Teaching spirituality to

nurses/midwives: towards an
evidence base
Dr Linda Ross (BA, RGN, PhD)
Senior Lecturer

Overview
1. Why is it timely to be looking at this?
2. What do we know?
3. Our main study
4. The pilot study
5. Questions for discussion

1. Why is it timely to be
looking at this?

Drivers

Increasing evidence base

Government health guidance/policy
Concerns about standards of care
National surveys
Codes of ethics
Education guidelines
Demonstration of competence

Evidence: mental & physical health benefits

Balboni TA, Vanderwerker LC, Block SD et al. Religiousness and spiritual support
among advanced cancer patients and associations with end of life treatment
preferences and quality of life. J Clin Oncol 2007; 26: 555-560.

Candy B, Jones L, Speck P et al (2009) Spiritual and religious interventions for adults
in the terminal phase of disease. The Cochrane Collaboration. London: John Wiley,
2009.

Hollywell C and Walker J. Private prayer as a suitable intervention for hospitalised

patients: a critical review of the literature. J Clin Nurs 2009; 18: 637-51.

Koenig H, McCullough M and Larson D. Handbook of religion and health. New York:
Oxford University Press, 2001.

Koenig HG. Research on religion, spirituality and mental health: a review. Can
Journal Psychiatry 2009; 54: 283-291.

Walsh K, King M, Jones L et al. Spiritual beliefs may affect outcome of bereavement:
prospective study. BMJ 2002; 324:1551-1554.

Evidence:protective effect on
psychological morbidity & QOL

McClain CS, Rosenfeld B and Breltbart W. Effect

of spiritual well-being on end-of-life despair in
terminally ill cancer patients. Lancet 2003;
361:1603-1607.

Tarakeshwar N, Vanderwerker LC, Paulk E et al.

Religious coping is associated with the quality of
life of patients with advanced cancer. J Pal Med
2006; 9: 646-657.

Evidence: spiritual care valued

by
patients
McClain et al 2003
Ross LA. Spiritual care in nursing: an overview of the research to
date. J Clin Nurs 2006; 15: 852-862.
McCord G, Gilchrist VJ, Grossman SD et al. Discussing
spirituality with patients: a rational and ethical approach. An Fam
Med 2004:2; 356-361.
MacLean CD, Susi B, Phifer N et al. Patient preference for
physician discussion and practice of spirituality. J Gen Internal
Med 2003:18; 38-43.
Ross L and Austin J. Spiritual needs and spiritual support
preferences of people with end stage heart failure and their carers: a
prospective qualitative interview study. In prep

Guidance/policy: global
E.g. WHO

Spiritual/ religious care

guidance

NHS Core Principles

Department of Health 2009
Marie Curie 2003
NICE 2004
Welsh Assembly Government 2010
Scottish Government 2009 & NES

Standards of care
E.g.
Mid Staffordshire Enquiry 2011
Parliamentary & health Service
Ombudsman 2011

National surveys
e.g. RCN survey (n=4054) 2010
www.rcn.org.uk/spirituality-survey
79% nurses do not receive sufficient
education and training in spirituality

Codes of Ethics
e.g.In providing care, the nurse promotes
an environment in which the human rights,
values, customs & spiritual beliefs of the
individual, family & community are
respected (ICN 2006, p2)

Nurse education guidelines

Conduct a detailed assessment of
patients spiritual needs
Plan, deliver & evaluate spiritual care
Demonstrate an understanding of issues
related to spirituality
(QAA 2001, p10, 12)

Competence
NMC essential skills clusters:
makes a holistic, person centred
assessment of physical, social, cultural
and spiritual needs.anddevelops a
comprehensive personalised plan of
nursing care. (p114)

Key question
How do we prepare nurses/midwives for
this role?

 Evidence that we are not

preparing them as we should

RCN resources (www.rcn.org.uk)

pocket guide (2011)

On-line resource (2012)

2. What do we know?

Input is piecemeal
Variable in amount and nature
No standardisation
Competency work started
Early work on impact of spirituality
teaching on student outcomes

3. Our main study

Main study: 23 universities, 12

countries (2011-15)
Country

Lead

No.
Unis

Estimated
sample
size

Data collection

Netherlands

Rene van Leeuwen

250

Collected 9/11

England

Wilfred McSherry
Aru Narayanasamy
Jenny Hall

830

Tbc Jan 12
Collected 10/11
Being collected

Wales

Linda Ross

135

Collected 10/11

Scotland

Beth Seymour

635

Malta

Donia Baldacchino

200

Tbc 11/11

Norway

Tove Giske

765

Being collected

Sweden

Tiburtius Koslander

50

Collected 10/11

USA (California)

Pamela Cone

60

Tbc Jan 12

Country

Lead

No.
Unis

Romania

Marta Payer

92

Collecting soon

Moldova

Anna Suvac

60

Columbia

Bertha Antolinez

120

Denmark

Vibeke stergaard
Steenfeldt

70

Total

Estimated
sample
size

3167

Data collection

Being collected
?

Aims
1.Describe development of student nurses
/midwives perceptions of spirituality and
competence in delivering spiritual care
during their undergraduate education
programmes.
2.To explore cross cultural differences/
similarities in the development of
perceptions and competence.

Research questions
1. How do students perceive spirituality &
spiritual care and how do their perceptions
change over time?
2. How competent are students in
delivering spiritual care and how does this
change over time?
3. How do students rate their personal
spirituality during their course?

Research questions cont.

What factors appear to contribute to:
4 changes in: perceptions of spirituality and
spiritual care; competence; personal
spirituality over time?
5 enable development of competence?
6 differences in perception and competence
between countries, between nurses and
midwives and between religious and
secular universities?

4. The pilot study

Specific aims of pilot study

Determine final set of questionnaires
Test demographic questionnaire
Idea of time. How long for completion of
questionnaires? administration by staff?
coding and input of data? Data analysis?
Idea of sample size?
Statistical analysis
Test out logistics

Method who?
Undergraduate nurses/midwives
Sept-Dec 2010
4 centres: Wales (UK), Netherlands,
Malta, Norway (531 students)
Funding: University of Glamorgan
Research Investment Fund

The sample
Total on the day
Norway
(religious)

No. completed

% of sample

82

67

12

UK (Wales)
(secular)

188

147

28

Malta
(secular)

182

181

34

Netherlands
(religious)

166

136

26

Total

618

531

100

What?
Item to be measured

Measure selected

Individual characteristics

Demographic questionnaire

Perceptions of spirituality & spiritual

care

Spirituality & Spiritual Care Rating

Scale (SSCRS, McSherry 1997, 2002)

Competency

Spiritual Care Competency Scale

(SCCS, van Leeuwen et al 2009)

Spiritual wellbeing

JAREL Spiritual well-being Scale

(Hungelman et al 1996)

Connectedness to self, environment/

others, transcendent

Spiritual Attitude and Involvement List

(SAIL, Meezenbroek, Garssen & van
der Berg, 2008)

Results: the sample

% (n)
Gender (n=531)

Female
Male

85.1 (450)
14.9 (79)

Age (n=529)

Up to 20
21-25
26-30
31-40
Over 41

57.1
22.9
5.9
8.9
5.3

Type of course
(n=531)

Nursing
Midwifery

94.7 (n=503)
5.3 (n=28)

(n=302)
(n=121)
(n=31)
(n=47)
(n=28)

Results: the sample

% (n)
Life View (n=519)

Christian
Jewish
Atheist
Humanist
Buddhist
Hindu
Muslim
Other

79.8 (n=414)
0.4 (n=2)
5.8 (n=30)
3.1 (n=16)
0.2 (n=1)
0.2 (n=1)
0.6 (n=3)
10(n=52)

Life View (n=487)

Religious
Non-religious

87.1 (n=424)
12.9 (n=63)

Life Event (n=514)

Yes
No

55.3 (n=284)
43.3 (n=230)

Life Event (n=217)

Positive
Negative

17.1 (n=37)
82.9 (n=180)

What factors impact upon the

measures?

Age no
Gender no
Country yes
Course yes
Type of university - yes
Religiosity yes
Life events - yes

Country
Netherlands students scored highest on
spiritual wellbeing, Welsh students scored
lowest
(JAREL, chi square)

Course
Midwives scored higher on competency
than nurses (SCCS, t test)
Midwives had a broader view of spirituality
& spiritual care than nurses (SSCRS, t
test)

Type of university
Students from religious universities
(Netherlands & Norway) scored higher on
competency (SCCS, t test) and spiritual
attitude/involvement (SAIL, t test) than
those from secular universities (Wales &
Malta).

Religiosity
Students professing a religion scored
significantly higher on;
-spiritual wellbeing (JAREL, chi square)
-competence (SCCS, t test)
-spiritual attitude/involvement (SAIL, t test)

Life events
Students who had experienced any life
events (+ or -) demonstrated:
-higher spiritual attitude/involvement scores
- a broader view of spirituality/spiritual care
(SSCRS, t test)

Other findings
JAREL x SCCS
Students who scored high on spiritual
wellbeing (JAREL, score 85-126) were
more likely to be rated as competent
(SCCS >3.5, chi square)

Other findings
SAIL x SCCS
+ve correlation between the 2 measures
suggesting that students with higher
spiritual attitude/involvement (SAIL) scores
are more likely to have higher competency
(SCCS) scores (chi square)

Other findings
Those with higher mean scores on the
caring for others subscale of SAIL:
-had higher spiritual involvement/attitude
scores (JAREL)
-non-religious
-regularly meditate/practise art/voluntary
work
-higher competency scores (SCCS)

Multivariate analysis
No good models identified for SCCS
SAIL (daily prayer, never meditate, under
20 yrs, Norway, weekly art, never in
nature, daily nature explained 30% of the
variance)
SSCRS (same factors explained 13 % of
the variance)

Summary: students most

competent
-higher spiritual wellbeing
-higher spiritual attitude/involvement
-midwives
-from religious universities
-religious

Summary: students most caring

of others
-higher spiritual wellbeing
-higher competency

Summary: students with

broader view of spirituality
- midwives
-experienced a life event (+ve or ve)

Summary: students with higher

spiritual wellbeing
-from Netherlands rather than Wales
-religious

Conclusions
Students belief system & life experience
impacts upon their view of spirituality &
spiritual care and their perceived
competence
Limitations: sample (size, 4 countries), one
point in time.

5. Questions for discussion

(allow 10 mins)
Should we be selecting students
differently?
Should spirituality feature in all
undergraduate nursing programmes?
Should there be a national curriculum?