Running Head: RECENT NURSING GRADUATES PERCEPTIONS OF EDUCATION

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1 Recent Nursing 1 Running Head: RECENT NURSING GRADUATES PERCEPTIONS OF EDUCATION Recent Baccalaureate Nursing Graduates Perceptions of Their Education in Spirituality Ashlee Bowman The University of Akron Patrice McCarthy PhD, CNS, RN

2 Recent Nursing 2 Abstract The need for health care providers to effectively address the connection between spirituality and health is becoming widely recognized, but nurses frequently report not feeling adequately prepared to meet the spiritual needs of their patients. While nursing education programs seek to address this aspect of patient care, few studies have explored recent graduates perceptions of how their education prepared them to address the spiritual care needs of their patients. The purpose of this descriptive study is to explore recent baccalaureate nursing graduates perception of how effectively their education prepared them to deal with the spiritual care needs of patients. The sample included fourteen graduates of a 2009 baccalaureate of nursing program with an average of 6-12 months professional work experience. Participants completed two Likert style surveys, Lemmer s Spiritual Care Content and McSherry s Spirituality and Spiritual Care Rating scale. These tools measured participant perceptions of spirituality related content included in their nursing education program and their perception of how prepared they are to address the spiritual care needs of patients. Graduates reported that most topics on spirituality were covered only briefly and some aspects of spiritual care were not addressed at all. Despite a general perception that the majority of the aspects related to patient s spiritual care needs were addressed to a limited degree, participants reported a high level of comfort about their own ability to provide spiritual care to their patients.

3 Recent Nursing 3 According to the American Nurses Association Code of Ethics with Interpretive Statements (2001), a nurse has the obligation to understand an individual s lifestyle, value system, and religious beliefs in planning health care with and for each patient (p. 7). Even though meeting the spiritual needs of patients is an important nursing measure, many nurses report not being educated to meet patients spiritual needs or to know their responsibilities as nurses related to dealing with the spiritual care of the individual (van Leeuwen, Tiesiga, Post, & Jochemsen, 2006). Researchers have explored nurses opinions about their effectiveness in meeting patients spiritual needs (Cavendish et al., 2004; van Leeuwen et al., 2006). They have consistently found that nurses do not feel that their education prepared them on the topic of spirituality (Baldaccchino, 2008; Cavedish, Luise, Russo, Mitzeliotis, Bauer, & Bajo, 2004; Wallace, Campbell, Grossman, Shea, Lange, & Quell, 2008). Lemmer (2002) asked faculty members from various baccalaureate nursing schools how they felt spirituality was incorporated into their curriculum. The researcher found that very few programs had program definitions of spirituality and that faculty felt unsure about their understanding of the spiritual dimension. Studies have also examined nursing student awareness of spirituality (Baldacchino, 2008; Narayanasamy, 1999; van Leeuwen, Tiesinga, Middel, Post & Jochemsen, 2008; Wallace et al., 2008), and how a student s understanding of spirituality changes as their education progresses (Pesut, 2002). Few studies, however, have explored recent graduates perceptions of how effectively their education prepared them to meet the spiritual needs of patients. If nurses are expected to holistically care for patients, students need to be properly educated to provide for the spiritual needs of their patients. Therefore, the purpose of this study is to explore recent baccalaureate nursing graduates perceptions of how effectively their education prepared them to deal with the spiritual needs of patients, and to compare the

4 Recent Nursing 4 relationship between what students perceived they learned and how it influenced their beliefs about dimensions of spirituality and meeting the spiritual needs of their patients. Recent graduates perceptions about the effectiveness of their education may have important educational and curriculum development implications. Review of Literature Researchers have described nurses opinions about their ability to care for the spiritual aspects of patients (Cavendish et al., 2008; van Leeuwen et al., 2006). Van Leeuwen and colleagues (2006) found that nurses identified how the communication techniques learned in nursing school were helpful, but they felt that additional information was needed in spiritual topics, such as personal self awareness and spiritual conversation techniques. Cavendish and colleagues (2004) concluded that nursing education needs an additional educational component to teach about the spiritual care of patients and states that educators cannot assume that nurses have a spiritual foundation for practice that is effective to meet the spiritual needs of patients (p. 208). Nurse researchers have investigated the effect of educational models of teaching spirituality on students awareness of spirituality (Baldacchino, 2008; Narayanasamy, 1999). Baldacchino (2008) developed a study unit on spirituality, using objectives and teaching methods based on the ASSET model (Narayanasamy, 1999). The ASSET model (auctioning spirituality and spiritual care in education and training model) uses the nursing process to teach students about spiritual care and focuses on the importance of self awareness. Knowing the definition of spirituality, communication, trust building, and giving hope are important skills necessary to implement spiritual care (Narayanasamy, 1999). Baldacchino (2008) found that the model

5 Recent Nursing 5 helped facilitate student awareness of consistency and continuity in the delivery of holistic care (p. 559). Researchers have also examined the effect of faculty-developed spirituality information on student awareness (Van Leeuwen et al., 2008; Wallace et al., 2008). Wallace and colleagues (2008) explored how faculty-developed programs to incorporate spirituality and spirituality care knowledge into course curriculum affected junior and senior student awareness of spirituality and spiritual care. They used the Spirituality and Spiritual Care Scale to measure the students awareness and found that the varied approaches all significantly increased student awareness. Van Leeuwen and colleagues (2008) using a quasi-experimental cross over design, measured student awareness with the Spiritual Care Competence Scale, and found that course-incorporated knowledge about spirituality and spiritual care enhanced student knowledge. Researchers have explored the effect of self-study spirituality programs and the effect of clinical rotations on spirituality (Rankin & Delashmutt, 2006; Taylor, Mamier, Bahjri, Anton & Petersen, 2009). For example, Taylor and colleagues (2009) studied current nurses and student nurses and found that a self-study program about spirituality improved attitudes toward nurseprovided spiritual care, ability to create and empathetic response to patient expressed spiritual pain, and even personal spiritual experience (p. 1136). Rankin and DeLashmutt (2006) incorporated a clinical rotation for senior baccalaureate students (N=188) at a faith-based community crisis center, which allowed the students to enhance their spiritual knowledge and understanding of nursing presence. They found that the students felt changed personally and professionally because of the clinical experience (p. 285). The researchers propose that by providing specific experiences, nursing education, and role modeling, the student can know the phenomena of spirituality and presence (Rankin & Delashmutt, 2006, p. 287). These studies

6 Recent Nursing 6 show that students can enhance their learning from education on the topic of spirituality (Rankin & Delashmutt, 2006; Taylor et al., 2009). Few studies, however, have explored students perceptions of how effectively their education prepared them for meeting the spiritual needs of patients. Student views of the ethical basis of teaching spirituality and the perceptions of their own spiritual development throughout school has also been explored by researchers, as well as the perceptions of faculty members of their undergraduate programs and spirituality in their curriculums (McSherry, Gretton, Draper & Watson, 2008; Lemmer, 2002; Pesut, 2002). McSherry, Gretton, Draper, & Watson, (2008) studied nursing student perceptions of the ethical basis of teaching spirituality and explored how the students viewed ethical concerns raised in the context of teaching about spirituality. They found that pre-licensure nursing students had some confusion of the distinction between spirituality and morality. A limitation of the findings from this study is that the findings are from the first year of a longitudinal study. Pesut (2002) explored spiritual well-being and the development of spirituality in first and fourth year baccalaureate students and found that the students rated highly on a spiritual well-being scale. They also found that the students increased their awareness of their spirituality as they progressed through the program. Pesut (2002) argues that students develop their own spiritual awareness as they go through nursing school. Limitations of the findings from this study are that the researchers studied a small sample of students enrolled at a private Christian school. Finally, the only study exploring faculty perceptions of spirituality education was a study by Lemmer (2002). Lemmer studied faculty from various baccalaureate schools throughout the country and asked faculty to rate to what extent spirituality was covered in their nursing programs. Overall, Lemmer found that faculty members were uncertain about having the

7 Recent Nursing 7 knowledge to teach spiritual care and about the uncertainty of how spirituality is defined. Many of the faculty stated they needed more education about the topic and that students seemed receptive of learning about the topic. Even though researchers have explored the effect of education on spirituality and spiritual care, how the topic should be taught, and perceptions of faculty, very few studies have examined recent graduates perceptions about the effectiveness of their education on helping them meet the spiritual needs of patients. The purpose of this study is to explore recent baccalaureate nursing graduates perceptions of how effectively they think they were prepared through their education to deal with the spiritual needs of patients. Methods Design The design of this quantitative study is exploratory and descriptive. Data was collected from a survey created on Survey Monkey that was ed to recent graduates asking them their perceptions about their education in spirituality. Data Analysis was conducted using SPSS to formulate frequency tabulations of each item and to do a descriptive analysis of demographic data. Sample The target population was the 2009 graduating class from one basic baccalaureate of nursing program. A convenience sample was used, and the survey was sent out to all 189 students of the 2009 graduating class. Subjects were included regardless of age, gender, or ethnicity.

8 Recent Nursing 8 Data Collection Cross-sectional data was collected with a survey, which consisted of items from the Spiritual Care Content Covered and Extent to which Covered in Nursing Programs tool used in the Lemmer (2002) study. This scale had a p value set at.5. The Likert style items, however, were revised to refer to graduates, rather than faculty members. This scale had 25 questions with a four point Likert scale. In this study, the tool was used to measure the extent to which each graduate felt the topics related to spirituality were covered during their education. A second tool titled Spirituality and Spiritual Care Rating Scale was used to measure participants comfort with spirituality and their perceived ability to provide spiritual care to their patients (McSherry, Draper, and Kendrick, 2002). This scale has an internal consistency reliability of a Cronbach s alpha coefficient of This scale was also used in the study by McSherry, Gretton, Draper, and Watson (2008), which explored the perceptions of students concerning the ethical basis of teaching spirituality. This scale has seventeen items with a five point Likert scale. Participants were also asked to complete a brief demographic questionnaire. Results Of the 189 ed surveys sent out, 54 s were returned due to the fact the s were not in operation. Of the possible sample of 135 graduates, 14 graduates completed the survey making the sample size 14 (Appendix I). The sample represented 10.4% of the population. Majority of the sample was female with 7.1% male respondents. Most subjects had graduated within one year from the time of the survey. Ninety-two percent of the sample was employed at the time they completed the survey. The majority (85.8%) of the sample had been employed a year or less.

9 Recent Nursing 9 According to the American Nurses Association (ANA), 57.9% percent of nurses work in hospitals and 8.7% work in a physician s office (ANA Issue Brief, 2009). This sample had a higher percent of nurses working in a hospital setting compared to the ANA average; however, the amount that worked in a physician s office was close to the average with 7.1%. Also according to the American Nurses Association (2011), in 2004, 2.4 million of the 2.9 million nurses were employed. This was comparable to the study sample with 92.9% being currently employed at the time of the study. The ANA also states that, 11 percent of men were enrolled in Baccalaureate of Nursing programs in 2005 (para.3). This percent is slightly higher than the sample with only 7.1% of this sample being male. When completing Lemmer s scale regarding Spiritual Care Content Covered and Extent to which Covered in Nursing Programs, the majority of the participants thought most topics were covered briefly and some topics were not taught at all (Appendix II). Results from items were grouped within spiritual topics categories including; a) knowledge base related to spirituality, b) patient assessment, c) types of interventions in patient care, and d) the nurse s self knowledge. The major findings related to knowledge base related to spirituality indicate that 50% of graduates felt the topic of the interrelationship of spiritual well-being with physical and emotional well being was only covered briefly. Regarding the topic of review of health practices of major religions, 58.3% thought the topic was covered to a moderate degree. Another major finding indicates that 66.7% of the graduates felt that the topic of crisis situations as triggers for spiritual questions was only covered briefly. Fifty percent of the recent graduates indicated that the topic of North American Nursing Diagnoses related to spiritual distress and spiritual well being was not covered at all. Finally, 83.3% thought the spiritual needs of atheists and agnostics were not taught at all.

10 Recent Nursing 10 Related to the category of assessment of spiritual needs, 75% of the graduates felt the topic of sensitivity of cues that may indicate spiritual needs was only covered briefly. Also, when asked about the topic assessment of spiritual needs 83.3% of the graduates felt the topic was only covered briefly. Finally, 58.3% of the graduates felt the use of a formal spiritual assessment tool was not taught at all. Major findings related to the topic of spirituality-focused interventions in patient care related to spirituality include that 50% of graduates felt the topic of provision of privacy and need for solitude was covered to a moderate degree. Another finding was that 33.3% of graduates felt the topic of appropriate times to make referrals to clients ministers was not taught at all. Also, when asked about the topic of nurses role in support of religious practices, 58.3% thought the topic was only covered briefly. Concerning active listening as a spiritual care intervention, 54.5% of graduates felt the topic was covered to a moderate degree. Lastly, major findings related to the category of nurse s self knowledge of spirituality include that 50% of the graduates felt the topic of importance of nurses self-knowledge when addressing clients spiritual needs was only covered briefly. Another major finding was that 58.3% of graduates felt the topic of factors related to the appropriateness of sharing spiritual beliefs with clients was only taught briefly. Despite the fact that the participants felt a lot of spirituality topics were only covered briefly, participants scored differently on McSherry, Draper, and Kendrick s Spirituality and Spiritual Care Rating Scale (Appendix III). When asked I believe spirituality is about having a sense of hope in life, 91.7% agreed with the statement. Concerning the statement, I believe spirituality does not apply to atheists and agnostics 41.7% strongly disagreed and 33.3% disagreed with the statement. With the statement, I believe spirituality is about finding meaning

11 Recent Nursing 11 in the good and bad events in life 33.3% of the graduates disagreed with the statement. Regarding the statement I believe spirituality has to do with the way one conducts one s life here and now 50% agreed with the statement and 25% strongly agreed. Finally, with the statement, I believe spirituality is a unifying force which enables one to be at peace with oneself and the world, 66.7% agreed with the statement and 25% strongly agreed. Participants also had strong response rates concerning ways nurses can provide spiritual care. On the survey, concerning the statement, I believe nurses can provide spiritual care by spending time with a patient, giving support, and reassurance especially in time of need, 54.5% agreed with the statement and 45.5% strongly agreed. Regarding the statement I believe nurses can provide spiritual care by arranging a visit with the hospital Chaplain, 41.7% agreed with the statement and 58.3% strongly agreed. With the statement, I believe nurses can provide spiritual care by enabling a patient to find meaning and purpose in their illness, 58.3% agreed with the statement and 8.3% strongly agreed. Lastly, when asked the statement, I believe nurses can provide spiritual care by having respect for privacy, dignity, and religious and cultural beliefs of a patient, 33.3% agreed and 58.3% strongly agreed. A Pearson correlation was calculated to determine the relationship between the Lemmer s Spiritual Care Content Covered and Extent to which Covered in Nursing Programs scale total and McSherry, Draper, and Kendrick s Spirituality and Spiritual Care Rating Scale scale total (Appendix IV). A significant strong positive relationship was found (r(12) =.926, p <.01. Therefore, there was a significant strong positive relationship between the perception of spiritual care content covered and spiritual care comfort.

12 Recent Nursing 12 Discussion Overall, the participants believed that most topics related to the spiritual care needs of patients were only covered at the minimal level (Appendix II). Participants reported teaching related to religion, culture, death and dying, active listening as a spiritual intervention and privacy were covered more than minimally. Most of the participants felt topics concerning spiritual knowledge such as spirituality related to physical and emotional well being was only covered minimally. Also, the majority of the participants felt the spiritual needs of atheists and agnostics were not taught at all. Participants felt topics related to assessment of spiritual needs of clients was either covered minimally or not covered at all, and more than half thought the use of a formal spiritual assessment tool was not taught at all. Lastly, a third of the participants felt the appropriateness of when to make referrals to ministers was not taught at all. McSherry, Draper, and Kendrick s Spirituality and Spiritual Care Rating Scale looked at understanding the dimension of spirituality and spiritual care. Concerning the topic of spirituality, most of the participants agreed with the statements and believed they were an important part to the spiritual dimension (Appendix III). Topics of spirituality related to hope in life, spirituality bringing peace with oneself and the world, and spirituality as the need to forgive and be forgiven were generally statements that participants agreed were important dimensions of spirituality. Most of participants believed spirituality does apply to atheists and agnostics, despite the fact they thought the topic was not covered in school. When asked statements related to spiritual care, participants agreed or strongly agreed with these statements as above, despite the fact they felt ways to assess for spiritual needs was not taught in school. If a nurse does not know how to assess for spiritual needs, then how are they able to know when a patient actually needs spiritual care? The majority of the participants felt nurses could provide care by arranging a visit

13 Recent Nursing 13 with the hospital chaplain, even though a third of graduates felt the topic was not covered in school. Findings from Lemmer s Spiritual Care Content Covered and Extent to which Covered in Nursing Programs tool that was given to recent graduates in this study are similar to the findings from Lemmer s study using the tool with faculty members (Appendix II). In Lemmer s study using faculty members, the faculty reported content covered briefly in their programs included prayer, use of scriptures, and needs of atheists and agnostics. The graduates reported similar findings, in that these same topics the graduates felt were covered briefly or not at all. Also in Lemmer s study, faculty felt the topics of spirituality as a search for meaning and purpose in life, as a search for hope for the future, and as the dimension concerned with individual s relationships with self and others, including the need for forgiveness were topics covered briefly (p.486). Lemmer s findings in this area are also similar to what the graduates reported were covered briefly. Topics related to death and dying, culture and spirituality, and respect for clients families were generally topics faculty felt were covered more both at regular institutions and more faith-based orientated institutions (Lemmer, 2002). Graduates also felt these topics were covered more than minimally; however, faculty felt topics related to spiritual assessment were content items more addressed and the graduates in this study felt assessment topics were not taught at all or covered minimally. Van Leeuwen and colleagues (2006) findings were also comparative to how graduates scored on Lemmer s Spiritual Care Content Covered and Extent to which Covered in Nursing Programs (Appendix II). In their study, nurses felt communication skills in school were helpful, which could be evidenced in this study with communication topics such as active listening graduates felt were covered more. Narayanasamy (1999) felt knowing the definition of

14 Recent Nursing 14 spirituality, and topics of communication, trust building, and giving hope were important skills necessary to implement spiritual care. The participants felt topics of giving hope and definitions of spirituality were topics covered only briefly, which could be a potential problem if the knowledge of these topics are important to provide spiritual care. Graduates reported a high level of comfort on the Spirituality and Spiritual Care Rating Scale despite the fact they felt topics were covered only briefly during their education. McSherry, Draper, and Kendrick (2002), also found that nurses are aware of the principles of spiritual care when given the Spirituality and Spiritual Care Rating Scale. They also found that all stages of nurses were able to distinguish what practices are related to spiritual care. These findings are also similar to what the graduates felt, in that the graduates were able to distinguish principles of spirituality and spiritual care (Appendix III). McSherry, Draper, and Kendrick also found that nurses viewed religion and spirituality as not being synonymous, and the graduates in this study also agreed. When McSherry, Gretton, Draper, and Watson (2008) used the Spirituality and Spiritual Care Rating Scale on student nurses to look at the ethical basis of teaching spirituality, the researchers also found that the students scored similarly. In their study, they also found that students have their own ideas about spirituality and students believe their own beliefs are their own business. Students did however think differently when their beliefs caused conflict with a patient (McSherry et al., 2008). This could be related to the graduates responses on the Spirituality and Spiritual Care Rating Scale; in that maybe new graduate nurses are pulling on their own ideas of spirituality rather than their education. Nurses beliefs about responsibility to provide for patient s spiritual care despite the limited depth of attention to spiritually related content suggests graduates are drawing from other resources than their professional education (Appendix III). This could be a potential problem in

15 Recent Nursing 15 that nurses are using their own knowledge which could be incomplete, and this could impact the ability to provide holistic care. Also, participants may have picked the socially acceptable answer for what care the nurse should provide and what spirituality is, but in fact, they do not really recognize when to provide spiritual care with their clients. Graduates may also equate the caring aspect of nursing care as the same as spiritual care which could be a reason for their responses on the Spirituality and Spiritual Care Rating Scale. Limitations There are some limitations to this study. First, the sample size was small and may not be representative of the population of the 2009 graduating class. Despite the small size, important trends were found from the graduates responses that need further exploration. Another limitation to this study is that 54 s that were sent were inoperable which decreased the potential sample size. An additional limitation to this study would be the fact that the survey was sent out in the summer, which could be a reason graduates did not respond. Lastly, another limitation would be that the graduates may have not been able to give correct answers concerning content due to the fact they forgot if the topics were covered in school due to time span since graduation. Nursing Implications This study has implications for nursing practice, research, education, and curriculum development. Spirituality is becoming an important dimension in nursing practice. The Joint Commission on Accreditation requires, The hospital performs a learning needs assessment for each patient which includes patient s cultural and religious beliefs (2009, p.13). In addition, the Joint Commission requires, The hospital plans the patient s care, treatment, and services based on needs identified by the patient s assessments, reassessment, and results of diagnostic testing

16 Recent Nursing 16 (2011, p. 11). If making a care plan is an important part of a patient s hospitalization, then nurses need be prepared in the use of formal spiritual assessment tools and the nursing diagnoses related to spirituality. Without the ability to properly assess a patient for their spiritual needs, nurses then are limited in their ability to holistically care for their patients. Overall, graduates in this study felt that curricular content related to spiritual care needs is very limited. Faculty should review their curriculum and explore additional opportunities to include more assessment and planning techniques to care for the spiritual needs of patients. This study also has implications for future nursing research. More research is needed to explore the link between spiritually related content of educational programs and how graduates develop in their ability to provide for the spiritual care needs of patients. Future research should also be done comparing the spiritual care knowledge of the beginning nursing student and the recent graduate nursing student.

17 Recent Nursing 17 References American Nurses Association. (2001). Code of ethics with interpretive statements. Silver Spring: Nursingbooks.org American Nurses Association. (2011). More about RNs and advance practice RN. Retrieved February 15, 2011from ANA Issue Brief. (2009) registered nurses employment and earnings. Retrieved February 15, 2011 from Baldacchino, D. (2008, July). Teaching on the spiritual dimension in care to undergraduate nursing students: the content and teaching methods. Nurse Education Today, 28(5), Retrieved June 9, 2009, from CINAHL Plus with Full Text database. Cavendish, R., Luise, B., Russo, D., Mitzeliotis, C., Bauer, M., Bajo, M., et al. (2004, March). Spiritual perspectives of nurses in the United States relevant for education and practice... including commentary by Buchanan D and Clark MB with author response. Western Journal of Nursing Research, 26(2), Retrieved June 9, 2009, from CINAHL Plus with Full Text database Lemmer, C. (2002, November). Teaching the spiritual dimension of nursing care: a survey of U.S. baccalaureate nursing programs. Journal of Nursing Education, 41(11), Retrieved June 9, 2009, from CINAHL Plus with Full Text database. McSherry, W., Draper, P., & Kendrick, D. (2002). The construct validity of a rating scale designed to assess spirituality and spiritual care. International Journal of Nursing Studies, 39(2002), Retrieved February 15, 2010, from CINAHL Plus with Full Text database.

18 Recent Nursing 18 McSherry, W., Gretton, M., Draper, P., & Watson, R. (2008, November). The ethical basis of teaching spirituality and spiritual care: a survey of student nurses perceptions. Nurse Education Today, 28(8), Retrieved June 9, 2009, from CINAHL Plus with Full Text database. Narayanasamy, A. (1999, May). ASSET: a model for actioning spirituality and spiritual care education and training in nursing. Nurse Education Today, 19(4), Retrieved June 9, 2009, from CINAHL Plus with Full Text database. Pesut, B. (2002, February). The development of nursing students' spirituality and spiritual care-giving. Nurse Education Today, 22(2), Retrieved June 9, 2009, from CINAHL Plus with Full Text database Rankin, E., & DeLashmutt, M. (2006, December). Finding spirituality and nursing presence: the student's challenge. Journal of Holistic Nursing, 24(4), Retrieved June 9, 2009, from CINAHL Plus with Full Text database Taylor, E., Mamier, I., Bahjri, K., Anton, T., & Petersen, F. (2009, April 15). Efficacy of a self-study programme to teach spiritual care. Journal of Clinical Nursing, 18(8), Retrieved June 9, 2009, from CINAHL Plus with Full Text database. The Joint Commission. (2011). Standards revisions related to the centers for medicare and medicaid services: Hospital accreditation program. Retrieved February 25, 2011 from The Joint Commission (2009). The joint commission 2009 requirements related to the provision of culturally competent patient-centered care hospital accreditation program HAP. Retrieved February 25, 2011 from

19 Recent Nursing 19 van Leeuwen, R., Tiesinga, L., Middel, B., Post, D., & Jochemsen, H. (2008, October 15). The effectiveness of an educational programme for nursing students on developing competence in the provision of spiritual care. Journal of Clinical Nursing, 17(20), Retrieved June 9, 2009, from CINAHL Plus with Full Text database. van Leeuwen, R., Tiesinga, L., Post, D., & Jochemsen, H. (2006, July). Spiritual care: Implications for nurses' professional responsibility. Journal of Clinical Nursing, 15(7), Retrieved June 9, 2009, from CINAHL Plus with Full Text database. Wallace, M., Campbell, S., Grossman, S., Shea, J., Lange, J., & Quell, T. (2008). Integrating spirituality into undergraduate nursing curricula. International Journal of Nursing Education Scholarship, 5(1), Retrieved June 9, 2009, from CINAHL Plus with Full Text database.

20 Recent Nursing 20 Appendix I Table 1.1 Demographic Characteristics of Participants N=14 Characteristic n % Age at time of survey (years) % % % % % Gender Female % Male 1 7.1% Time since graduation (years) % % Currently Employed Yes % No 1 7.1% Length of Employment (months) % % % % > %

21 Recent Nursing 21 Table 1.1 Continued Characteristic n % Employment Setting Acute Care % Critical Care % Children s Hospital % Doctor s Office 1 7.1% Other 1 7.1% Population of employment setting Adults % Geriatrics % Community % Children %

22 Recent Nursing 22 Appendix II Table 1.2 Lemmer s Spiritual Care Content Covered and Extent to which Covered in Nursing Programs 1 Measure The interrelationship of spiritual well-being with physical and emotional well being. Not taught at all Covered briefly Covered to a moderate degree Covered in depth 0.0% 50.0% 41.7% 8.3% Sensitivity to cues that may indicate spiritual needs (e.g., presence of religious articles, verbalization about God). Assessment of spiritual needs (i.e., how to identify spiritual needs of clients and families). Spiritual needs of dying individuals and their significant others. Review of influence of cultural beliefs and values on spiritual care. Provision of privacy for clients and families need for solitude. Recognition of clients definition of spirituality. 8.3% 75.0% 16.7% 0.0% 0.0% 83.3% 16.7% 0.0% 0.0% 41.7% 41.7% 16.7% 0.0% 25.0% 41.7% 33.3% 0.0% 33.3% 50.0% 16.7% 8.3% 50.0% 33.3% 8.3%

23 Recent Nursing 23 8 Importance of nurses self-knowledge when addressing clients spiritual needs. 0.0% 50.0% 25.0% 25.0% Appropriate times and methods of making referrals to pastoral care or clients ministers. Nurses role in support of religious practices (e.g., medicine man, sacraments). Spirituality as clients relationship with a higher power as individual clients define it (e.g., God). Active Listening as a spiritual care intervention. Review of beliefs and health practices of major religions (e.g., birth/dying rituals, dietary requests). Crisis situations as triggers for spiritual questions and concerns. North American Nursing Diagnosis Association diagnoses related to spiritual distress and spiritual well being. 33.3% 41.7% 16.7% 8.3% 0.0% 58.3% 33.3% 8.3% 8.3% 58.3% 33.3% 0.0% 0.0% 27.3% 54.5% 18.2% 0.0% 33.3% 58.3% 8.3% 8.3% 66.7% 25.0% 0.0% 50.0% 25.0% 25.0% 0.0%

24 Recent Nursing Spirituality as the search for meaning and purpose in life. Being with/presence to as a spiritual care intervention. Use of touch as a spiritual care intervention. Spirituality as the search of hope for the future. Factors related to the appropriateness of sharing nurses spiritual beliefs with clients. Spirituality as the dimension concerned with one s relationships with self and others, including the need for forgiveness. Times and ways of praying with patients and/or families. 0.0% 83.3% 8.3% 8.3% 8.3% 50.0% 25.0% 16.7% 16.7% 41.7% 33.3% 8.3% 41.7% 41.7% 8.3% 8.3% 16.7% 58.3% 25.0% 0.0% 16.7% 58.3% 25.0% 0.0% 41.7% 33.3% 25.0% 0.0% 23 Spiritual needs of atheists and agnostics. 24 Use of scriptures. 83.3% 16.7% 0.0% 0.0% 100.0% 0.0% 0.0% 0.0% 25 Use of a formal spiritual assessment tool. 58.3% 25.0% 16.7% 0.0%

25 Recent Nursing 25 Appendix III 1 Table 1.3 McSherry, Draper, and Kendrick s Spirituality and Spiritual Care Rating Scale Measure Strongly Strongly Disagree Uncertain Agree disagree Agree I believe nurses can provide spiritual care by arranging a visit by the hospital Chaplain or the 0.0% 0.0% 0.0% 41.7% 58.3% patient s own religious leader if requested well being I believe nurses can provide spiritual care by showing kindness, concern and cheerfulness when giving care I believe spirituality is concerned with a need to forgive and a need to be forgiven I believe spirituality involves only going to Church/ Place of worship I believe spirituality is not concerned with a belief and a faith in a God or a Supreme Being I believe spirituality is about finding meaning in the good and bad events of life I believe nurses can provide spiritual care by spending time with a patient, giving support, and reassurance especially in time of need 0.0% 0.0% 8.3% 33.3% 58.3% 0.0% 16.7% 8.3% 50.0% 25.0% 91.7% 8.3% 0.0% 0.0% 0.0% 41.7% 16.7% 25.0% 16.7% 0.0% 0.0% 33.3% 16.7% 41.7% 8.3% 0.0% 0.0% 0.0% 54.5% 45.5%

26 Recent Nursing 26 8 I believe nurses can provide spiritual care by enabling a patient to find meaning and purpose in their illness 0.0% 16.7% 16.7% 58.3% 8.3% 9 I believe spirituality is about having a sense of hope in life 0.0% 8.3% 0.0% 91.7% 0.0% I believe spirituality is to do with the way one conducts one s life here and now I believe nurses can provide spiritual care by listening to and allowing patient s time to discuss and explore their fears, anxieties, and troubles I believe spirituality is a unifying force which enables one to be at peace with oneself and the world I believe spirituality does not include areas such as art, creativity, and self expression I believe nurses can provide spiritual care by having respect for privacy, dignity, and religious and cultural beliefs of a patient I believe spirituality involves personal friendships, relationships I believe spirituality does not apply to Atheists or Agnostics 0.0% 8.3% 16.7% 50.0% 25.0% 0.0% 0.0% 8.3% 41.7% 50.0% 0.0% 8.3% 0.0% 66.7% 25.0% 33.3% 58.3% 8.3% 0.0% 0.0% 0.0% 0.0% 8.3% 33.3% 58.3% 0.0% 0.0% 0.0% 66.7% 33.3% 41.7% 33.3% 25.0% 0.0% 0.0%

27 Recent Nursing I believe spirituality includes people s morals 0.0% 25.0% 0.0% 58.3% 16.7%

28 Recent Nursing 28 Appendix IV Table 1.4 Means, Standard Deviations, and Correlations of Spirituality Scales Measure Mean SD Correlations Lemmer s Scale ** McSherry s Scale ** Note. **p<.01