Spiritual and religious issues often become extremely important for patients during major life events such as birth, trauma, and death (Fink et al., 2014). The United States is rich in cultural and religious diversity. Healthcare professionals must have the knowledge, skills, and attitudes to provide care for people whose beliefs differ from their own, particularly during difficult circumstances (Fink et al., 2014). Spirituality enables people to deal with stress and hardships, and facilitates a sense of hopefulness while promoting comfort (Frouzandeh et al., 2015).
For the purposes of this study, the researchers used the definition and nursing perspective of spirituality provided by Salmon et al. (2010): “Spirituality is whatever the client perceives it to be and nurses need to listen to clients and respect their diversity of beliefs” (p. 78). Therefore, it is crucial for nursing courses to include spiritual and religious issues. One concern nurse educators may have in facilitating open dialogue about worldview in the classroom is that students could be judgmental toward one another when their philosophies differ. A more effective approach would be to encourage students to critically reflect upon their own beliefs and how these may impact their attitudes and behaviors toward patients (Pesut, 2003). According to Giske and Cone (2012), it is important for nursing faculty to be comfortable talking about spiritual issues in the classroom because it is vital for students in understanding their professional role in providing spiritual care, knowing themselves more deeply, becoming less private, and being more willing to share. The researchers in that study categorized spiritual care into three phases: 1) preparing for connection through awareness of personal beliefs, lessons, and discussion in the classroom as preparation for clinical practice; 2) connection with and supporting patients; and 3) reflecting upon personal experiences. The current study was conducted in hopes that students would ponder questions regarding life, death, and spirituality, then internally reflect upon their personal beliefs. Feeling comfortable and confident about their own worldviews will positively impact the spiritual care nursing students provide in the clinical setting.
The definition of spirituality is complex and often challenging for an undergraduate student to grasp because of its subjectivity and abstract nature (Yilmaz & Gurler, 2014). Traditional college students are at a pivotal time in their lives when they are establishing their own identity and searching for answers about spiritual matters (Becker, 2009). Theorist Betty Neuman (1995) believed some individuals may not initially be aware of their spirituality, but over time and through lived experiences, may develop a more conscious understanding of it.
Worldviews are mental roadmaps that people use to explain life and existence. These views contain beliefs and meanings that determine actions and reactions, and therefore, have an impact on the people we care for. To assist students in understanding their own worldviews, educators must initiate these conversations in a safe space that allows students to reflect constructively upon their beliefs. According to Pesut (2003), “researchers have found that many patients view God as a significant source of health and healing. To exclude discussions of God from spiritual education in nursing is to exclude the belief of a significant portion of the population our graduates will care for” (p. 291). Florence Nightingale, along with nurse theorists Jean Watson and Betty Neuman, embraced the spiritual element of the whole person and acknowledged that the nurse is responsible for caring for the spiritual needs of patients (Salmon et al., 2010). A strong sense of spirituality can improve one's self-awareness and confidence while improving an individual's belief in the innate ability to achieve goals (Jun & Lee, 2016).
The current study was conducted in response to Briggs and Lovan's (2014) research where 85.3% of participants felt the same classroom activity heightened their awareness about spiritual issues and/or questions with which their patients may be dealing. Moreover, 73.3% of respondents indicated the same activity caused them to think about spiritual matters and/or questions they had not considered before.
REVIEW OF LITERATURE
A common theme in the literature supports the importance of spiritual interventions in healthcare settings (Speck, 2005). In a study by Tiew et al. (2013), participants considered spirituality as an inherent part of being human, developmental in nature, and vital for well-being. Spirituality provides viable support to assist individuals who are confronting stressors perceived as overwhelming or challenging (Boswell et al., 2013). Gallison et al. (2013) found that 96% of the nurses in their study believed addressing a client's spiritual needs fell within their scope of practice; however, nearly half (48%) reported rarely participating in spiritual care. It is critical to help students overcome their reluctance toward speaking about religion and spirituality. Many people are shaped by the notion that religion and spirituality are private issues that should not be discussed in public (Pesut, 2008). Rather than focusing attention solely toward the physical aspects of nursing care, Pesut argues, “Perhaps it is time to reclaim the concept of the soul, that timeless unique essence that acknowledges personhood beyond the ability to think or have positive feelings” (p. 172).
According to Salmon et al. (2010), student nurses may possess very narrow definitions, if any at all, about their spirituality. Strand et al. (2017) found several students in their study who initially lacked confidence and were reluctant to engage in spiritual talks due to inadequate communication skills. A systematic literature review by Lewinson et al. (2015) confirmed that nurses were aware of their lack of knowledge, understanding, and skills in the area of spiritual care and had a desire to be better informed. Boswell et al. (2013) found that nurses who were uncomfortable with their own spirituality felt it was stressful to manage the spiritual needs of others. Meyer (2003) observed that the greatest predictor of students' ability to provide spiritual care was awareness of their own spirituality. A study by Gallison et al. (2013) revealed that nurses were not prepared to meet spiritual needs of patients, with 61% of respondents scoring less than the ideal mean. Ross et al. (2016) noted that nurse/midwifery educators felt it challenging to enhance spiritual care competency in students who were not religious and investigated how they might encourage students to broaden their perspectives. The results of that study reinforced other findings in the literature that one's own spirituality served as the strongest predictor of perceived ability to provide spiritual care for others.
So what roadblocks inhibit spiritual competence in nurses and students? Gallison et al. (2013) concluded that a nurse's greatest perceived barrier lies in the beliefs that a patient's spiritual life is private; that there is insufficient time to discuss spiritual matters; concern with the gray area between proselytizing versus spiritual care; and difficulty meeting needs when spiritual beliefs differ from their own. Even when nurses identified themselves as spiritual, the results indicated spirituality assessments of patients were inadequate.
The literature review demonstrates a lack of education and a need for better education in the nursing curriculum. Meyer (2003) reported that spirituality content comprised less than 6% of classroom topics and less than 10% of clinical discussions. In that study, the most significant predictor of students' perceived ability to confidently provide spiritual care was the emphasis on spirituality in the curriculum. Therefore, it was suggested that the spiritual domain should receive more attention.
The lack of spiritual education in nursing programs also was identified by Yilmaz and Gurler (2014) and Boswell et al. (2013) as a possible reason nurses may be hesitant to promote spiritual health in their patients. These two studies supported additional holistic education including body, mind, and spirit connections to enhance the healing process. Catanzaro and McMullen (2001) believed nurse educators should be entrusted to fill the spiritual vacuum that exists in nursing education. From their perspective, spirituality is not simply taught, but incorporated into one's way of life. Lewinson et al. (2015) promoted the idea of raising awareness and facilitating competence and confidence with the spiritual dimension of nursing.
Taylor (2013) found that comfort with spiritual assessment can be learned regardless of personal characteristics if there is proper training and a perception of importance. Although a discussion of worldviews in the classroom may seem risky, Pesut (2003) sees a benefit in open dialogue that allows students to experiment with issues and questions they will inevitably encounter in the clinical setting. The author presents a valid question: “How can we expect students to explore beliefs and meaning with their patients if we are not willing to do the same in the classroom?” (p. 292).
The literature revealed the first step of implementation should include spiritual self-assessment, improved sense of self-efficacy, and sensitivity. However, the need for improved self-awareness among students was a common theme found in the literature (McSherry et al., 2006; Tiew et al., 2013). Salmon et al. (2010) suggested that faculty members need to be more sensitive and aware of spirituality in themselves, students, and clients. The lack of guidance regarding spiritual self-awareness is concerning, according to Pesut (2008). After reviewing 10 textbooks on nursing fundamentals, Pesut stated:
Less well developed was the competency of nurses' self-awareness related to spirituality and religion. Self-awareness entails having thought through one's perspective related to religion and spirituality and understanding how that perspective may influence interactions with patients. Although the literature frequently acknowledged the need for this self-awareness, little or no guidance was given about what this means or how it should occur. (p. 169)
What can be done to improve this deficit? An effective intervention found in the literature was reflective journaling. According to Catanzaro and McMullen (2001), it is beneficial to include a journal reflection about spirituality as part of a clinical assignment because students may not introspectively consider their own spirituality unless prompted to do so. They found that students who were most comfortable with their spirituality were the first to share their thoughts and feelings.
Bush (1999) and McSherry (2000) also supported the benefits of reflective journaling to facilitate self-awareness and humility in the spiritual realm. Catanzaro and McMullen (2001) conducted a study where clinical students were asked to keep a reflective journal and address their personal relationship with God or another higher power to which they related. Although many students were uncomfortable with self-reflection at first, this strategy helped to facilitate personal transformation and allowed students to become more sensitive to the spiritual needs of others. Based on feedback from former students, the researchers found that personal growth and sensitivity continued even after graduation. Briggs and Lovan (2014) concluded, “When students write their own beliefs in narrative form, it gives them a voice and a sense of empowerment over their own philosophies and ideas” (p. 187).
Helpful interventions documented in the literature for improving confidence with spiritual issues in nursing include end-of-life simulation experiences for nursing students involving the use of standardized patients trained to present the characteristics of actual patients in clinical scenarios (Fink et al., 2014). Others recommend spiritual care training courses (Frouzandeh et al., 2015); facilitated discussions in the classroom (Pesut, 2003); practicing spiritual talks with patients in the clinical setting (Strand et al., 2017); and using Gordon's Functional Health Patterns as an interactive discussion method in the curriculum (Yilmaz & Gurler, 2014).
The purpose of this exploratory study was to investigate first semester nursing students' considerations of, and responses to, basic questions on the meaning of life, death, afterlife, truth, God, and spirituality. Students need to consider what they believe before they can effectively assist patients and families who are asking these types of questions. It is unrealistic to expect students to provide holistic healthcare if they have never taken time to contemplate what these issues mean to them personally. If students are caught off-guard, having never considered the answers to the 10 questions presented in this classroom activity, they may be unequipped for providing adequate care for patients and families undergoing life-altering illnesses and trauma.
This research study went through an expedited review process and received approval through Western Kentucky University's Institutional Review Board. The narrative reflection activity took place in a nursing classroom setting. The results remained anonymous and there was no penalty for refusing to participate. Potential benefits included deeper reflection into one's own beliefs, perspectives, and values. There were no reports of negative outcomes, discomfort, or anxiety among participants.
Design and Participants
This study was conducted in a public secular Southcentral Kentucky University. Participants were given 1 minute per question to reflect and write narrative responses to the questions being read aloud from a large screen in the front of the classroom. The 10 questions, based on concepts presented in the spiritual health chapter of students' fundamentals of nursing textbook, were written by the classroom professor, who was the principle investigator of the study and first author of this article. Content validity was verified by two other faculty members within the same course. The terms faith, purpose, afterlife, God, religion, truth, death, atheist, agnostic, body-mind-spirit connection, and spiritual well-being/distress were included in the reading assignment. Other terms discussed in the textbook chapter that were not included in the 10 questions (for the sake of time) were self-responsibility, peace, hope, prayer, meditation, forgiveness, church, integrity, values, and humility. A convenience sample of 107 first semester nursing students enrolled in a Fundamentals of Nursing course participated. This classroom activity was embedded in the curriculum within the larger topic of spiritual health. Student participants ranged in age from 19 to 39, with the largest portion (89.7%) being 19 to 24 years old. The majority of participants were female (85%), whereas 15% were male. Race was identified as White (90%), Black/African American (7%), Asian (2%), and other (1%). When asked, “Do you consider yourself a religious and/or spiritual person?” 89% reported yes, whereas 11% reported no.
A faculty member not associated with the Fundamentals course read the purpose of the study to the class, giving students the option to participate without penalty for refusal. All students signed consent forms agreeing to participate in this ungraded anonymous classroom exercise. Students were informed that no answer was considered right or wrong, and they were encouraged to openly express their answers in writing, even if their response was, “I don't know.” When the activity was complete, concepts that were addressed in the questions were defined and explained in the usual lecture style format.
Data Collection and Analysis
Researchers collected demographic and qualitative data from participants immediately after the classroom reflection activity. The entire process took approximately 15 minutes during class time in the Fundamentals of Nursing course. Data were analyzed by the research team using thematic analysis to identify major themes. Thematic analysis began with reading all responses to the open-ended questions in order to facilitate code generation. Initial coding was very specific to capture the variation among responses to ensure completeness; a second and third analysis of the data allowed researchers to synthesize codes into broader categories and then identify themes.
The number of themes varied widely, from 2 to 12, depending on the nature of the question. All three researchers involved in this project reviewed and refined coding to ensure accuracy. The top three themes for each response are outlined in this manuscript along with the percentage of student participants who revealed that theme in their narrative responses. Some students chose not to respond to a few of the questions, and no reason was provided when left unanswered. When reviewing the responses, there was no difference in the quantity of responses provided by students who identified themselves as religious/spiritual and those who did not. At the conclusion of the class period, a few students anecdotally expressed their appreciation for the activity, stating it was enjoyable and helpful.
Question #1: What is the purpose of life on earth?
Most respondents (91.6%) indicated they had thought about the purpose of life on earth; however, 7.5% had not. Of the 107 narrative responses provided, 33.5% indicated that the purpose of life is other-oriented; 25% believe it is God-oriented/directed, whereas 20.5% reported that it is self-oriented.
Question #2: What do you believe happens when the heart stops beating?
Similarly, 91.6% of respondents reported they had thought about what happens to a person when the heart stops beating, whereas 8.4% had never thought about this situation. Half of the participants (50.4%) believed there is an afterlife (heaven, hell, purgatory, God's judgment); 16.8% indicated the spirit separates from the body, and another 12.2% reported that there is an undefined or individualized existence in the afterlife.
Question #3: Are the body, mind, and spirit connected? In other words, will a deficit in one affect the other two?
When asked about the connectivity of the body, mind, and spirit, 68.2% of respondents indicated that they had thought about this connection and 31.8% had never considered it. Of the total number of respondents, 85% believed the body, mind, and spirit are connected, 3.7% believed they are not connected, whereas 11.2% were unclear or provided no response.
Question #4: Do heaven and/or hell exist? Who or what determines a person's residence there in the afterlife?
Almost all respondents reported they had thought about the answer to these questions (99.1%). Most participants (81.3%) reported they believed heaven and/or hell exists, whereas 15.9% expressed uncertainty, and 1.9% reported no as their answer. Themes for responses included 34.7% as God determines a person's residence in heaven and/or hell in the afterlife, whereas 32.2% indicated an individual's actions make that determination, and 17.9% referenced a relationship with Jesus Christ as the determining factor for residing in heaven.
Question #5: What does “truth” mean? Who or what determines truth?
Results were evenly split with 49.5% having thought about the meaning of the word truth, whereas the same number had never considered what truth means. Almost half (49.2%) of respondents stated truth to be actuality/facts/honesty; 17.8% provided no response to the question; and 11.9% believed truth to be subjective. When asked who or what determines truth, almost half of participants (49.5%) provided no response, 26.4% indicated that truth is determined by individuals, and 17.3% felt truth is determined by God.
Question #6: Define God in your own terms.
Although 86.9% of participants reported they had thought about their personal definition of God, 12.1% had never considered defining God in their own terms. Students' responses revealed 23.7% defining God as omnipotent (all-powerful), omniscient (all-knowing), and/or omnipresent (all-present), whereas 23.2% defined God as creator, and 15.8% identified God as savior/forgiver.
Question #7: What is “spiritual well-being” in contrast to “spiritual distress?”
When asked whether they had ever thought about spiritual well-being versus spiritual distress, a small percentage of respondents (38.3%) indicated they had considered these two issues, but the majority (61.7%) had not. The students felt spiritual well-being meant satisfaction in beliefs (39.3%) or peace in relationship with God (16.2%), whereas 15% had missing or unclear responses. Spiritual distress was defined as being uncertain, confused, or questioning one's beliefs (28.5%), and as being lost, lacking, or not knowing one's beliefs (19.6%). Several participants (16.8%) had missing or unclear responses to the question.
Question #8: What does it mean to be an atheist? What does it mean to be agnostic?
Most (84.1%) of respondents indicated they had considered what it meant to be atheist or agnostic. Incorrect definitions were provided by 39.3% of participants about the term atheist. Many students (27.1%) did not attempt to define agnostic, whereas 20.6% provided inaccurate definitions, and 19.6% responded they did not know what the terms meant.
Question #9: Would spiritual or religious beliefs influence your own healthcare decisions?
In response to the inquiry about spiritual or religious beliefs influencing one's own healthcare decisions, 66.4% of respondents indicated they had given it thought, whereas 32.7% had not. The answer occurring most frequently was no response at all (42.1%). As part of their beliefs, 21.2% reported their desire for organ/blood donation and another 17.7% showed a preference toward “do not resuscitate.”
Question #10: How will you feel when a patient's beliefs contradict your own?
Respondents were asked if they had anticipated their feelings or possible reactions when a patient's beliefs contradict their own. The majority (82.2%) responded in the affirmative, whereas 17.8% had not considered this. To support their response, 27.6% indicated that they will respect and recognize personal rights/choices; 25% will support and accept patients' beliefs; and 9.5% reported they will advocate for and honor patients' wishes.
Based on these findings, many nursing students have never considered their personal beliefs about spiritual issues that some may describe as basic or essential to knowing oneself and others holistically. The problem lies in the fact that, although individuals may describe themselves as religious or spiritual, they may have a difficult time articulating definitions or describing concepts. The goal of a classroom reflection activity, such as the one described in this study, is not for students to come to an agreement about the answers, but rather to seek out answers within their own heart, mind, and conscience. Without interventions strategically placed in the curriculum that allow for personal reflection and exploration of these topics, students could enter clinical settings unprepared for questions that will ultimately arise. One may conclude that a student who has never pondered answers to the questions presented in this study could enter the workforce ill equipped for providing competent spiritual care for others.
The results of this study provide strong evidence for the benefits of including a reflection activity about spiritual issues in the nursing curriculum. It is not sufficient to increase a student's knowledge about spiritual health concepts or simply teach them how to conduct a spiritual assessment. Educators must first explore the impact of personal reflection to assist students in determining their own beliefs (Briggs & Lovan, 2014). In today's society, it is common for people to become task-oriented, equating their productivity with accomplishing daily “to-do” lists. Eventually, days, months, or even years may go by before a person is prompted to stop and think about deeper, more meaningful issues. Busyness can be a distraction to a person truly knowing who he or she is and identifying one's purpose in life. Consideration of matters such as meaning of life, death, and the afterlife can lead to a sense of clarity and peace.
A convenience sample of students enrolled in one nursing course within a university prevents generalizability to a larger population. Students were allowed only 60 seconds per question to respond to each of the 10 questions asked, although they were encouraged to discuss and reflect upon their beliefs with family and friends beyond the classroom. Additional research is needed with larger numbers and more diverse populations. It would be beneficial to collect data from a cohort of students over a period of time to measure growth and confidence in their personal spiritual awareness between program entry and exit. A replication study comparing student responses between secular and faith-based schools of nursing would be insightful.
As educators, we cannot assume that students have allowed their minds to wonder or come to grips with spiritual and/or religious issues if they have not been encouraged to do so in their younger years. Based on the results of this study, many participants had never thought about some fundamental life questions. When we encourage students to spin the wheels of their minds, we are not prescribing which direction their worldview roadmap will take them; instead, we are providing them a venue to freely investigate the spiritual realm in a safe environment, free of judgment. Teaching spiritual topics can be challenging for the nurse educator, but using the method described in this study allows individuality in the reflection of personal values without fear of bias. This classroom activity serves as a springboard for future discussions with others where students can grapple with, clarify, and articulate their beliefs. Providing time for quiet reflection in response to thoughtful questions may be the conduit that sparks students' interest and leads them to realize their personal philosophies about important spiritual issues. The age of a traditional college student is a perfect time for reflection because they are at a point in their life journey where they are deciding who they are as young adults and what ideals they stand for. As educators, we have an opportunity and responsibility to provide a safe setting in which learners can delve deeper into their minds and spirits if they were previously uncertain about their beliefs. Our ultimate goal as nurse educators is to bring students to a state of mind where they can learn more about themselves, as well as the human body, mind, and spirit, and therefore, provide holistic therapeutic interventions to those in need.