F E AT U R E S

Spirituality of Staff Nurses

Application of Modeling and Role Modeling Theory
■ Mary Elaine Koren, PhD, RN ■ Christina Papamiditriou, PhD

This qualitative study examines the spiritual needs of staff nurses. Focus group participants discussed “care of the
patient” and “care of self.” We use theory to argue that self-care is essential for the care of both nurses and
patients, and spirituality is the foundation of nurses’ work. KEY WORDS: meaning and purpose, model and role
modeling theory, nurse, self-care, spirituality Holist Nurs Pract 2013;27(1):37–44

Nurse’s work is spiritual in nature.1 Nurses touch
patient’s lives during many significant moments: the
birth of a child, the experience of acute and chronic
pain, and the loss of life; yet, little is known about the
spirituality of staff nurses. The purpose of this article
is to explore the meaning and purpose of spirituality in
the work environment of staff nurses.
Defining spirituality is no easy task. There are a
plethora of definitions of spirituality in the nursing
literature.1,2 For purposes of this study, we describe
spirituality as the pursuit of meaning and purpose in
life and the shared interconnections with the world,
with a Higher Power, and with other persons who
share this world. It can also, but not always, be
transcendence to another level of being.3
The nursing literature is steeped in methods nurses
can use to provide spiritual care for their patients.4,5
However, there is a lack of information regarding
ways nurses might nourish and enhance their own
spirituality.6 Jackson7 and McEwan8 state that if
nurses are not aware of their own spiritual needs, they
will not be able to provide for the spiritual desires of
their patients. If we accept the fact that nursing is
spiritual in nature, we need also accept that nurses
have a need for continued sustenance of their spiritual
Author Affiliations: Northern Illinois University School of Nursing and
Health Studies, DeKalb, Illinois.
The authors declare no conflict of interest.
The author thanks Judith Hertz, an expert consultant, and Ellen Schultz for
reviewing the article for accuracy of MRMT content.
Correspondence: Mary Elaine Koren, PhD, RN, Northern Illinois Univer-
sity School of Nursing and Health Studies, 1240, Normal Rd, DeKalb, IL
60115 (mkoren@niu.edu).
DOI: 10.1097/HNP.0b013e318276fc38
requirements. Yet, the spiritual needs of the practicing
nurse are not typically evaluated or addressed. And all
attempts at surveying nurses’ spiritual needs alert us
of the research gap in this area.6
LITERATURE REVIEW
Literature reveals survey methods have been used to
examine spiritual practices of nurses. The results of a
survey by McSherry and Jamieson9 found that nurses
desired more spiritual support of their work. The
survey of practicing nurses by Grant et al10 found
many instances of spirituality in nurse’s work; yet,
there is little opportunity for nurses to discuss and
expound on their own spirituality. In this survey, one
nurse described a patient situation in which the patient
discussed his thoughts and feelings as he approached
death. The nurse described this emotional experience
as spiritual, yet there was little opportunity for the
nurse to process or share these experiences with
others. During the hectic pace of the staff nurse, there
is rarely time to share meaningful moments and
process what implications such moments might have
in the nurse’s work life.
Yang and Mao6 believe nurses must first have an
awareness of their own spirituality before they can
deliver spiritual care to their patients. Exploring
spirituality is a journey that takes time and effort and
nurses need to take time to cultivate their own
spirituality for this journey and care for themselves.
What we have learned from this review of the nursing
literature is there is an abundance of information
regarding how nurses assess and implement nursing

37

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38 HOLISTIC NURSING PRACTICE • JANUARY/FEBRUARY 2013
FIGURE. Modeling and role modeling theory. Reproduced
with permission from Erickson.13
interventions to support the spirituality of patients.
However, there is little information related to the
spirituality of nurses and how nurses find meaning and
purpose in the work they perform. The purpose of this
study was to explore how staff nurses experience
spirituality in their work. In addition, facilitators and
barriers to spirituality were examined.
CONCEPTUAL UNDERPINNINGS OF THIS
STUDY
The theory of modeling and role modeling (MRMT)
framed our data analysis and findings. At the heart of
MRMT is the concept of holism. Holism refers to the
integration of the biophysical, psychological, social,
and cognitive aspects of each nurse.11 At the core of
the holistic person is spiritual drive, which is the
essence of the nurse and thus defines the nurse. It
permeates all the other aspects of the nurse.12
Modeling and role modeling states nurses provide
patient care by constructing a model of patient care
based on the patient’s perceived world. In other words,
the nurse attempts to view the patient’s situation
through the eyes of the patient (see the Figure).
From this point of view, it is important to establish
a significant relationship with the patient to construct a
patient-centered model of care.11 Erickson12 states
that how well a person’s needs are met will influence
relationships with others. Nurses’ needs are no
exception to this: if nurses have their basic needs met,
they in turn can establish meaningful relationships
with their patients. Thus, nurses who practice self-care
may indeed be better equipped to provide quality
patient care.
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Erickson12 also states life is a journey in which one
is constantly searching for the meaning and purpose of
life. The nurses in this study expressed how their
nursing practice helps them find the meaning and
purpose of their lives. So, it can be said that the work
nurses perform helps them find meaning and purpose
in their lives.
Self-care is a concept within the MRMT and
informs us of the importance of caring for self. The
concept of self-care applies to both patients and
nurses. The theory suggests nurses practice
appropriate self-care through (a) acquiring knowledge
of what is best for them, (b) allocating the resources
(both internal and external resources) for achieving
what is best, and (c) developing the ability to use the
knowledge and resources to care for themselves.11
Nurses practice self-care by taking care of themselves
first. Phrased differently, ministry to others is
impossible without adequate self-care. It thus follows
nurses spiritual self-care needs must be met before the
needs of patients are met.
To practice self-care, it is necessary to obtain
self-care resources. Self-care resources, as described
in the MRMT, are internal and external. Internal
resources reside within each person, are part of his/her
personal being, and are unique to each individual.13
An example of an internal resource would be someone
who exhibits hope or an optimistic outlook on life.
External resources are those people and things that
provide support.13 An example of an external resource
is a clinical educator available to nurses for
consultation regarding specific patients. We now turn
to how these nurses described spirituality in their work
and the facilitators and barriers of spirituality.
AIMS OF THE STUDY
The overall aim of this study is to understand the role
of spirituality in staff nurses’ daily work practice.
Knowing more about how spirituality is experienced,
used, and negotiated by nurses is important for both
research and practice purposes. For research purposes,
this scholarly exploration of the spirituality of staff
nurses will add to the evidence-based practice of the
spiritual well-being of staff nurses. Also, by
identifying the spiritual needs and experiences of staff
nurses, it will facilitate the definition of the term
“spirituality,” which currently is poorly
operationalized.6 For practice purposes, identifying
facilitators and barriers to supporting spirituality in

nursing care will assist in the development of support
systems that directly nurture nurses’ needs. The
specific objectives of this study, therefore, were to
(a) identify the spiritual needs of nurses, (b)
understand how nurses experience and use spirituality
in their daily work practice, and (c) identify
facilitators and barriers to supporting the spirituality
of the practicing nurse.
METHODS
Design
We used a descriptive qualitative research design14 to
study staff nurses in an acute inpatient setting. Data
were collected via focus groups of staff nurses. Focus
groups allowed us to collect in-depth information
about participants’ spiritual needs as well as
facilitators and barriers of spirituality in the
workplace. The merit of this method centers on the
interactions among focus group participants as they
share their experiences and discuss their practices with
other focus group participants.15
Setting and sample
Data were collected from a 400-bed suburban
community hospital located outside a large
metropolitan area. Eleven nurses, 5 in one focus group
and 6 in the second focus group participated in the
study. All the nurses were female and all but 2 were
married. The majority (n = 7) of participants ranged
in the age from 36 to 55 years and reported either a
bachelor’s degree (n = 8) or associate’s degree in
nursing (n = 2). One nurse reported no religious
preference; the others reported various Christian
denominations (5 Catholics, 5 Protestants). Although
every attempt was made to recruit from various
clinical units, 8 of the nurses worked on an orthopedic
and neurology unit, 1 nurse worked in labor and
delivery, 3 worked on an oncology unit, and 1 worked
in women’s health.
Procedures
Institutional review board approval was obtained from
both the academic institution and the participating
hospital. Recruitment and focus group facilitation took
place as follows. Flyers with a description of the
research and the name and contact number were
posted on all hospital units of the participating
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Spirituality of Staff Nurses 39
hospital. Nurses who were interested in participating
in the study were asked to contact the primary
investigator. Once a group of 4 to 6 nurses indicated a
desire to participate in the study, a mutually agreeable
time was established where we met with the
participants in a private room. At that time, the nurses
were asked to sign a consent form and invited to join
the focus group discussion. All discussions were
audio-recorded. One investigator facilitated the focus
group discussion while the other helped with the
logistics of the meeting and noted all nonverbal
behaviors. We asked each focus group broad
questions related to spirituality (see the
Appendix).
DATA ANALYSIS
Data were professionally transcribed into Word
documents verbatim from the audio-recorded sessions.
We coded separately and then exchanged and
discussed themes and categories. We performed a
content analysis of the data to analyzed themes that
emerged from the focus groups transcripts. We used a
constant comparative methodology to develop and
refine categories, common themes, critical exceptions,
and relationships across categories and themes.16,17
Once we had preliminary themes and categories, we
solicited the advice of an expert consultant to help
finalize the themes. The expert consultant has written
and lectured extensively on the theory of MRMT.
After this consultation, we continued with the
constant comparative method by reviewing the
data anew and reflecting on possible new
themes.
We kept an audit trail of discussions, resolutions of
disagreements, and suggestions. An audit trail is an
organized collection of materials that attests to
the generation of findings because it maintains
records of procedures followed during the
analysis.
Last, we shared preliminary themes and categories
with a group of graduate nursing students (n = 16) in
the context of a research methodology class to solicit
feedback and member checking. This process of
validation, discussion, and possible disagreement is
important in qualitative analyses for the accurate
description of complex phenomena such as
understanding the experience of spirituality of staff
nurses.
40 HOLISTIC NURSING PRACTICE • JANUARY/FEBRUARY 2013
RESULTS
Two overarching themes emerged from the data: care
of patient and care of self.
Care of the patient
Nurses in this study described 3 aspects of patient care
during which they experienced some form of
spirituality: (1) meaning and purpose in their work, (2)
relationships with patients, and (3) caring.
Meaning and purpose
Nurses experienced meaning and purpose in their
work by providing direct and intimate patient care.
“I do find meaning and purpose for the work that I
do . . . . You’re involved in very personal aspects of
your patient’s life. So, there’s some type of profound
meaning and purpose in the work we do.”
“Whatever I give out, I get back. So, if I don’t give
out, I don’t get back. So, mine is just all personal. The
job can’t give me anymore.”
“I think what is meaningful is to make someone’s life,
you know, more comforting. We may not solve all
their problems, but we can certainly provide them
strength while they are here. I think that everything
that we do there is not an element that is not
meaningful.”
Relationship with patients
The nurses discussed how important it was to
establish a relationship with the patient, which is an
essential aspect of patient care and is also related to
spirituality.
“A nurse having a special interaction with a patient . . .
I think that can be spiritual within itself. And can
really feed our need of, you know, purposeful job.
What we do is really important.”
“That is one of the best jobs in the world. Because
they were needing somebody. They would have
welcomed anybody in their life. They welcomed you.
You had the opportunity to be that one person they
bonded with.”
“The biggest part of being a nurse is a relationship
with the patient in my mind.”
“I think it is the relationship with the patient, the
connection to the patient [that provides meaning and
purpose in nursing practice]. I think it would be very
difficult to do what we do and have it be all business.”
Caring
The nurses described the importance of providing
nursing interventions in a caring manner. They also
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
stated they were unable to function as a robot and
perform tasks in a mechanical manner. Instead, they
viewed how important it is for the nurses to not only
perform the task at hand but to also care about the
welfare of each patient.
“You can either task it or actually do the caring and
that is what gives meaning to care.”
“There is a technical side and there is a caring side . . .
And the patient telling you and making you feel that
you did good, plus your internal wow, look at what I
did. It’s a wonderful thing.”
In these ways, nurses in this study talked about
caring for patients providing meaning and purpose in
their work, thus alluding to how spirituality is present
for them in their daily work environment.
Care of self
Just as essential as care for the patient is care for self.
When the nurses in this study were asked to
summarize in 1 or 2 words the day’s discussion, they
stated, it was self-care. They admitted there was often
little time left in the day to address their own needs.
The nurses discussed internal motivation or the drive
to perform their work. The nurses also described
the external resources, or places and things that
provide support. External resources and internal
resources are terms derived from MRMT.
Internal resources
Internal resources can be defined as resources that
reside within and are part of our personal being. These
resources are unique to each individual. Care for self
evolves from within the individual. This internal
resource of self-care guides thought and decisions.13
An example of an internal resource is the wisdom
gained through the challenges and joys of life.
“I think [spirituality] is an internal driver and how you
process whatever you experience as an internal
driver.”
“And you really have to think about what is driving
your career everyday; everyday a patient that you take
care of; every interaction; every time you have to
stand up for a patient; what is driving you?”
“I think this whole spiritual piece of it is really
internalized.”
External resources (Facilitators)
Care for self also involves external resources,
which are people and things that provide support.13

An example of an external resource would be mobile
phones provided to nurses during working hours. The
nurses discussed the external resources in the hospital
work environment that enhanced quality patient care.
The nurses described “hot topics.” These are
discussion points relevant to nursing care, provided to
employees during the lunch hour.
“[We had] a hot topic and it was yoga. And it was an
instructor from [place] came over and do their hot
topic lunch and they do a yoga session.”
Yet, another nurse described a ceremony in which
her hands were blessed.
“I think one of the things that really touched my heart
this year . . . We had the chaplain bless the hand of the
nurse.”
Nurses week, a week devoted to the recognition of
staff nurses, was another positive aspect in the work
life of these nurses.
“The nurse’s week is really wonderful, a reflected
kind of the work we do . . . different events like taking
time to take care of yourselves . . . massages . . .
Avon.”
One nurse commented on how helpful the memorial
service was.
“I know also they have the memorial service for the
patients that have passed. They’re very supportive on
that.”
Several of the nurses were involved in debriefings
and perceived those as helpful.
“I like those debriefings. I have been to them in the
past. They have spiritual guidance.”
External resources (Barriers)
The nurses suggested persons and things, external
resources, they felt could improve the work
environment and provide avenues of self-care.
“I think something I would love to see is more
organizational presence somehow support of us.”
One of the nurses noted it would be helpful if there
was some type of social network that was available
online to staff nurses only.
“ . . . trying to see if we can put up like a social
network you can only access it only from with[in]
these walls, pretty much.”
Many of the nurses talked about the need to discuss
daily issues with other staff nurses.
“You need to distress. You just need to dump it once a
week.”
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Spirituality of Staff Nurses 41
“And I think we all want to emotionally and
spiritually [be there] for our patients but sometimes
we really need someone to give to us.”
“I need 5 minutes of somebody.”
“I think it would be great if we were vulnerable with
one another and say, you know what, I’m really not
handling this well.”
“It was very important that staff nurses felt like there
was support from both their peers and management. It
was important that someone was consistently
available to back them up.”
The nurses said chaplains did provide needed
support for patients and families; however, the staff
nurses felt the chaplains could also offer support to
them.
“I think that I would like more connections with the
Chaplain staff. Just to come by and say ‘How is
everybody doing? Is there anything that we can do for
you?’ Give me an extra boost to get through a difficult
night or difficult situation or a difficult patient. I wish
there was more.”
DISCUSSION
The nurses in this study described how they
experienced spirituality or found meaning and purpose
through the work they performed as a nurse, such as
through their nurse-patient relationships and the
caring moments during patient care. These findings
are congruent with other recent studies such as
Vouzavali et al18 hermeneutic exploration of the
relationship between 12 intensive care nurses and their
patients. The subjects in this study described how
those relationships provided profound meaning and
purpose in their work. The surgical nurses in the
phenomenological study of Jangland et al19 described
how nurses empower and encourage patients to
participate in their own care, by establishing a
meaningful relationship with patients. Finally,
Miner-William’s20 findings tell us that through the
nurse-patient relationship nurses demonstrate caring
for the patient and meaning and purpose in their
practice.
The nurses’ description of caring for the patient
closely reflects Watson’s Theory of Caring. Watson
states as follows:
It is when we include caring and love in our science,
we discover our caring-healing professions and
disciplines are much more than a detached scientific
42 HOLISTIC NURSING PRACTICE • JANUARY/FEBRUARY 2013
endeavour, but a life-giving and life-receiving
endeavour for humanity.21(p3)
The practice of caring for patients identified by the
nurses in this study parallel Watson’s Theory of
Caring.
Theory of modeling and role modeling
The rest of the discussion is derived from the MRMT
and is organized around the concepts of internal and
external resources. The discussion also provides
clinical implications for administrators and staff
nurses.
Internal resources
The nurses in this study described their internal
resources or motivation in caring for patients. They
described the thought processes nurses have regarding
the care performed. On the basis of these findings, we
recommend daily reflection and probing of nurses’
intensions regarding patient care. Nurses need the time
to think and reflect about their practice. Some
questions nurses may consider include the following:
Why am I a nurse? What type of nurse am I? What
motivates me to come to work each day? Why do I
provide the type of care that I provide? What
motivates my practice of nursing?
External resources/facilitators
The nurses in this study also identified those
external resources that support the spirituality of the
staff. The institution used as the research site has
implemented numerous functions to support the
spirituality of staff nurses. During lunch it offers hot
topics, which are presentations geared to staff nurse
interests. Speakers provide relevant information to
staff during the lunch time hour. The participants
stated these discussions were positive experiences that
contribute to their spirituality and should be continued
in the future. “Hot topics” can be implemented in any
acute care setting.
There are special ceremonies during Nurses week
to honor nurses, which include blessing of the hands,
debriefings, and memorial services.
Blessing of the hands of staff nurses is an
intervention that has been used by other institutions to
renew the spirit of nurses. Wolpert22 describes a
method used to bless the hands of health care
providers. Blessing of the hands can be a powerful
intervention to support the spirituality of practicing
nurses.
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Debriefings are multidisciplinary discussions of
patient status. The goal of a debriefing is to learn,
evaluate, and support the staff after some type of
critical incident as described by Salas et al,23 who
outline the necessary steps to implement this process.
On the basis of the findings of this study, debriefings
are recommended in clinical practice as a potential
method to further support the spirituality of nurses.
The nurses also described a memorial service for
staff and family members for those patients who have
died in the hospital. These services take place several
months after the death of the loved one and are also
perceived as a positive experience for families, friends,
and the staff. Once again, on the basis of our findings,
memorial services would be helpful interventions for
both families and nurses in an acute care setting.
External resources/barriers
The nurses in this study identified external
resources that could be incorporated into their
environment. An online social network, designed
specifically for staff nurses, would be relatively easy
to implement. This social network would be accessible
only to staff nurse and exclude administrators. Only in
this way would staff nurses be free to express
themselves without judgment.
Participants in this study discussed the need for a
support group that meets for a brief period of time on
a weekly basis. During this time, staff nurses would be
free to discuss any occurrences or incidents from the
week. Other staff nurses would be available for input
and support. In this way, staff nurses would have a
place to freely express themselves, and others would
be available who understand the many challenges of
the acute care setting. It would also allow time for
nurses to reflect on their own practice. Baldacchino24
found one of the by-products, so to speak, of an
educational program on spiritual care was nurses
became more aware of their own spirituality and the
need for a more reflective practice. Support groups for
nurses have been reported in the literature as an
effective method to sustain nurses in the work they
perform.19,25 The support groups will also provide a
time for nurses to review their internal resources or
motivation for practice, as discussed previously.
Hospital chaplains, as discussed by the nurses, offer
tremendous support to patients and family members.
However, the role of chaplains can be extended to
include listening and supporting staff nurses. This
would be especially significant when a patient has
died and/or had a significant change in medical status.

Supportive chaplains would provide another avenue
through which staff nurses can express their thoughts
and feelings. Chan26 suggested that chaplains become
a part of the health care team and thereby promote
more collaboration between nurses and chaplains.
And the last, but not least, of these external
resources is nurse administrators and nurse leaders,
who might take the time to visit each of the clinical
units on a regular basis. During this time, the nurse
leaders can observe the life of the staff nurse and
better recognize the challenges of taking care of
patients on a daily basis. It will also allow time when
the nurse leaders can acknowledge the hard work the
staff performs. It would provide an avenue for more
open communication. If the administrators make
themselves more accessible, the staff will be more
willing to approach administrators with suggestions of
how to improve the work environment and provide
higher quality of care.
Limitations of the study
This was a pilot study that took place in a suburban
community hospital. The findings can be applied to
similar clinical settings. However, the results should
be applied with caution due to the small sample size
and the convenience sampling.
Future research
Future research may focus on the following questions:
What are the most important spiritual practices to
support staff nurses? What do they look like? How do
we implement them?
CONCLUSIONS
This is the first study to assess the spirituality of staff
nurses from the staff nurse perspective. Previous
studies have developed interventions for staff nurses
but have not first ascertained the needs of practicing
staff nurses. This is also the first study to interview
staff nurses regarding their spiritual needs. We learned
from this discussion the importance of establishing
relationships with patients, caring for patients rather
than just performing technical skills, and the
interactions with patients are the activities that bring
meaning and purpose in the work of the staff nurse.
Nurses also suggested more administrative presence
on the units, time to discuss and reflect on pertinent
daily events as they relate to their spirituality, and
more chaplain support as ways to provide more
spiritual support to them.
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Spirituality of Staff Nurses 43
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44 HOLISTIC NURSING PRACTICE • JANUARY/FEBRUARY 2013

Appendix: Focus Group Questions

• Do you find meaning and purpose in your clinical practice, and if so, how?
• Does this meaning and purpose you find in your clinical practice relate to quality patient care?
• What are the barriers/benefits of supporting nurse’s spirituality
• Some would describe this as spirituality. What word would you use to describe our discussion?

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