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Exploration of Clinical Nurses’ Perceptions of Spirituality and Spiritual Care

Wu, Li-Fen; Lin, Lih-Ying

doi: 10.1097/JNR.0b013e318236cf78
Original Articles

Background: Florence Nightingale emphasized the need for nurses to honor the psychological and spiritual aspects of patients to promote patients’ health. Whereas Chan’s (2010) study of a public hospital in Singapore presented similar findings, few studies have explored clinical nurses’ perceptions of spirituality.

Purpose: The purpose of this study was to investigate the role of specific nurse demographic characteristics in predicting perception differences with regard to spirituality and spiritual care.

Methods: The Chinese version of the Spirituality and Spiritual Care Rating Scale was developed using a translate and back-translate process, achieving a content validity index of .98. This study used a cross-sectional descriptive survey with 350 clinical nurses as the study sample. Three hundred forty-nine valid questionnaires were returned (response rate, 99.71%). The institutional review board of the hospital approved this study.

Results: Most participants were women, ranging in age from 23 to 64 years. Participants’ clinical experience ranged from less than 1 year to 40 years, with a mean experience value of 13.42 years. Participants were distributed among all clinical specialties. Slightly less than half (41.83%) professed no religious belief, and most were not involved in religious activities (55.01%, n = 192). A little over half (53.58%, n = 187) had received spiritual care lessons during nurse training, and more than half (58.74%, n = 205) had received spiritual care continuous education after graduation. This survey found perception of spirituality positively related to holding a master’s degree, 11 to 19 years of clinical experience, specialty in palliative nursing, and having received spiritual care lessons during nursing training or continuing education. Clinical nurses who held a master’s degree or received spiritual care lessons during continuing education had higher levels of spiritual care perception.

Conclusions/Implications for Practice: This study found education to have a positive impact on participants’ perception of spirituality and spiritual care. A higher education level and more spiritual care lessons or training courses were found to increase perception level. Study findings provide preliminary insights into nurses’ perceptions of spirituality and spiritual care in Taiwan. Findings demonstrate an urgent need for additional education programs or training in spiritual care to improve the ability of nurses in catering to the spiritual needs of patients and guide clinical nurses when conducting spiritual care.

1RN, PhD, Associate Professor, Department of Nursing, National Taichung Nursing College • 2RN, MSN, Director, Department of Nursing, Taichung Veterans General Hospital.

Accepted for publication: August 22, 2011

*Address correspondence to: Lih-Ying Lin, No. 160, Chung-Kang Rd. Sec. 3, Taichung City 40705, Taiwan, ROC. Tel: +886 (4) 2359-2525 ext. 6000; E-mail: leah@vghtc.gov.tw

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Introduction

Florence Nightingale, regarded as the founder of modern nursing, emphasized the need for nurses to honor the psychological and spiritual aspects of patients to promote patients’ health (Macrae, 2001). Tanyi (2002) emphasizes that understanding the spiritual dimension of human experience is very important to nursing, because nursing is a practice-based discipline that focuses on the human being. Nurses care for patients on a daily basis and do not separate spiritual care from caring for the whole person. Chung, Wong, and Chan (2007) showed that nurses’ perceptions of their own spirituality influence the degree to which patients’ spiritual needs are identified and interventions are planned and implemented. Chan’s (2010) study of a public hospital in Singapore presented similar findings. She found a positive correlation between spiritual care perceptions and spiritual care practices among nurses, indicating that the greater a nurse’s spiritual care perceptions are, the more frequently spiritual care is included in his or her practice. However, there has been little study of clinical nurses’ perceptions of spirituality and spiritual care in Taiwan.

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Literature Review

Murray and Zentner (1989) defined spirituality as, “A quality that goes beyond religious affiliation, that strives for inspirations, reverence, awe, meaning and purpose, even in those who do not believe in any uprightness. The spiritual dimension tries to be in harmony with the universe, and strives for answers about the infinite, and comes into focus when the person faces emotional stress, physical illness or death.” Mansfield, Mitchell, and King (2002) also proposed that spirituality provides a personal sense of meaning and life purpose, which is not confined to the beliefs and practices of a particular religion. McSherry, Draper, and Kendrick (2002) indicated that spirituality was not only a concept associated with religion, systems of faith, and worship but also a universal concept, unique to all people, such as creativity, art, and self-expression. Spirituality is a much broader phenomenon than simply a formal religious expression.

The literature providing instances associating spiritual care with the quality of interpersonal care includes assisting an individual to find meaning and purpose in their illness (Simsen, 1985), listening attentively to a patient (Burnard, 1988), enabling an individual to maintain their religious practices while in the hospital (Narayanasamy, 1993), maintaining privacy and dignity (McSherry, 2000), validating clients’ feelings and thoughts, facilitation, instilling hope (Tuck, Wallace, & Pullen, 2001), expressing love and compassion toward patients, conveying a benevolent attitude (Tanyi, 2002), listening, being present, prayer, use of religious objects, and talking with clergy (Grant, 2004).

Taiwan is an immigrant society of over 23 million people living in an area around 13,800 square miles. As much as 80% of the population adheres to some form of traditional folk religion, which includes aspects of shamanism, ancestor worship, and animism (U.S. Department of State, 2009). Such folk religions may overlap with an individual’s belief in Buddhism, Taoism, or Confucianism. A small percentage of the population considers themselves Protestants, Roman Catholics, and Sunni Muslims (U.S. Department of State, 2009). In Taiwan, spirituality is considered a part of religious culture. In much of the literature, spirituality is used to indicate religion, and spiritual care is mostly practiced in hospice care centers by religious people (Shaw, Joseph, & Linley, 2005).

Narayanasamy (1991) emphasizes that an individual’s spirituality may be determined by aspects of life that are deeply personal and specific, such as values, beliefs, and relationships. Hence, personalized care is an important element that must be considered in any exploration or definition of spirituality.

This study aimed to explore Taiwanese clinical nurses’ perceptions of spirituality and spiritual care and investigate whether their demographic characteristics can predict differences in individual perceptions of spirituality and spiritual care.

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Methods

Research Design

The study used a cross-sectional descriptive design and employed a survey questionnaire to solicit responses from a large number of participants within a limited time frame.

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Sample and Setting

A large medical center in Taiwan with more than 1,500 clinical nurses of different backgrounds was purposely selected as the study sample. The researcher used GPower v3.1 software to analyze F tests (one-way) to compute the point at which the alpha error probability reached .05, the power (1 − β error = 0.95) number of the group reached 5, and the required total sample size was determined at 305, with actual power being 0.95. Purposive sampling was used, and one working day was randomly selected. All nursing staffs on duty were invited as study participants. Three hundred fifty clinical nurses were invited to join, thus satisfying sample size requirements (n > 305). The job responsibilities of clinical nurses focus mainly on providing direct patient care. Clinical nurses thus have high relevance to the current study topic, and their backgrounds provided information for understanding the issue and facilitating comparisons with previous findings.

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Instruments

A data sheet was designed to collect information on the participants’ demographic profile, including gender, age, educational level, clinical experience, specialty, and religion.

The study used the Chinese version of the Spirituality and Spiritual Care Rating Scale (SSCRS-C) as the study tool. The SSCRS was developed by McSherry et al. (2002) and was categorized into four subscales: (a) Existential Elements, 5 items; (b) Spiritual Care, 5 items; (c) Religiosity, 3 items; and (d) Personalized Care, 3 items. Each statement in the SSCRS was rated on a 5-point Likert-type scale, ranging from strongly disagree to strongly agree. Positively worded items were scored 1 to 5; negatively worded items were scored in the reverse manner. For interpretation, perception of spirituality was calculated by total scores for the Existential Elements, Religiosity, and Personalized Care subscales. The perception of spiritual care was calculated using the Spiritual Care subscale. In general, higher scores indicate a higher level of perception of spirituality or spiritual care.

The Cronbach’s alpha coefficient of SSCRS was .64, which showed a reasonable level of internal consistency reliability (McSherry et al., 2002).

The first author personally contacted the author of the original SSCRS and received a letter granting permission to use the scale and a copy of the SSCRS. A bilingual nurse who was born in Taiwan and studied in an English-speaking country for 4 years translated the SSCRS English version (E1) into Chinese (C1). A panel of five nurse experts reviewed the translation and produced a reconciled Chinese version (C2) during their meeting. The Chinese version (C2) was back-translated by another bilingual translator (E2). After a comparison of the original version (E1) and the back-translated version (E2), the panel reviewed, reworded, and approved the result. Nine nurse scholars examined the SSCRS-C for semantic equivalence and content validity. The content validity index for the SSCRS-C reached .98.

A pilot study of 50 nurses substantiated research instrument efficacy. Participants provided feedback when they misunderstood a question as well as when a question was vague or not smooth. The author organized their feedback, rewording the sentences and correcting for errors in spelling or format. The pilot study suggested that the instrument could be completed within 15 to 20 minutes.

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Operational Definitions

Clinical nurse: A nurse employed during the study period by the sample hospital.

Perception of spirituality: The sum of the scores of the Existential Elements, Religiosity, and Personalized Care subscales of the SSCRS-C. Existential elements were concerned with the theoretical issues surrounding the need to invest in life with meaning and purpose, which implies having a sense of hope, that is, “I believe spirituality is about having a sense of hope in life.” Religiosity suggested that spirituality was not only a concept associated with religion, systems of faith, and worship but also a universal concept, unique to all people, that is, “I believe spirituality does not apply to Atheists or Agnostics.” Personalized care suggested aspects of spirituality that are unique, different, and specific to each individual, that is, “I believe spirituality involves personal friendships, relationships.” Negatively worded items were scored in a reverse manner. In general, higher scores indicate a higher level of perception of spirituality.

Perception of spiritual care: The score of the Spiritual Care subscale of the SSCRS-C. Variables appear to identify the main elements of spiritual care highlighted as important in the literature, that is, “I believe nurses can provide spiritual care by showing kindness, concern and cheerfulness when giving care.” In general, higher scores indicate higher level of provision of spiritual care.

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Data Collection Procedures

A research assistant distributed letters with information on the purpose and procedures of the study, together with the study questionnaire, to all participants. Confidentiality and anonymity in data handling were assured. Three hundred fifty questionnaires were delivered, and 349 completed questionnaires were returned, giving a response rate of 99.71%. Table 1 presents a full summary of respondent demographic information.

TABLE 1

TABLE 1

TABLE 2

TABLE 2

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Data Analysis

This study used descriptive statistics to describe participants’ demographic characteristics. An independent t test and one-way analysis of variables (ANOVA) were used to determine differences in participants’ perceptions of spirituality or provision of spiritual care and participants’ demographic characteristics. The level of significance was set at .05.

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Ethical Considerations

The institutional review board of the hospital approved this study (TCVGH-C10099). After the initial screening for participants’ eligibility and an explanation of the purpose, all participants were advised of test data confidentiality.

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Results

Participant Characteristics

Most participants were women (99.71%, n = 348), with men accounting for only 0.29% (n = 1). Ages ranged from 23 to 64 years, with a mean age of 37.3 years. The highest educational level of participants was bachelor’s degree (69.34%, n = 242), and their clinical experience ranged from less than 1 to 40 years, with a mean professional experience of 13.42 years. Participants covered a wide range of clinical specialties, including medical–surgical nursing (45.85%, n = 160), maternity–child nursing (12.03%, n = 42), palliative nursing (5.73%, n = 20), critical nursing (26.36%, n = 92), psychiatric nursing (2.58%, n = 9), and nursing administration (7.45%, n = 26). Nearly half (41.83%, n = 146) had no religious beliefs, 18.05% (n = 63) held Buddhist beliefs, 13.18% (n = 46) held Taoist beliefs, 18.05% (n = 63) held folk religious beliefs, 5.45% (n = 19) were Protestants, and 0.57% (n = 2) were Catholics. Most were not involved in religious activities (55.01%, n = 192). A little over half (53.58%, n = 187) had received spiritual care lessons during nurse training, and more than half (58.74%, n = 205) had received spiritual care continuous education after graduation (Table 1).

The mean score on the SSCRS-C was 65.85, and the standard deviation was 6.04. The results of the four subscales were as follows: (a) Existential Elements: M = 19.88, SD = 2.46. Median and mode were 20. Five variables dealt with issues concerning life with meaning and purpose and the need to find meaning and purpose during times of illness or hospitalization. Responses showed that participants tend to agree that spirituality incorporates existential elements. (b) Spiritual Care: M = 20.48, SD = 2.28. Median and mode were 20. Five variables dealt with issues concerning the main principles associated with spiritual care. Participants agreed that nurses must listen, spend time, respect privacy and dignity, maintain religious practices, and deliver care by displaying qualities such as kindness and concern. (c) Religiosity: M = 10.99, SD = 2.37. Median was 11, and mode was 12. Three variables dealt with issues regarding the idea that spirituality was not only a concept associated with religion, systems of faith, and worship but also a universal concept, unique to all people. It would appear that this factor measures religiosity and that participants were seemingly opposed to the notion that spirituality only applies to religious people. (d) Personalized Care: M = 11.94, SD = 1.39. Median and mode were 12. Three variables measured underlying associations related to the dimension of spirituality, which is dictated by the need to accommodate personalized care, for example, individual beliefs, values, morals, and relationships. The sum of the scores of the Existential Elements, Religiosity, and Personalized Care subscales represents perception of spirituality. The t test and ANOVA results indicated a statistical significance in the mean score for spirituality among participants of different education levels (F = 4.62, p = .01), clinical experience (F = 4.88, p = .002), specialties (F = 6.23, p = .00), and participation in spiritual care lessons during nursing training (t = 2.28, p = .02) and continued education (t = 6.20, p = .00). Scheffe’s test for post hoc test showed that clinical nurses holding a master’s degree had higher scores than those with associate’s degrees; nurses with 11 to 19 years of clinical experience had higher scores than those with less than 3 years of experience; nurses specializing in palliative care had higher scores than those nurses in other specialties. Higher scores indicated a higher level of perception of spirituality (Table 2).

The score of the Spiritual Care subscale represented perception of spiritual care. The t test and ANOVA results indicated statistical significance in mean perception of spiritual care score among participants of different education levels (F = 4.34, p = .01) and participation in spiritual care training during continued education (t = 2.58, p = .01). Scheffe’s test for post hoc test showed that clinical nurses with a master’s degree had higher scores than those with an associate’s degree. Higher scores indicated a higher level of perception of spiritual care (Table 2).

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Discussion

This article presented the results of developing the SSCRS-C during the translation and back-translation process and used the scale to assess the perception of spirituality and spiritual care of 349 clinical nurses in Taiwan. The SSCRS-C used in the study showed a reasonable level of internal consistency reliability with a Cronbach’s alpha coefficient of .83. Results suggest that the SSCRS-C may be used as a constructed instrument in Chinese-speaking areas.

Nearly all participants (99.7%) were women—a common phenomenon in the nursing profession since the days of Nightingale. Coleman and Ganong (1985) found that women are better at expressing their feelings and at empathizing with the feelings of others. Women are held to be affectionate, compassionate, and sensitive to others’ needs. These features are considered as the core characteristics of nurses even today.

Results of this study revealed significant differences in mean SSCRS-C scores among participants of different education levels. Participants’ education levels appear to have a positive impact on perceptions of spirituality and spiritual care. Findings concurred with previous studies that emphasized that nurse concepts of the nursing practice can be continually broadened through knowledge acquisition (Wong, Lee, & Lee, 2008). Further analyses showed that “receive spiritual care lessons during nursing training” and “receive spiritual care training during continue education” indicate a higher level of perception of spirituality or provision of spiritual care. Clinical nurses in palliative nursing earned higher scores in this study. This phenomenon infers that this group has received more spiritual care lessons in their working environment. Similar studies, such as Bay, Ivy, and Terry (2010), reported that even a 2-day class positively changed perceptions of spirituality in nurse participants.

A clinical experience is a perception of spirituality variable. Clinical nurses with 10 to 19 years of experience had higher scores than those with less than 3 years of experience. Bellack and Morjikian (2005) claimed that clinical nurses with more than 3 years of clinical experience are competent to implement total patient care, because clinical experience is an effective means through which nurses develop the psychomotor and technical skills necessary to understand and manage patient problems. In other words, a 3-year experience is essential for professional nurses who have to design and manage a holistic plan for nursing care, understand patient needs, and guide patients through the maze of healthcare resources in a community.

This study found no difference between religious belief and SSCRS-C score. The findings reported here are the opposite of Chan (2010) regarding religious beliefs being a predictive factor that makes practicing spiritual care more likely. Baldacchino (2006) presented that spiritual care may be influenced by culture. Spirituality in Taiwanese society has been perceived to be interchangeable with religion. Tzeng and Yin (2006) reported on religious influences in and on Taiwanese society. Nurses hope that hospitals can provide appropriate religious services, thereby enabling nurses to better respect the religious needs of their patients. A phenomenon in this participant group was that only half expressed religious beliefs and had a relatively low frequency of religious activity participation. Furthermore, nurses with higher education or nurses who have received more spiritual care training no longer view religion as being synonymous with spirituality.

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Conclusions

Holistic nursing emphasizes physical, psychological, social, and spiritual care. Clinical nurses need a personal spiritual perspective to support patient needs to find meaning and purpose in life and provide spiritual care during times of illness or hospitalization. The SSCRS-C was developed for use as an instrument for measuring the perception of spiritual and spiritual care in Chinese-speaking areas.

The findings of this study provide preliminary insights into nurses’ perceptions of spirituality and spiritual care in Taiwan. Education has a positive impact on participants’ perceptions of spirituality and spiritual care. A higher education level and more spiritual care lessons or training courses can increase perception level. Results recommend that additional education programs or trainings on spiritual care are urgently needed to improve the ability of nurses in catering to the spiritual needs of patients and guide clinical nurses when conducting spiritual care.

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Limitations

In this study, nearly all (n = 348, 99.71%) participants were women—a nursing phenomenon in Taiwan. Hence, it is recommended that further study be conducted to explore the influence of gender on nurses’ perceptions of spirituality and spiritual care. The current study was limited by its focus on one large hospital, which may weaken the generalizability of findings. A random sampling of different hospitals is recommended for a future study.

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Acknowledgments

This study was supported by a grant from Taichung Veterans Hospital and National Taichung Nursing College (TCVGH-NTCNC 998501). The authors sincerely thank all the participants and Yu-Jing Tsai for helping with data collection.

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References

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Keywords:

clinical nurse; perception; spirituality; spiritual care; Taiwan

Copyright © 2011 by the Taiwan Nurses Association.