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Relationship of Nurses' Spirituality To Their Understanding and Practice of Spiritual Care
Relationship of Nurses' Spirituality To Their Understanding and Practice of Spiritual Care
158 2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd
JAN: ORIGINAL RESEARCH Spirituality and nursing care
2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd 159
L.Y.F. Chung et al.
and envisioned nursing administrators shaping the future of transpersonal caring. ‘Transpersonal’ refers to deep connec-
nursing care systems. Malinski (2002), on the other hand, tedness of relationship, subjective meaning and shared
suggests researching spirituality and healing from the humanity. Watson argues that the body is situated in a
perspective of awareness, choice, and person–environment spiritual environment within a field of consciousness, con-
integration to find a new perspective which better reflects nected and integral to all consciousness (Rafael 2000). When
Roy’s (2000b) vision for nursing. people care, they move beyond ego to spiritual, cosmic
These different understandings not only show that there concerns and connections at the transpersonal spirit-to-spirit
are different understandings of what is meant by ‘human level. Consciousness is shared intentionally, with the result
being’, but also differing worldviews. Martsolf and Mickley that healing potential actualized (Rafael 2000, Walton 2002).
(1998) adopted Fawcett’s (1995) categories of worldview Watson (2001) admits that her model is abstract and is still
(reciprocal interaction and simultaneous action) to argue that evolving, but is a way to understand how delivery of spiritual
different worldviews may account for inconsistent definitions care is possible only through personal experience.
of spirituality. In brief, nursing scholars agree that humans are bio-
In the reciprocal interaction worldview, people are viewed psycho-social-spiritual beings. Some scholars consider spirit-
as having interactive dimensions (e.g. Roy 1984). Interactions ual care as the core (e.g. Nightingale, Watson), but others
between people and environment are reciprocal and changes treat it as an isolated dimension without any integration (e.g.
may occur in either. Therefore, nurses assess clients’ physio- Henderson’s).
logical, psychological, social, cultural and spiritual dimen-
sions and view them as interactive and interrelated, yet
Spirituality and its characteristics
unique.
The simultaneous action worldview identifies humans by One of the obstacles in researching and practising spirituality
patterns and considers spirituality within this context (e.g. in nursing has been the lack of conceptual clarity and
Parse 1995a,b). Nurses recognize overall patterns of client consensus in understanding spirituality (Martsolf & Mickley
interaction with their environment by being present and 1998, McSherry et al. 2004, Gall et al. 2005). Spirituality can
providing assistance in re-patterning (Martsolf & Mickley be viewed as an integrating force (Kelley et al. 2002), or a
1998). multidimensional concept including meaning, value, tran-
Parse (1981, 1987) has continued her work in this field by scendence, connecting and becoming (Martsolf & Mickley
developing the theory of human becoming which assumes 1998). Common characteristics: (1) search for meaning and
that humans are open, unitary beings freely choosing purpose; (2) relationships; and (3) transcendence will be
personal meaning and evolving towards greater complexity discussed below.
through continuous transaction with the environment. She
presents three themes: meaning, rhythmicity and co-trans- Search for meaning and purpose
cendence. Meaning is discovered as apart of life, or in A quest for meaning and purpose is usually regarded as the
moments of everyday existence, while rhythmicity refers to existential aspect of spirituality (Ross 1997, Fawcett & No-
co-creating rhythmical patterns of relating through revealing– ble 2004). Finding meaning can be interpreted as having a
concealing, enabling–limiting while connecting–separating. specific goal and experiencing it in everyday living (Land-
Co-transcendence is the process of reaching beyond the self. mark et al. 2001). Each individual is personally responsible.
Spirituality is implicit in such a view of human beings, which The search for a specific meaning to life provides not only a
allows for recognition of both nurses’ spiritual perspectives primary motivational force (Frankl 1963, 1988), but also a
and clients’ participative experiences. Furthermore, the framework of reference to justify behaviour.
importance of nurses’ presence in the moment as a potential Recognizing the meaning of life is a core component of
means of illuminating meaning, synchronizing rhythms, and spirituality inherent in holistic nursing theory. It recognizes
helping people to improve their quality of life through the wholeness of individuals and their connectedness to a
transcendence is recognized (Parse 1993, Walker 1996, supreme being (Cavendish et al. 2001). Self-care is an
Cavendish et al. 2004). important factor in discovering meaning (Burkhardt &
Caring to Watson (1999) is fundamentally a spiritual act Nagai-Jacobson 2002). Self-care facilitates self-awareness,
that assists clients to achieve a greater sense of self, and hence promoting growth, healing and transformation (Lau-
harmony of body, mind and soul (Taylor 2002). Watson terbach & Becker 1996). The role of nurses is to encourage
(2002) suggests the concepts of ‘intentionality’ and ‘con- clients in self-care activities to find meaning (Delaney 2005)
sciousness’ as a means to understand what happens in when illness intervenes, and present worldviews cannot
160 2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd
JAN: ORIGINAL RESEARCH Spirituality and nursing care
explain the situation. Worldviews are the mental manuals, explore nurses’ spiritual perspectives and care that hospice,
values and standards which explain the world and our lived critical care, mental health and parish nurses show a
experiences, drive our behaviour (Pesut 2003), and help us to heightened sense of personal spirituality, and value the
make sense of our spirituality. integration of such care into their practice (Narayanasamy
& Owens 2001, Tuck et al. 2001, Cavendish et al. 2004,
Relationships Kociszewski 2004, Belcher & Griffiths 2005). These studies
Relationships are the connections we have with ourselves, identify the most frequent forms spiritual care offered by
others, God/Supreme Being, and the environment (Stoll 1989, nurses which include: listening, touching, being present,
Hungelmann et al. 1996, Burkhardt & Nagai-Jacobson prayer, use of religious objects, attendance at religious
2002). Our relationship with ourselves comes about through services, talking with clergy, reading the bible (Don 2004),
the integration of all our human dimensions and is known conveying a benevolent attitude (Taylor et al. 1995), accept-
through thoughts and feelings. It is manifested by inter- ance and non-judgemental attitude, validation of clients’
dependent relationships with others, which encourages mu- feelings and thoughts, facilitation, instilling hope (Sellers &
tual growth. However, it requires confronting our own Haag 1998), discussing an issue in depth, suggesting the
personal weaknesses, and working towards change. Through clients seek help, making a referral to spiritual experts and
acting in ways which achieve balance in interpersonal re- informing clients of local resources (Kristeller et al. 1999).
lationships, we learn to be at ease with both independence Another aspect of spiritual care arises from the assumption
and interdependence (Pesut 2003). Furthermore, the pursuit that humans, as part of an indivisible, universal conscious-
of balance also requires interaction with God/Supreme Being, ness, transcend space and time. Interventions such as visual-
which may be expressed through activities such as reflection, ization, guided imagery, dream work, therapeutic touch or
meditation, prayer, art, music, and nature appreciation. Reiki therapy, are seen as ways of helping heal clients’ souls.
This kind of energy-based raises problems of competence in
Transcendence delivery (Pesut 2006) and, furthermore, not only nurses but
Connectedness integrates the entire human, developing inner also clients may feel uncomfortable or unconvinced about the
strength and peace (Benzein et al. 1998, Kelley et al. 2002, efficacy of such interventions. Indeed, Taylor and Mamier
Tanyi 2002), as well as reaching out beyond personal con- (2005) found that spiritual care that was less intimate,
cerns and transcending self-boundaries (Reed 1992, Harrison commonly used and not overtly religious was most wel-
& Burnard 1993, Ross 1997). comed.
The transcendent nature of spirituality makes it difficult to
comprehend through objective analysis alone; however,
Theoretical framework
through action and the synthesis of meaning, transcendence
can be understood (Kendrick & Robinson 2000). The To provide a definition of spirituality for this study, we
experience of transcendence is dynamic as it is a continual incorporated all characteristics described in the literature. We
search to find enrichment through connectedness. In our make the assumption that individuals are personally respon-
study, we use the term ‘spirituality’ to denote the deepest core sible for finding and pursuing their own existential meaning
of personhood, which entails relationships with the self, and purpose. Through interacting with themselves and others
others and God/Supreme Being in the search for meaning, appreciation and development of the meaning of life are
connectedness and transcendence. heightened (Ross 1997, Fawcett & Noble 2004). Spirituality
is defined in our study as relationship with the self (the self
dimension) and with a dimension beyond ourselves (the
Understanding and practice of spiritual care
beyond dimension).
Although there is a growing consensus in categorizing Our second assumption is that nurses need a personal
characteristics of spirituality, there is less when defining spiritual perspective in order to provide spiritual care (Dossey
what is meant by ‘spirituality’ and ‘spiritual care’. Spirituality & Keegan 2000). With dimensions of both the self and
is, however, usually perceived as personal and subjective beyond, we both connect with and transcend the everyday
(Hall 1997, Smith & McSherry 2004). world, and this is manifest in the spiritual care provided.
However spirituality is defined, nurses’ self-awareness and Spiritual care does not, however, take place in a vacuum but
personal spiritual perceptions are important when providing is supported by our worldviews which underpin the two
spiritual care (Dossey & Keegan 2000, Cavendish et al. dimensions and, in particular, our understanding of spiri-
2004). It has also been shown in a number of studies that tuality and spiritual care.
2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd 161
L.Y.F. Chung et al.
In summary, spirituality, and understanding and practice to the questionnaire. The beyond dimension (items 7–9)
of spiritual care, constructed the framework we used to refers to the relationship with God or a Supreme Being, and
develop the instrument and test the following propositions: the self dimension (items 1–6 and 15–21) refers to the
• Nurses’ spirituality correlates with their understanding of relationship with oneself; understanding and practice of
spiritual care. spiritual care were measured by items 10–14 and 22–27
• Nurses’ spirituality correlates with their practice of spirit- respectively. In order to prevent any response-set bias, five of
ual care. the 27 items (18Æ5%) were phrased in a converse manner.
• Nurses’ demographic variables correlate with their spiri-
tuality, understanding and practice of spiritual care.
Validity and reliability of the instrument
162 2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd
JAN: ORIGINAL RESEARCH Spirituality and nursing care
The Kaiser–Meyer–Oklin value ¼ 0Æ55; Barlett’s test (v2 ¼ 653Æ75, d.f. ¼ 351, P < 0Æ001); overall alpha ¼ 0Æ80; overall mean total ¼ 3Æ60,
SD¼ 0Æ29.
demonstrated a satisfactory internal reliability threshold for a the 2002 class recess of the BSN course. After explanation
new instrument (Shelley 1984). of the nature, procedures and potential significance of the
study, as well as assurances of confidentiality and the right
to withdraw, all 61 study participants signed consent
Ethical considerations
forms. The questionnaires were then distributed with the
A university human ethics committee approved the study. request to return them to a designated mail box within
Recruitment was undertaken by a research assistant during 2 weeks.
2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd 163
L.Y.F. Chung et al.
Participant characteristics
Relationship of demographic variables with spirituality,
The majority of nurses were single, young women with
understanding and practice of spiritual care
experience of admission to hospital either as a patient or a
patient’s relative. Thirty-four (63Æ4%) reported their religious Mann–Whitney U and Kruskal–Wallis tests were performed
affiliations as Christianity (40Æ9%), Buddhism (8Æ2%) and to detect any differences between demographic variables and
Taoism (14Æ3%). The mean length of total postregistration spirituality, and understanding and practice of spiritual care
work experience was 6Æ3 years, 3Æ0 years in their present (SPSS, version 10.0, SPSS Inc. 2001). As shown in Table 4, we
specialty (Table 2). found no statistically significant relationship between any
demographic variables and the self, beyond dimension,
understanding and practice of spiritual care except nurses’
Relationship of nurses’ spirituality to their understanding
religion. Nurses who had no religion belief had a higher
and practice of spiritual care
beyond dimension score (mean ¼ 3Æ9, SD ¼ 0Æ7) than nurses
A correlation matrix of the self and beyond dimensions, who claimed a religious belief (mean ¼ 3Æ1, SD ¼ 0Æ6,
understanding and practice of spiritual care is shown in P ¼ 0Æ001).
Table 3. A significant positive correlation was found between
the self and beyond dimensions (rs ¼ 0Æ35, P < 0Æ001), the
Factors contributing to understanding and practice of
self and understanding of spiritual care (rs ¼ 0Æ57,
spiritual care
P < 0Æ001), and the self and practice of spiritual care
(rs ¼ 0Æ26, P < 0Æ05). We also found the correlation between We used multiple linear regression analyses to determine the
contribution of the self and beyond dimensions to under-
standing and practice of spiritual care, adjusted by age and
Table 2 Participants characteristics work experience both postregistration and in present speci-
n (%) alty.
Table 5 shows that the self was statistically significant
Sex
(beta ¼ 1Æ06, |t| ¼ 10Æ74, P < 0Æ001) in relation to under-
Male 6 (9Æ8)
Female 55 (90Æ2) standing of spiritual care, but not to the dimension beyond
Marital status the self (beta ¼ 0Æ01, |t| ¼ 0Æ11, P ¼ 0Æ916), nor other
Married 25 (41Æ0) adjusted factors. With regard to practice of spiritual care,
Unmarried 36 (59Æ0) our results showed that the self was statistically significant
Age (years)
(beta ¼ 0Æ68, |t| ¼ 3Æ62, P ¼ 0Æ001) but the beyond dimen-
21–30 33 (66Æ0)
31–40 13 (26Æ0) sion (beta ¼ 0Æ19, |t| ¼ 1Æ16, P ¼ 0Æ258) and other adjusted
40þ 4 (8Æ0) factors were not.
Religious affiliation
Yes 34 (63Æ4)
Christianity (40Æ9) Discussion
Buddhism (8Æ2)
Taoism (14Æ3) Relationship of spirituality to understanding and
No 18 (34Æ6) practice of spiritual care
Work experience
Postregistration (years) Our study demonstrates correlations between nurses’ self,
Mean (SD ) 6Æ3 (6Æ4) beyond dimension, understanding and practice of spiritual
Range 0Æ5–31Æ0
care. As stated in the theoretical framework session, spiritu-
Present specialty (years)
Mean (SD ) 3Æ0 (3Æ3) ality refers to relationships with the self and with God/a
Range 0Æ0–15Æ0 Supreme Being (i.e. the beyond dimension). Only the self and
Previous hospitalization not beyond dimension was a statistically significant factor in
The self 24 (43Æ6) practice of spiritual care. A correlation between nurses’
Relatives 27 (49Æ1)
spirituality and understanding of spiritual care is logically
The self and relatives 4 (7Æ3)
implied, but not the practice of spiritual care. This finding is
164 2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd
JAN: ORIGINAL RESEARCH Spirituality and nursing care
Table 4 Comparison of the self, the dimension beyond the self, understanding and practice of spiritual care by demographics
Sex
Male 6 3Æ7 (0Æ1) 3Æ2 (0Æ7) 3Æ5 (0Æ4) 3Æ8 (0Æ6)
Female 55 3Æ6 (0Æ4) 3Æ6 (0Æ8) 3Æ7 (0Æ4) 3Æ4 (0Æ5)
Mann–Whitney U-test U ¼ 149Æ5, P ¼ 0Æ714 U ¼ 113Æ5, P ¼ 0Æ218 U ¼ 116, P ¼ 0Æ247 U ¼ 118, P ¼ 0Æ268
Marital status
Married 25 3Æ7 (0Æ3) 3Æ5 (0Æ8) 3Æ7 (0Æ5) 3Æ4 (0Æ5)
Unmarried 36 3Æ6 (0Æ3) 3Æ6 (0Æ7) 3Æ6 (0Æ4) 3Æ5 (0Æ4)
Mann–Whitney U-test U ¼ 377, P ¼ 0Æ678 U ¼ 422, P ¼ 0Æ678 U ¼ 433Æ5, P ¼ 0Æ806 U ¼ 384Æ5, P ¼ 0Æ333
Age (years)
21-30 33 3Æ6 (0Æ4) 3Æ6 (0Æ7) 3Æ7 (0Æ5) 3Æ4 (0Æ5)
31-40 13 3Æ6 (0Æ3) 3Æ4 (0Æ9) 3Æ6 (0Æ3) 3Æ3 (0Æ5)
40þ 4 3Æ7 (0Æ2) 3Æ3 (1Æ1) 3Æ5 (0Æ6) 3Æ7 (0Æ3)
Kruskal–Wallis test v2 ¼ 0Æ97, P ¼ 0Æ617 v2 ¼ 0Æ384, P ¼ 0Æ825 v2 ¼ 1Æ17, P ¼ 0Æ558 v2 ¼ 2Æ79, P ¼ 0Æ248
Religious affiliation
Yes 18 3Æ6 (0Æ4) 3Æ1 (0Æ6) 3Æ6 (0Æ5) 3Æ6 (0Æ5)
No 34 3Æ7 (0Æ3) 3Æ9 (0Æ7) 3Æ7 (0Æ4) 3Æ5 (0Æ4)
Mann–Whitney U-test U ¼ 270, P ¼ 0Æ487 U ¼ 129, P ¼ 0Æ001 U ¼ 238, P ¼ 0Æ185 U ¼ 282, P ¼ 0Æ641
Work experience
Postregistration (years), rs 61 0Æ203, P ¼ 0Æ116 0Æ089, P ¼ 0Æ496 0Æ124, P ¼ 0Æ340 0Æ174, P ¼ 0Æ180
Present specialty (years), rs 61 0Æ09, P ¼ 0Æ591 0Æ245, P ¼ 0Æ138 0Æ128, P ¼ 0Æ443 0Æ075, P ¼ 0Æ655
Previous hospitalization
The self 24 3Æ7 (0Æ4) 3Æ7 (0Æ9) 3Æ7 (0Æ5) 3Æ4 (0Æ5)
Relatives 27 3Æ6 (0Æ3) 3Æ5 (0Æ6) 3Æ6 (0Æ4) 3Æ4 (0Æ5)
The self þ relatives 4 3Æ8 (0Æ2) 3Æ4 (1Æ0) 3Æ7 (0Æ3) 3Æ7 (0Æ3)
Kruskal–Wallis test v2 ¼ 2Æ54, P ¼ 0Æ281 v2 ¼ 1Æ21, P ¼ 0Æ546 v2 ¼ 0Æ34, P ¼ 0Æ845 v2 ¼ 1Æ24, P ¼ 0Æ54
Life event
No 43 3Æ6 (0Æ3) 3Æ5 (0Æ7) 3Æ6 (0Æ4) 3Æ5 (0Æ5)
Yes 13 3Æ8 (0Æ4) 3Æ8 (0Æ8) 3Æ8 (0Æ5) 3Æ5 (0Æ6)
Practice 5 3Æ6 (0Æ1) 3Æ4 (0Æ8) 3Æ6 (0Æ4) 3Æ3 (0Æ4)
Kruskal–Wallis test v2 ¼ 1Æ55, P ¼ 0Æ460 v2 ¼ 1Æ81, P ¼ 0Æ404 v2 ¼ 1Æ64, P ¼ 0Æ440 v2 ¼ 1Æ40, P ¼ 0Æ498
different from those of other studies that show that nurses’ The 13 self items in the NSDSC questionnaire refer to
spirituality is a significant factor in supporting the under- the relationship with the self in searching for and reviewing
standing and practice of spiritual care. Cavendish et al. the purpose of life, living up to personal values, satisfaction
(2004), for example, asserted that nurses’ spirituality was with life, loving oneself and evaluating one’s own spiritual
intrinsic to their lives and was the basis of their spiritual care health. The three beyond items refer primarily to a
practice. Belcher and Griffiths (2005) surveyed 204 hospice personal relationship with a higher being that gives inner
nurses about their spiritual practices and their ability to apply resource and direction to life. The five items relating to
their spiritual values to client care, and concluded that understanding of spiritual care concern beliefs held about
personal spirituality and a knowledge base of spiritual care spiritual care, and the six items relating to practice of
needs were statistically significant factors supporting spiritual spiritual care focus on managing relationships with clients
caregiving. in giving spiritual care (e.g. exploring clients’ hopes and
2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd 165
L.Y.F. Chung et al.
Table 5 Multiple linear regression (n ¼ 61) on factors contributing to understanding and practice of spiritual care
Spiritual care
Understanding Practice
sources of strength, spiritual values, and being with clients spirituality (Hollins 2005). The term religion is usually used
if needed). to describe a fixed system of ideological commitments,
In addition, the results of our multiple linear regression regulating the conduct of members, and the rites and
analyses demonstrate the contribution of the self to under- practices used in the system of worship (Ellis 1980).
standing and practice of spiritual care adjusted by age, work Spirituality, however, can be defined as the quality of having
experience (postregistration and in current specialty). The a dynamic and personal relationship with God (Ellis 1980).
importance of the self to spiritual care is shown through the This suggests that people may be so readily absorbed in the
need for continuous development within the self through rituals and regulations of the prescribed routine of a
seeking greater self-awareness, wholeness and a sense of particular religion (Vassallo 2001) that they lose sight of
satisfaction. The contented whole self reaches out to under- the meaning itself and the process of its manifestation
stand others (Chilton 1998) and enables us to focuses on (Matthew, Chapter 23 in the Bible).
others’ concerns when delivering spiritual care (Kendrick & Nurses tend to equate spirituality with religion (Oldnall
Robinson 2000). 1996, Narayanasamy 1999c), possibly due to their nursing
heritage. Bown and Williams (1993), however, suggest that
nurse researchers focusing on religion but not spirituality to
Relationship of demographic variables with spirituality
study holism limit the understanding of holistic care, as
and understanding and practice of spiritual care
holism supports spirituality as a dimension of personhood
No differences were found between the demographic vari- including those with no formal religious belief.
ables and understanding or practice of spiritual care. These Spirituality is personally experienced and interpreted. Only
findings are inconsistent with those of Cavendish et al. the individual can tell others about his/her spirituality
(2004), where married people scored higher on the spiritual (Harrison & Burnard 1993, Hall 1997), which is character-
perspective scale (SPS) than single people or those living with ized by personal meanings that define identity, life purpose,
a significant other. Both young (under 40) and older (above wellness, illness and relationships with others (Duldt 2002).
40) nurses with a religious affiliation had higher SPS scores Religion refers to specific faith traditions and unique
than their counterparts with no religious affiliation. theological and scriptural orientations. However, there is
Another finding, that the beyond dimension is negatively debate about the relationship between religion and spiri-
related to religion, questions the claim that spirituality equals tuality. For example, Dyson et al. (1997) argue that a
religion (Weaver & Flannelly 2004). This finding reminds us differentiation of religion and spirituality is required to
to differentiate religion and spirituality (Labun 1988, Reed encourage the development of a definition of spiritual care,
1991, Peri 1995). while Hammond (2003) states that most people who practise
This phenomenon may be symptomatic of different inter- a religion believe spirituality and religion to be inseparable.
pretations of religion and spirituality. Religion has been Religion is a set of beliefs that attempts to answer life’s
understood both individually and institutionally. James questions and provide guidelines to which individuals adhere.
(1902, cited in Hill & Pargament 2003) distinguished a Individuals’ quest for meaning can be raised from an
firsthand, experiential religion that is direct and immediate individual level by participation in a religious community
from a secondhand institutional religion that is an inherited (Hammond 2003). Although religion can provide a platform
tradition. Religion has arguably now become separated from for the expression of spirituality, it is contended that
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L.Y.F. Chung et al.
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