the intervention group defined the terms of spirituality and spiritual care more accurately than did the control group students. Discussion: Nurses are professionally and ethically responsible for providing spiritual care. Nurses’ competence in meeting the spiritual needs of their patients should be improved by undergraduate education on spiritual care. Nursing scholars reported a significant difference in the knowledge and attitudes toward spirituality of nursing students as a result of the integration of spirituality into the undergraduate nursing curriculum. Conclusion: Spirituality should be more widely included in nursing education. Keywords Nursing education, spiritual care, spirituality, teaching spirituality
Corresponding author: Meryem Yilmaz, Department of Nursing, Faculty of Health Sciences, Cumhuriyet University, 58140 Sivas, Turkey. Email: [email protected]
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Introduction Although the nursing profession has its roots in spirituality,1 the spiritual dimension of holistic nursing is an area that has been neglected during both nursing education2 and the practice of nursing.3 In the 19th century, Florence Nightingale taught that spiritual education and development were important in the training of nurses.4 In addition, the World Health Organization (WHO) reported in 1998 that a spiritual dimension should be added to the physical, mental, and social dimensions of health; they modified the definition of health as follows: ‘‘Health is a dynamic state of complete physical, mental, spiritual, and social wellbeing and not merely the absence of disease or infirmity.’’5 The International Council of the Nurses’ Code of Ethics for Nurses6 recognizes that the need for nursing care is universal and states that professional nurses are responsible for promoting an environment in which the human rights, values, customs, and spiritual beliefs of the individual, family, and community are respected.6 Contemporary nursing theory supports holistic nursing care that includes attention to the spiritual dimension,7 and the nursing literature reports on the need to educate nursing students with regard to spiritual care; the assessment of the impact of such education is widely recognized.2,8–11 However, until recently, many nursing programs’ spirituality has received far less attention.12 Meyer13 reported that less than 6% of nursing curricula included topics on spirituality. In countries such as the United Kingdom and the United States, accreditation for nursing programs includes assessment and care of the spiritual dimension.13 Studies have been carried out to measure the outcomes of such teaching programs.4,9,14,15 However, there is evidence that suggests that there is no consensus on a universally recognized training program that includes the spiritual domain as part of the nursing curriculum.15,16 There continues to be debate in the literature regarding spiritual care in nursing education, on the teaching content as well as the methods11,17–19 and organization of curricula.15,20 There has been limited research examining the format of how this education should be carried out.11
Background Nurses are professionally and ethically responsible for providing spiritual care.21 Spirituality in patient care is acknowledged in the ethical codes guiding standards of practice, conduct, and behavior.22 Attention to patients’ spirituality as a moral obligation of care is now widely accepted as part of nursing.23 However, the ethical obligation of nurses for providing sufficient knowledge as well as discussion of attitudes and awareness related to the concept of spirituality, during undergraduate education, has been neglected and requires greater recognition. Pesut23 stated that ‘‘ethical universalism consists of principles such as those contained in professional codes of ethics or those embraced by particular spiritual traditions.’’ Spirituality began to appear in the late 1970s. However, little attention has been given to the spiritual development of nurses and nursing students. According to the results of studies by scholars in nursing, integrating the concept of spirituality into the undergraduate nursing curriculum increases the knowledge, attitudes, and awareness associated with spirituality of nursing students.8–11,24 However, spirituality has not kept pace and has not consistently been integrated into the undergraduate nursing curricula. In a study reported by Lemmer,15 nursing teaching plans were investigated; spiritual education was found to be lacking in the majority of universities surveyed. A few nursing faculties could define their approach to spirituality and had enough knowledge to teach nursing students about spiritual knowledge and interventions. Pesut24 emphasized that the training of spiritual care is more complex than physical care; this is due to the broad, abstract, value-laden, and multidimensional construct of spirituality. Therefore, it is not easy for nursing students to understand; it is difficult to teach nursing students about the spiritual needs of patients.25 Pesut24 reported that barriers to integrating spiritual care into the curriculum might include the complexity of defining the concept of spirituality within a multicultural society with secular values and materialism. In addition, many nursing programs have resource limitations and lack models to follow, prepared faculty, and 2
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accountability with regard to this topic. Hence, it is necessary to find the appropriate way to teach them so that they can understand the concept of spirituality, including its definition as well as learning how to incorporate this into patient care.17,24 There has been some effort to incorporate the concept of spirituality into nursing curricula by nursing scholars.11,18 Some investigators have recommended that students learn spiritual care through models, such as case studies; exemplary care plans;17 art gallery visits;19 role-playing activities; brainstorming, participatory, and student-centered methods;26 writing in journals and sharing the journal entries in the classroom;27 nursing process,28 and multiple teaching methods have been suggested.11 Narayanasamy17 developed the Actioning Spirituality and Spiritual Care Education and Training (ASSET) model in 1999, a problem-based approach. The ASSET model incorporates the triad of structural content, the learning process, and educational outcomes. The American Nurses Association (ANA) professional standards committee has suggested that holistic care be included in the nursing curricula.25 In Turkey, the 4-year nursing education program is based on a holistic nursing model: ‘‘The human is a whole that has bio-psychosocial dimensions.’’ The patient’s physical, social, and psychological dimensions are emphasized during the education of nursing students using this perspective. But the spiritual dimension has commonly been neglected in the nursing curricula of programs in Turkey. Spirituality is a concept that only recently started to be discussed in the fields of alternative medicine and nursing, in Turkey. Although the concept has been taught for a few years, in Turkey, as a separate course at some schools, changes in the field with regard to the application of these concepts have been insufficient. Recently, research in the area of spiritual care has increased, but a very limited number of studies have been published about issues related to spirituality and spiritual care, in the field of nursing, in Turkey.29–33 The Republic of Turkey is a secular country; there are many ethnic groups with a variety of rituals and practices as well as many different beliefs. However, the individuals in this society all share Islam as a common religion. In Turkey, spirituality and religion are certainly an important aspect of life for many; the word spirituality is associated with religion for the majority of the population. In Islamic communities, this is due to cultural beliefs and practices, religious and personal values, and religious dimensions of spirituality such as prayer and belief in God/Allah, or a higher power. There is no scientific study, conducted in Turkey, on this subject in the general population. However, the word spirituality was associated with religion, in our study on nurses31 and our observations. No prior study has been performed to determine the level of knowledge and practice of nursing students regarding spirituality and spiritual care, and the impact of systematically adding spirituality into the nursing curriculum in Turkey. This article describes the integration of spirituality into a baccalaureate nursing program, using Gordon’s Functional Health Patterns (FHPs). The FHP is a model devised by Marjory Gordon. There are 11 pattern areas: health perception–health management, nutrition–metabolic, elimination, activity–exercise, sleep–rest, cognitive–perceptual, selfperception–self-concept, role–relationship, sexuality–reproductive, coping–stress tolerance, and value– belief. Each pattern is an expression of bio-psychosocial integration, thus no one pattern can be understood without knowledge of the other patterns. The FHPs are influenced by biological, developmental, cultural, social, and spiritual factors. The FHPs provide an easily learned framework of assessment and critical thinking for the development of clinical judgment. In Gordon’s34 framework, spirituality is found within the pattern of values and beliefs. It describes patterns of values, goals, and beliefs (including spiritual beliefs) that guide choices and decisions.
The integrated curriculum The management at faculty redesigned the 4-year undergraduate curriculum. After reviewing other curricula from both national and international nursing schools, an integrated curriculum program was established, and the FHPs were chosen to guide the process. The concept of spirituality was incorporated as a 3
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separate subject into the curriculum. In this program, brainstorming, small group discussions, patient casestudy analysis, and students’ observations on the subject were used as interactive methods. The students played a more active role.
The traditional curriculum The concept of spirituality was not incorporated as a separate subject into the curriculum. The message that a patient is a whole with his or her values and beliefs (as a religion) was emphasized in the nursing education. The courses in this program were often carried out in the classroom or a clinic, and the educators played an active role. In this program, there were no case studies or small discussion groups.
Objectives The objectives of this study were as follows: (a) to identify the impact on the level of knowledge and practice, among senior nursing students, of spirituality, added to the integrated nursing curriculum and (b) to compare the integrated curriculum with the traditional nursing curriculum.
Methods Research design This was a quasi-experimental intervention study. The study was carried out to measure the efficacy of integration of spirituality into the curriculum with regard to senior nursing students’ knowledge of spirituality and spiritual care. In this study, two groups were evaluated: the control group and the intervention group. The students in the control group were taught with the traditional curriculum, and the students in the intervention group were taught with an integrated curriculum according to the FHPs.
Participants and research context In this study, ‘‘a simple random sampling method’’ was used. The students were assigned as ‘‘the intervention group/integrated system’’ that were informed about spirituality or as ‘‘the control group/traditional system’’ that received no information on spirituality. The traditional and integrated education systems had a total of 156 students in the final year. The study included a total of 130 volunteer senior-year students, including 72 out of 75 students (96%) and 58 out of 81 students (77.6%); these students participated in the study as the control group and the intervention group, respectively. The students who were absent at the time of data collection were not included in the study. The participants were similar in terms of age, gender, culture, and beliefs. All the participants were women. The religious affiliation of the participants reflects the religious affiliation of the Turkey population. The study was conducted at the Department of Nursing of the Faculty of Health Sciences (NHSF), Cumhuriyet University, in Central Anatolia/Turkey.
Instruments Personal information form. This was prepared by researchers and consisted of 12 questions on age, knowledge on spirituality, knowledge received about spirituality, ways to receive knowledge, the adequacy of the knowledge, the reading of scientific publications, practices concerning spirituality in clinics, practices 4
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Questions 1. Age 2. Have you ever received knowledge about spirituality? 3. Where did you receive the knowledge? 4. Have you received enough knowledge related to spirituality? 5. Do you know the concept of spirituality? 6. Have you ever read scientific publications related to spirituality? 7. Have you implemented spirituality care in clinical practice? 8. What have you done about spiritual care? 9. Do nurses provide holistic care in clinical practice? 10. Do nurses pay attention to patients’ spiritual needs in clinical practice? 11.What is the meaning of spirituality? 12.What is spiritual care?
Figure 1. Personal information form (PIF).
concerning spiritual care, whether nurses deliver holistic care in clinical practice, and the definitions of spirituality and spiritual care (see Figure 1). The Spirituality and Spiritual Care Rating Scale. This scale was developed by McSherry, Draper, and Kendrick in 2002 and consists of 17 items. It includes a 5-point Likert scale, with subscales of spirituality and spiritual care (6, 7, 8, 9, 11, 12, and 14), religiosity (4, 5, 13, and 16), and personalized care (1, 2, and 10). In all, 13 items were scored from 1 ‘‘strongly disagree’’ to 5 ‘‘strongly agree,’’ and 4 items were scored in the reverse order. A mean total score of 5 showed a high level of perceived spirituality and spiritual care. In general, higher scores indicate a higher level of perception of spirituality or provision of spiritual care.35 The Turkish version of the Spirituality and Spiritual Care Rating Scale (SSCRS) was used in this study. Ergu¨l and Bayık Temel30 determined the validity and reliability of the Turkish version of the scale. The Cronbach’s alpha, on the Turkish version of the scale, was 0.76.
Data collection The data were collected at the end of the spring semester of the 2009–2010 (control group) and 2010–2011 (intervention group) academic years. There was no pretesting done or assessment at any other time during the curriculum. The data collection forms mentioned below were distributed to the students who agreed to participate in the study. Students independently completed the forms in their classrooms under the supervision of researchers. It took approximately 30 min for the students to complete the forms. 5
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Ethical considerations Permission to conduct the study at the nursing school was obtained from the schools’ management teams (there was no Institutional Ethics Board). The rights of the participants were protected in this study by obtaining informed consent, as participants were given full information about the study, as to what the requirements, purpose, and benefits were. Respect for confidentiality and anonymity was maintained by ensuring that information given by the participants was kept private. Protecting the right to withdraw from the study was enforced by informing the participants that they could refuse to participate at any time during the research process.
Procedure The students in the intervention group received information about spirituality, and the students in the control group did not (see Figure 2). During the first 2 years of the program integration, spirituality was taught to students. In the first year, 3 h were used to teach patterns of values and beliefs according to the FHPs. The course included small group discussions, which were guided for 1 h by questions prepared by the first researcher. Students were gathered in a classroom after the group discussion. The first researcher gave a 2-h theoretical lecture to the students on spirituality using PowerPoint presentations. During the second year, the importance of spirituality in adulthood and at advanced ages was taught using PowerPoint presentations (see Figure 3). During the third year, real patient scenarios were prepared after discussions by both the researchers and faculty members according to all 11 areas of the FHPs, which were taught to groups of 15–18 students. The nursing diagnosis of spiritual distress and nursing interventions were discussed according to the data on patterns of values and beliefs. Two patient scenarios (breast cancer and heart surgery) were discussed. The scenarios were developed based on the data collected from actual patients. Illness can challenge one’s personal system of meaning. Scenarios were chosen that could confuse meaning and purpose in life at times of crisis and life-threatening illness/potentially leading to death, such as patients who had cancer or required heart surgery. During the discussions, no PowerPoint presentations were used. In addition to the scenarios, concepts were discussed with a patient care plan configured according to the FHPs during 8 weeks of clinical practice. Students in their senior year had a year-round internship with two semesters of 15 weeks each; they discussed concepts as they related to patient care plans that were then applied in the clinical settings with patients. The curriculum did not include any additional programs that are associated with this topic, which might have influenced student learning. The questionnaires were administered once for both the intervention and control groups after the programs were completed, during the final examination week.
Data analysis All questionnaires were coded. SPSS version 14.0 was used for all analyses. The quantitative data collected from the personal information form (PIF) were analyzed using descriptive statistics using proportion, frequency, and chi-square analyses. The results of the SSCRS are reported as means (+ standard deviation (SD)) and the independent t tests were used to determine the SSCRS score differences among study participants. The qualitative responses on the PIF were then coded and later analyzed using descriptive statistics, proportions, and frequency of spiritual care practices and definitions of spirituality and spiritual care were noted. 6
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Department of Nursing, Health Institute, Cumhuriyet University
Control Group (N = 72)
1st year Bio-psychosocial care; in the 2nd, 3rd and 4th years, there was no teaching on spirituality concepts
Intervention Group (N = 58)
1st year and 2nd year 1. Small group discussion (15-18 students) on spirituality 2. PowerPoint presentation on spirituality
3rd year 1. Small group discussion in written cases of patients (15-18 students) 2. Discussion on patient care plan prepared according to FHPs during eight-week practice at clinics
4th year Discussion on patient care plan prepared according to FHPs during internship Figure 2. The concept of spirituality in the curricula. FHP: functional health pattern.
Findings Characteristics of the sample The total response rate was 85% (N ¼ 130); 77.6% (n ¼ 58) of the students in the intervention group and 96% (n ¼ 72) in the control group completed the questionnaires, and 156 students completed the nursing programs; these students participated in the study as or the intervention group, respectively; all the students were females and none was married. The mean age was 21.8 years (SD ¼ 0.95 years); for the intervention group the mean age was 22.1 years (SD ¼ 0.97 years), and for the control group it was 21.8 years (SD ¼ 1.47 years). Other characteristics of the study participants are summarized in Table 1; about 95% of the students 7
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First year
Small group discussion about questions:
1h
What is holism? What is holistic care? What are values? What is belief? What are spirituality concepts? What is religion? What is the difference between religion and spirituality? What are the reasons to emerge regarding spirituality concepts? PowerPoint presentation on spirituality concept (related to
2h
the above questions) Second year 2h
What is spiritual distress? What are the indicators of spiritual distress? What are verbal statements of persons in spiritual distress?
Third year
Discussion of patient scenarios (breast cancer and heart surgery)
8+8 = 16 h
and in clinical practice and patient care plan by FSO discussion of spiritual distress Year-round internship
Fourth year
Patient care planning/spiritual distress
Figure 3. Course program related to spirituality (intervention group).
in the intervention group and 54.2% of the students in the control group stated that they had knowledge about spirituality. A total of 76.9% of the students in the control group and 98.1% of the students in the intervention group remarked that the knowledge was adequate, and 37.5% of the students in the control group and 67.2% in the intervention group reported that they read scientific publications related to spirituality. Most of the students (93.1% in the control group and 84.5% in the intervention group) pointed out that the nurses in clinics did not offer holistic care and did not attend to the spiritual needs of patients. There were significant differences in receiving information about spirituality and the implementation of spiritual care between the control group and the intervention group (Table 1).
Posttest scores of SSCRS Table 2 shows the means and SD posttest scores of the SSCRS; for the intervention group (M ¼ 56.34, SD ¼ 5.47), this was higher than the control group (M ¼ 53.81, SD ¼ 4.37). The mean score on the subscale of ‘‘spirituality and spiritual care’’ was 25.09 (SD ¼ 2.78) in the control group, while it was 27.10 (SD ¼ 3.69) in the intervention group. For the subscale of ‘‘religiosity,’’ the control group scored 8
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Table 1. Posttest scores of status and ways of receiving knowledge, observations, and practices related to spirituality. Students’ responses Knowledge about spirituality Yes No Where receiving knowledge Undergraduate education No undergraduate educationb Adequate knowledge received Adequate Not adequate Reading scientific publication related to spirituality Yes No Implementing spirituality care in clinical practice Yes No Nurses Offered holistic care Did not offer holistic care Nurses Gave attention to patients’ spiritual needs Did not give attention to patients’ spiritual needs Total
Control group n (%)
Intervention group n (%)
Test
39 (54.2) 33 (45.8)
55 (94.8) 3a (5.2)
w2 ¼ 25.52 p ¼ .000
0 (0.0) 39 (100.0)
55 (100.0) 0 (0.0)
w2 ¼ 94.00 p ¼ .002
30 (76.9) 9 (23.1)
54 (98.1) 1 (1.9)
w2 ¼ 46.56 p ¼ .000
27 (37.5) 45 (62.5)
39 (67.2) 19 (32.8)
w2 ¼ 11.36 p ¼ .001
45 (62.5) 27 (37.5)
50 (86.2) 8 (13.8)
w2 ¼ 9.17 p ¼ .002
5 (6.9) 67 (93.1)
10 (15.5) 48 (84.5)
w2 ¼ 3.337 p ¼ .068
8 (11.2) 64 (88.8) 72 (100.0)
4 (6.9) 54 (93.1) 58 (100.0)
w2 ¼ 0.681 p ¼ .409
a
Discontinuous. Congresses and symposia, written, verbal media, and family.
b
12.26 (SD ¼ 2.44), and the intervention group scored 10.72 (SD ¼ 2.45). The mean scores of both groups for the subscale of ‘‘personalized care’’ were similar (M ¼ 14.43, SD ¼ 2.14; M ¼ 14.34, SD ¼ 1.80, respectively). There was a significant difference between groups in the mean scores on the scale and on all subscales, except for personalized care.
Posttest scores of spiritual care practices of the students during clinical practice As shown in Table 3, a total of 84.4% of the control group and 40.0% of the intervention group noted that they prepared a proper environment for patients to pray, say Salat/prayer, and read the Qur’an (the sacred book of Islam); 64.0% of the intervention group students had diagnosed ‘‘spiritual distress’’ and performed appropriate interventions. None of the students in the control group diagnosed ‘‘spiritual distress.’’
Posttest scores of descriptions of spirituality and spiritual care Table 4 presents posttest scores the definitions for spirituality and spiritual care of the students in both groups. A total of 24.9% of the students in the control group and 31.3% of the students in the intervention group described spirituality as ‘‘the inner world that generates a purpose in life with regard to an individual’s values and beliefs,’’ 20.7% of the students in the control group and 27.7% of the students in the intervention group described it as ‘‘the meaning of life,’’ and 18.1% of the students in the control group and 9
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Table 2. Posttest scores of Spirituality and Spiritual Care Rating Scale (SSCRS) mean. SSCRS scores
N
General Control group 72 Intervention group 58 Total 130 Subscales Spirituality and spiritual care Control group 72 Intervention group 58 Total 130 Religiosity Control group 72 Intervention group 58 Total 130 Personalized care Control group 72 Intervention group 58 Total 130
Mean
SD
Minimum
Maximum
Test
53.8194 56.3448 54.9462
4.37125 5.47258 5.03370
42.00 45.00 42.00
68.00 69.00 69.00
t ¼ 2.926 p ¼ .004
25.0972 27.1034 25.9923
2.78911 3.69300 3.36304
17.00 14.00 14.00
31.00 35.00 35.00
t ¼ 3.425 p ¼ .001
12.2639 10.7241 11.5769
2.44945 2.45516 2.56048
6.00 5.00 5.00
18.00 15.00 18.00
t ¼ 3.558 p ¼ .001
14.3472 14.4310 14.3846
1.80890 2.14486 1.95842
11.00 9.00 9.00
19.00 20.00 20.00
t ¼ 0.237 p ¼ .809
SD: standard deviation.
Table 3. Posttest scores of spiritual care practices of the students during clinical practice.
Practices of spiritual carea Respecting individuals’ values and beliefs Being merry/compassionate Respecting individuals’ privacy Encourage patients to pray/say Salat and read Qur’an Diagnosing spiritual distress and conducting interventions for the nursing diagnosis Ensuring everyone shares his or her feelings Allowing patients’ relatives to visit them
Control group (n ¼ 45) n (%)
Intervention group (n ¼ 50) n (%)
9 (20.0) 4 (8.9) 12 (26.7) 38 (84.4) 0 (0.0)
14 (28.0) 4 (8.0) 9 (18.0) 20 (40.0) 32 (64.0)
8 (17.8) 8 (17.8)
11 (22.0) 2 (4.0)
a
Multiple answers were given.
54.5% of the students in the intervention group defined spiritual care as ‘‘care that respects an individual’s values and beliefs.’’
Discussion Incorporating the concept of spiritual care into nursing curricula improves the preparation of nurses to address the spiritual needs of patients. However, more organized discussions are needed about where and how spirituality should be incorporated into nursing education.9 While some nursing researchers have emphasized that teaching the concept of spirituality should focus on an integrated training model,26,36 others have supported the traditional educational model.24 The proposed integration model was developed to include concepts of spirituality in the subjects taught throughout the training process. Teaching spirituality 10
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Table 4. Posttest scores of descriptions of spirituality and spiritual care.
Descriptions of the studentsa What is spirituality? Inner world that generates a purpose in life toward individuals’ values and beliefs Strength that brings hope in life Meaning of life A term including religious practices/relations with Allah A concept that includes religion but is broader than religion Ignored topic in clinical practice Very important concept in human’s life Psychological comfort Love Missed What is spiritual care? Care that respects individuals’ values and beliefs Care considering ethical principles Apply religious practices that relax individuals Provide a peaceful environment for individuals Prevent experiences of spiritual distress Ensure sharing their feelings Empathy Provide holistic care Emotional support Missed
Control group n (%)
Intervention group n (%)
18 (24.9) 3 (4.1) 15 (20.7) 14 (19.4) 1 (1.4) 0 0 12 (16.6) 0 9 (12.5)
24 (31.3) 14 (22.9) 17 (27.7) 4 (6.9) 1 (1.7) 1 (1.7) 2 (3.4) 4 (6.9) 2 (3.4) 4 (6.9)
13 (18.1) 0 6 (8.3) 2 (2.7) 0 10 (13.8) 5 (6.9) 30 (41.6) 13 (18.1) 9 (12.5)
34 (54.5) 1 (1.7) 2 (3.4) 4 (6.9) 3 (4.2) 3 (4.2) 0 10 (13.8) 2 (3.4) 4 (6.9)
a
Multiple answers were given.
in a single module or course might not be adequate. In this context, several researchers have recommended that teaching spirituality is more effective when the faculty loosely defines spirituality, identifies specific topics to be taught, and uses real-life teaching strategies that assist nurses in developing diagnoses concerning spiritual strengths, distress, or despair.26,37 Wallace et al.10 developed a curriculum for teaching spirituality to nurses and integrated it into 13 different nursing curricula; they reported that the spiritual knowledge and attitudes of 34 senior nursing students improved significantly after the students received the integrated curriculum. The findings of this study showed significant differences between the general SSCRS scores of senior undergraduate nursing students in the two groups studied (F ¼ 8.559, p ¼ .004). The differences observed might have been due to the integration of spirituality into the curriculum. More specifically, the differences might have been due to spirituality being defined more clearly in the intervention group of students, patient scenarios being used in the classroom, and the patient care plans discussed with faculty members in the clinical setting. Spirituality was not discussed in classrooms or on the clinical rotations of the students in the control group. The use of patient scenarios for teaching is a useful student-centered approach to learning that allows students to solve real or simulated problems in a safe classroom environment. The patient scenarios give students the opportunity to think and reflect over an experience before being confronted with it in real time. In addition, such an approach might help students become critical thinkers and practitioners. The discussions might help the students increase their self-awareness and knowledge about the spiritual dimension of patients using the FHPs. However, although useful, such discussions are insufficient. Researchers have suggested that the necessary knowledge, skills, and principles of spiritual care can be 11
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achieved using case studies.35 Wallace et al.10 showed a significant difference in the knowledge and attitudes toward spirituality among senior-level nursing students as a result of the integration of spirituality into the undergraduate nursing curriculum. Lovanio and Wallace8 found that the spiritual attitudes and knowledge of undergraduate nursing students were significantly different when spiritual education was included in a course. Baldacchino11 suggested that the practice of self-reflection, consideration of case studies, and small group discussion were useful non-traditional methods for nursing teachers to improve nursing students’ understanding of spiritual care and provided them with the understanding of holistic care. Taylor et al.14 used a quasi-experimental study that identified significant improvement in the spiritual care attitudes, abilities, experiences, and knowledge of nursing students and nurses after using self-learning spiritual education materials. Other studies reported that providing spirituality and spiritual care education to nursing students increased their knowledge and attitudes.9,24 The findings of this study showed that there was no significant difference in the scores on the subdimension of personal care on the SSCRS between the two groups. This outcome might have been due to the similar teaching methods, regarding the personal care of patients, in the curricula used for both groups, and perhaps the emphasis on the importance of bio-psychosocial and holistic care. In this study, while the posttest scores on the SSCRS for spirituality and spiritual care were higher in the intervention group of students, the scores on the SSCRS for the religious sub-dimension were higher in the control group of students (see Table 2). These findings suggest that the control group was more attentive to the religious need/observances than the intervention group. This finding could be due to the fact that participants in the control group did not view spirituality as something separate from religious belief and religious practice. In addition, the concept of spirituality and the word/concept of religion are frequently used interchangeably in our culture. The complexity of the concept of spirituality may have contributed to this outcome; participants might have preferred to use the ‘‘religious domain’’ when this topic was brought up instead of spirituality. In addition, the definition of spirituality might not have been loosely defined, in the control group. Although holistic care was included in the curriculum of the control group of students, spirituality was not incorporated into the curriculum. In this group, holistic care was defined as physical, mental, and social or bio-psychosocial care, not spiritual care. Spiritual care is different from bio-psychosocial care and emotional support even though spiritual distress is often made manifest by emotions. North American Nursing Diagnosis Association’s (NANDA)38 defining characteristics of spiritual distress were included, without religious/cultural ties. It is defined as the impaired ability to experience and integrate meaning and purpose in life through connectedness with the self, others, art, music, literature, nature, and/or a God/or power greater than oneself.39 The students in the control group learned about spirituality, in their community and on the Internet, as religious values and beliefs and by enculturation. Thus, for the control group of students, spirituality was more closely related to religiosity. In addition, in Turkey, spirituality is viewed synonymously with formal religion, often described in terms of religious beliefs, and practices and many people express and experience their spirituality within the context of religion. Religion can serve as a vehicle for expressing spirituality through a framework of values, beliefs, and ritual practices.40 Religions provide a set of beliefs about a God or supernatural powers upon which practices are based. Spirituality is a concept much broader than religion.41 Spirituality is characterized by faith, a search for meaning and purpose in life, a sense of connection with others, and a transcendence of self, resulting in a sense of inner peace and well-being.41 Burkhardt42 described it as inner strength, meaning and purpose, and harmonious interconnectedness. Coyle43 later described it as a belief in God or higher power, religious practices, and personal values. It is difficult for nursing students to understand the distinction between religion and spirituality. Wallace et al.10 reported that nursing curricula should enable students to understand spirituality in a broader context, one that goes beyond religious beliefs. In addition, nursing students should be taught differences between religion and spirituality as well as what they have in common. Moreover, Pesut24 suggested effective 12
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methods for resolving the difficulties in understanding these concepts, such as providing sufficient training and reading on the topics. However, in this study only a very limited number of publications for the students regarding spirituality, in the field of nursing, were found to be available in Turkish; this resulted in the level of reading scientific publications being less than desired, even among the students in the intervention group (67.2%), who were continually encouraged by teachers to look for resources and read more publications on the topic. In this study, the students reported that nurses in the clinical settings did not provide holistic care to their patients and did not care for the spiritual needs of their patients (see Table 1). In a previous study,20 the most common obstacles reported, preventing nurses from giving spiritual care to their patients, was the lack of time and education on the topic. In a study carried out in Turkey, spirituality (73%) and spiritual care (93.4%) were not defined by the majority of nurses; however, most of them (83.2%) reported that education was necessary to identify spiritual dimensions and that their education with regard to spirituality was insufficient.31 In another study, Turkish nurses’ perception of spirituality and spiritual care was reported to be insufficient.33 It implies that the majority of nurses may not be familiar with the concepts of spirituality and spiritual care. They do not seem to consider spirituality and spiritual care to be something separate specific nursing but something integral to the art and science of nursing. In a study reported by Narayanasamy,44 although nurses were aware of the spiritual needs of patients, they found that these needs were poorly met. Nurses’ competence in meeting the spiritual needs of their patients should be improved by education on spiritual care. However, the spiritual needs of patients must be seen in the context of service requirements and the successful business outcomes of a given clinical setting. Currently, the attitudes of nurses contribute to an emphasis on providing physical care to patients rather than spiritual care.45 As nursing has become more oriented toward task accomplishment, the spiritual dimension of care has been neglected, and this has threatened the concept of holistic care. This is because the spiritual dimension has not been considered to be relevant to patient care.26 However, if nurses are expected to provide holistic nursing care, then nurse educators must address all dimensions of holistic nursing throughout undergraduate curricula. Spiritual nursing care is increasingly being cited in the nursing literature as a fundamental ethical obligation. This obligation is based on the argument that nurses provide holistic care, spirituality is a universal dimension of the person, and so nurses should care for the spiritual dimension.46 In addition, among professional healthcare disciplines, the role of spirituality in patient care is acknowledged in ethical codes, guiding standards of practice, conduct, and behavior.22 It is believed that spirituality is the cornerstone of nursing practice and that addressing spiritual care needs and preferences in patient care practice is both a moral and ethical obligation.47 Some nursing models, which include spirituality in their theory, such as Roper et al.’s model and Neuman’s systems model, can be applied to incorporate spirituality into nursing curricula.48 Moreover, additional research is needed to articulate how spirituality can best be taught in both the classroom and during clinical practice. The challenge is for students to clearly understand the importance of spirituality in relationship to the delivery of nursing care in the clinical setting.4 In addition, Salmon et al.4 have stressed the importance of student learning in real-life situations. Nursing scholars9,26 have emphasized that the clinical environment provides rich experiences for students to discover spiritual dimensions, and that the nurses working in clinical areas should be role models for students. However, the medical literature shows that healthcare professions neglect spiritual care.7 Baldacchino49 reported that ‘‘since spiritual care is not being given the merited attention, learning the spiritual dimension in care through role models appears to be impracticable.’’ Therefore, learning about the spiritual dimension from role models in the clinical setting is hard to achieve. Thus, the fact that nurses do not provide holistic care or that they fail to pay attention to the spiritual needs of their patients limits the ability of nursing students to develop the skills needed for providing spiritual care. The practice of nursing can be used to demonstrate how spirituality could be incorporated into the patient’s plan of care. This will involve identifying the patient’s spiritual needs through conducting a spiritual assessment, planning, and implementing the appropriate interventions 13
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to help patients meet their needs and evaluating to what extent these interventions have been successful.28 Moreover, in this study, discussions on the concept of spirituality, patient care planning, and in various clinical areas increased the students’ understanding of the concept of spirituality. The results of this survey demonstrated that students in both the intervention and the control groups could prepare a proper environment for patients to pray/say Salat and read the Qur’an; they usually cite religious practices as forms of spiritual care in clinical practice. Spiritual care practices were not as common in the control group compared to the intervention group. This might have been due to the understanding of spirituality by students who developed from their religious teachings, personal beliefs, and their worldviews. The students likely had a well-developed cultural standpoint and their upbringing likely informed them to perceive spirituality as rooted in religion rather than developing a more humanistic perspective, or vice versa.50 In Turkey, both spirituality and religiosity are features of cultural identity and praying is widely used as a therapeutic tool by Turkish citizens. Meraviglia51 reported that ‘‘Prayer is an indicator of the defining attribute of connectedness with God and meaning in life is an outcome of spirituality.’’ In this study, when examining the answers given by the students to the question What is spirituality and spiritual care? the intervention group students defined the terms of spirituality and spiritual care referred more commonly to the meaning and purpose of life when compared to the control group students, but there responses were not satisfactory in intervention group. These findings suggest that students in the intervention group require further education on the topic of spirituality. The definition of spirituality is not easy for an undergraduate student to understand because of the subjectivity and abstract nature of this concept. Golberg52 notes that the understanding of the word spirituality is complicated by the fact that the word is an abstract noun, whereas the word spirit is a concrete noun. Golberg also describes the concept of spirituality as a quality within where the concrete spirit exists. Teaching about spirituality and spiritual care begins with a broad, universal, all inclusive definition of the concept spirituality. The lack of spiritual education in nursing programs may be the reason for the hesitancy to assess the spiritual needs and promote the spiritual health of patients in clinical practice.
Limitations There were several limitations of this study. The sample size, although adequate for examining the integration of the spiritual domain into the undergraduate nursing curriculum, limits generalization of the results. However, the findings can be generalized to similar cultural groups. In this study, all the students were female. The plan is to include males in future studies.
Conclusion This is the first study in Turkey to compare and evaluate a traditional undergraduate nursing curriculum with a curriculum that integrated spiritual care into the education of undergraduate nursing students. FHPs were used for the first time to integrate the spiritual domain into the curriculum. The findings from this study suggest that using interactive methods and integration of spirituality into the undergraduate nursing curriculum increased the students’ spiritual knowledge and attitudes. Gordon’s FHPs provide a holistic structure, which allows for the integration of the spiritual domain into the undergraduate nursing curriculum. The inclusion of spirituality into nursing education should be practiced more widely. In the future, data from pretest/posttest studies and analysis of students’ personal spirituality may add to improved understanding in this area of research. 14
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Relevance to clinical practice A holistic approach to patient care should include the care of a patient’s spiritual needs as well as their physical needs. Because spirituality is a moral obligation of care. This study provides data that support the recommendation that spirituality should be integrated into baccalaureate nursing programs in order to prepare student nurses to meet the spiritual needs of patients. Acknowledgments The authors would like to thank the students who participated in the study. Conflict of interest The authors declare that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-forprofit sectors. References 1. Narayanasamy A and Owens J. A critical incident study of nurses’ responses to the spiritual needs of their patients. J Adv Nurs 2001; 33(4): 446–455. 2. Pesut B. Developing spirituality in the curriculum: worldviews, intrapersonal connectedness, interpersonal connectedness. Nurs Educ Perspect 2003; 24(6): 290–294. 3. Tiew LH, Creedy DK and Chan MF. Student nurses’ perspectives of spirituality and spiritual care. Nurse Educ Today 2013; 33(6): 574–579. 4. Salmon B, Bruick-Sorge C, Beckman SJ, et al. The evolution of student nurses’ concepts of spirituality. Holist Nurs Pract 2010; 24: 73–78. 5. Nagase M. Does a multi-dimensional concept of health include spirituality? Analysis of Japan Health Science Council’s Discussions on WHO’s ‘‘Definition of Health’’ (1998). Int J Appl Soc 2012; 2(6): 71–77. 6. International Council of Nurses. The ICN Code of Ethics for Nurses, http://www.icn.ch/images/stories/documents/ about/icncode_english.pdf (2012, accessed 25 November 2013). 7. McEwen M. Spiritual nursing care. Holist Nurs Pract 2005; 19: 161–168. 8. Lovanio K and Wallace M. Promoting spiritual knowledge and attitudes: a student nurse education project. Holist Nurs Pract 2007; 21: 42–47. 9. Van Leeuwen R, Tiesinga LJ, Middel B, et al. The effectiveness of an educational programme for nursing students on developing competence in the provision of spiritual care. J Clin Nurs 2008; 17: 2768–2781. 10. Wallace M, Campbell S, Grossman SC, et al. Integrating spirituality into undergraduate nursing curricula. Int J Nurs Educ Scholarsh 2008; 5: 1–13. 11. Baldacchino DR. Teaching on spiritual dimension in care to undergraduate nursing students: the content and teaching methods. Nurse Educ Today 2008; 28: 550–562. 12. Keefe S. Infusing spirituality into health education. New Engl Adv Nurse 2005; 9: 41–42. 13. Meyer JE. New paradigm research in practice: the trials and tribulations of action research. J Adv Nurs 2003; 18: 1066–1072. 14. Taylor EJ, Mamier I, Bahjri K, et al. Efficacy of a self-study programme to teach spiritual care. J Clin Nurs 2008; 18: 1131–1140. 15. Lemmer C. Teaching the spiritual dimension of nursing care: a survey of US baccalaureate nursing programs. J Nurs Educ 2002; 41: 482–490. 15
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