Developing an Elective on Spirituality for the BSN Curriculum

Abstract

When a curriculum evaluation of a BSN program at a public university revealed a content gap on spirituality and spiritual assessment, faculty developed an elective covering a nurse's role in spiritual care and assessment of patients. The resulting 300-level course was of hybrid design and received positive evaluation from students after implementation.

INTRODUCTION

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A historical understanding of the southeastern United States, as well as the student body of this particular university campus, is required to appreciate the need for course development in spirituality. This southeastern campus serves students who are predominately from South Carolina (83%; College Factual, n.d.). The majority of adults from this area identify as Christian (76%; ^{Pew Research Center, 2019a}) with 34% of those living in the state identifying as Evangelical Christian (^{Pew Research Center, 2019b}). In contrast, the United States as a whole has fewer adults identifying as Christian (70%) or Evangelical Christian (25%; ^{Pew Research Center, 2019c}). Many students at this university have little exposure to cultural or religious diversity. The ^{Pew Research Center (2015)} identifies that the Christian share of the nation's population is declining, whereas the number of adults who do not identify with any organized religion is growing. In addition, non-Christian religious groups are growing and represent the youngest members by age in the U.S.

The department of nursing undertook an evaluation of the prelicensure Bachelor of Science in Nursing (BSN) and RN-BSN curriculum to determine gaps in content and areas for improvement. The American Association of Colleges of Nursing's Essentials of Baccalaureate Education for Professional Nursing Practice (2008), Quality and Safety Education for Nurses (QSEN) (^{QSEN, 2019}), and American Nurses Association (^{ANA, 2015}) Nursing Scope and Standards of Practice were the guiding frameworks for curriculum redesign. One area identified as a deficiency was in-depth teaching on spirituality and spiritual assessment in order to provide comprehensive holistic nursing care. Through content mapping and analysis, the faculty identified where and how to thread the concept of spirituality into the revised curriculum. Each course with a clinical or laboratory component would include patient-centered care with a focus on holistic care. In addition, an elective course was developed for students desiring a more detailed exploration of the nurse's role in spiritual care and assessment of patients.

NURSING'S ROLE IN SPIRITUAL ASSESSMENT

Historically, addressing the spiritual needs of patients has been a fundamental nursing role (^{Lewinson et al., 2015}). The American Nurses Association (2015) mentions spirituality eight times in Nursing Scope and Standards of Practice. Specifically, the art of nursing embraces spirituality, the knowledge of nursing includes research on spirituality, nurses assess and establish goals with patients pertaining to spiritual needs, and nurses incorporate spiritual considerations in health promotion and health teaching. ^{The Joint Commission (2019)} requires that patients receive a spiritual assessment and access to religious and spiritual services; this assessment is often conducted by nurses.

Although spirituality is an integral part of holistic care, this content is underrepresented in nursing education programs (^{Lewinson et al., 2015}). Little research is available on teaching spiritual care to nursing students. Many core textbooks provide insufficient direction on what to teach nursing students about spiritual care (^{Timmins et al., 2015}). Knowledge and practice gaps on teaching spirituality in nursing education include lack of understanding, lack of support, curriculum structure, and unprepared faculty (^{Gulnar et al., 2018}). According to ^{Minton et al. (2018)}, “nursing curriculum must include purposeful engagement and focused debriefing in spiritual assessment and care” (p. 173).

COURSE APPROVAL

New course approval was first vetted through the nursing program and department via presentation at both the curriculum and faculty organization committees. The faculty member developing the course provided a course justification, tentative syllabus, and content mapping to the revised curriculum. With minor revisions, the course was approved at the department level and then submitted to the university-wide courses and curriculum committee for approval. At this level of the approval process, objections were met concerning the following:

• choice of textbooks
• nurses' qualification to perform spiritual assessment
• faculty qualifications to teach a course on spirituality
• whether this course violated separation of church and state
• whether this course duplicated an existing course on world religions
• concern if the faculty member who is openly Christian would be proselytizing
• the necessity for such a course.

These objections led to the course initially being denied approval and sent back to the department for revision.

The faculty member developing the course addressed concerns using the following strategy. First, the course justification document was modified to include additional references to the nurse's role in spiritual assessment as cited in the ANA Nursing Scope and Standards of Practice (2015). The Joint Commission requirement of assessing for and providing spiritual care for patients, and the availability of a specialty nursing practice in Faith Community Nursing: Scope and Standards of Practice (^{ANA and Health Ministries Association, 2017}). Second, after careful review of available textbooks, it was determined that no references were available with a recent copyright (less than 5 years) from an academic publisher. The decision was made to utilize open access resources and to create a faculty lending library of available resources (Table 1).

Table 1. - Open Access and Lending Library Resources Used in the Course

Source	Content	Access
Online open access articles	Variety of topics	University library
Online reference material	USCB Library guide to eastern and western religions Online guide to ethical theories and principles	University library
Spiritual assessment tools	Various articles and websites	Blackboard
Lecture	Various topics	Pdf in blackboard
Videos	Various topics	YouTube
Case studies	Various topics	Online access ANA ethics cases
Books	Variety of books on nursing and spirituality	Available to borrow from faculty office

Faculty qualifications to teach a course on spirituality were demonstrated through presentation of the faculty member's certification as a faith community nurse. The question of separation of church and state was addressed with a letter of support from the department dean citing academic freedom and appropriateness of material to the nursing discipline. In addition, this course would appear as an elective versus a requirement. Finally, student course evaluation data were provided that identified a desire to have more elective nursing courses available, especially for the RN-BSN and second-degree students. Specifically cited were courses that addressed diversity, culture, and spiritual care of patients.

The nursing department approved the updated course justification and proposal. Being mindful of the concerns of the course and curriculum committee, the revised course description clearly stated the role between healthcare and spiritual assessment (Box 1). Upon resubmission to the university courses and curriculum committee, the proposal was approved and sent to the faculty senate. Approval was obtained at the faculty senate level without objection or abstention with minimal discussion or questions.

DESIGN AND CONTENT

The new course title was Spirituality, Health and the Healthcare Professional. It was designed as a 300-level course and cross-listed with the public health program. The student learning objectives reflect the upper level curriculum design of this course (Table 2). Being respectful of the students' heavy clinical load at the junior and senior levels of the BSN program, the course design was a hybrid of face-to-face and online content. The class met once weekly on campus for 90 minutes with supplemental online work that supported the in-class activities. The course content outline progressed from a general overview of spirituality to more in-depth analysis of the role of nurses and spiritual assessment (Table 3).

Table 2. - Student Learning Objectives

Articulate the difference between religion and spirituality. Identify how religious and/or spiritual beliefs can affect human behavior and health. Use basic interpersonal skills and tools to assess patients' spiritual needs. Identify the relationship of health to spiritual beliefs. Develop plans of care or health promotion activities that address the unique spiritual needs of patients. Explore the influence of one's own spirituality and professional use of self in addressing patients' spiritual needs.

Table 3. - Course Outline

Week	Classroom Activity/Topic
Week 1	Module 1: Introduction to Spirituality and Health Define spirituality and the spiritual concepts: practice, beliefs, values, love, forgiveness, purpose, faith, hope, peace
Week 2	Historical perspectives of practice of health and healing
Week 3	Discussion of definitions of health: medical, spiritual, religious, personal
Week 4	Module 2: Spirituality as religious systems of beliefs and values and their influences on health and healing Primal faiths: American Indians, tribal Africans, pagan traditions Eastern faiths: Confucianism, Taoism, Hinduism, Buddhism Monotheistic religions: (Abrahamic Western) Judaism, Christianity, Islam
Week 5	Presentations of religious/spiritual articles/objects and their significance to the person
Week 6	Module 3: Spirituality as nonreligious systems of beliefs and health and well-being Secularism, spiritualism, atheism Spiritual but not religious (SBNR): mind-body-spirit connection, holistic activities, tai chi, reiki, yoga
Week 7	Module 4: Spirituality as life meaning, purpose, and connectedness to others Life meaning and purpose Connectedness, being present, higher power or force Why spirituality and religion matter. Do they matter? The caring relationship
Week 8	Midterm Exam
Week 9	Module 5: Spiritual Assessment Nursing Scope of Practice: Standard 1: Assessment; Standard 3: planning; Standard 5b: health teaching and health promotion Spiritual needs/beliefs of patients and healthcare professionals in provision of healthcare Spiritual assessment tools and strategies in the provision of spiritual care
Week 10	In-class activity: small group practice with spiritual assessment tools
Week 11	Module 6: Interprofessional healthcare roles Nursing, medicine, and allied health providers (mental health, rehabilitation) Chaplains, spiritual guides, social work, faith community nurses Interdisciplinary team for spiritual care
Week 12	In-class guest panel presentation from different faith and spiritual perspectives
Week 13	Module 7: Ethical considerations Ethical theories: Utilitarianism, Deontology, Virtue, Ethics of Caring Ethical principles: beneficence, nonmaleficence, justice, autonomy, veracity, fidelity, confidentiality Codes of Ethics: Nuremberg, Declaration of Helsinki, IRBs, Code of Ethics for Nurses
Week 14	Threats to spiritual care Boundaries and barriers Legal issues
Weeks 15/16	In-class small group activities: case studies and the law Final examination

Activities

The students enrolled in this elective course represent a variety of learning levels. Some students are first-generation college students, others are second-degree students, and still others are in the RN-BSN completion program. Designing activities for this array of learners entailed creativity, flexibility, and student input. The online activities included discussion board posts, review of case studies, and exploration of articles related to spirituality and nursing. In-class activities included traditional lectures, a show-and-tell session on items that provide patients spiritual comfort, discussion of case studies related to ethics of spiritual care, practice utilization of spiritual assessment tools, and guest speakers.

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Assessment of learning was measured through a midterm and a final examination containing short essay and multiple choice questions (10% each), three reflection papers (20% each), discussion board posts (10% total), and class participation (10%). Topics of papers addressed religious and spiritual diversity, spiritual assessment of an individual, and personal/professional growth with a spiritual self-assessment. The six online discussion boards ran over 2 weeks each and covered the topics of introduction of self, spiritual rituals important to patients, life purpose, spiritual assessment tools, clinical site assessment, and ethical dilemmas related to spirituality. Class participation was based on attendance and participation in small group activities such as the show-and-tell day, prepared questions for the guest speaker, analysis of case studies, and practice with spiritual assessment tools.

STUDENT RESPONSE

Students completed surveys prior to course implementation, midterm, and postcourse to elicit what was working well, what could be improved, and personal insights gained from taking a course on spirituality. Four common themes were noted:

• increased confidence in providing spiritual care
• increased knowledge of various faith traditions
• improved self-awareness of bias
• awareness of evidence-based spiritual assessment tools.

CONCLUSION

The development of a nursing elective course on the topic of spirituality was needed and supported by the literature. Nursing touches on every aspect of human existence: physical, spiritual, and psychological. As nurses, we inherently understand the relationship of health to the body, mind, and spirit. Our obligation as nurses to provide patient-centered, holistic care is mandated both by our standards of practice and by regulatory organizations. As nursing educators, the development of course content that addresses the spiritual needs of patients is essential to ensure nursing students have the skill set to provide holistic patient-centered care.

Box 1. Course Description

NURS B305 Spirituality, Health, and Healthcare Professions 3 credit hours. This course explores provision of healthcare taking into account the patient's spiritual needs. The intersection of self and other in relation to religion, spiritual practices, culture, and diversity, in relationship to health issues will be examined. Other topics include the discussion of the ethical provision of healthcare by the healthcare professional, spiritual assessment of patients, and provision and the importance of the consideration of spiritual care needs by the healthcare team. The focus will include modules on definitions of spirituality, both religious and nonreligious, definitions of health, spiritual assessments of patients, the roles of the interdisciplinary healthcare team, and ethical issues related to attending to the spiritual needs of patients. (^{University of South Carolina Beaufort, 2018})