NURSING STUDENTS’ PERCEPTIONS AND ATTITUDES ABOUT SPIRITUALITY AND SPIRITUAL CARE IN PRACTICE TIEW LAY HWA B. Nursing, (La Trobe), Grad Dip Advanced Nursing, (La Trobe), M.Sc.(Training) (Leicester) A THESIS SUBMITTED FOR THE DEGREE FOR DOCTOR OF PHILOSOPHY (NURSING) DEPARTMENT OF NURSING NATIONAL UNIVERSITY OF SINGAPORE 2011 Dedication I dedicate this Doctoral Dissertation to my husband, Bob, who laboured with me on this PhD journey. Today, I am able to submit my Thesis only because of his unceasing love, care, motivation, encouragement, support, and inspiration. I also like to dedicate this piece of work to the many nursing students who have participated in this study and have allowed me to accomplish this dream. I endeavour to pass on what I have gained and to give back to others in the areas of nursing, healthcare, and education. ii Acknowledgements It all began with God. “For everything, absolutely everything, above and below, visible and invisible .everything got started in Him and finds purpose in Him” (Colossians1:16). Indeed, the entire PhD journey is a miraculous adventure with God. Reflecting on the past three years when pursuing my PhD, I marvelled at God’s loving presence, leading, guiding, and encouragement during this arduous journey. Accordingly, the search for knowledge of spirituality has richly blessed and touched me spiritually. Looking back, it has been a tumultuous journey that without God’s divine intervention, I would have abandoned early on. I recalled being given a letter and verbal warning when I did not so well in one of my subjects. “But with God, all things are possible” (Matthew 19:26) and in Philippians 4:13, “I can all things through Christ who strengthens me.” By God’s grace, I completed my coursework within one academic year and according to the PhD programme requirements (the maximum timeline to complete the PhD coursework was one and half-years). Inopportunely, I was stricken with breast cancer while pursuing my coursework. However, God faithfully and unfailingly enabled me to pull through this sickness and study triumphantly. Not only was I able to complete my study, I am able to complete it miraculously within three years of study. The Lord I serve is a victorious God and I give Him glory and thanks. iii Throughout this journey, God sent many people to be partners with me on. One of the most loyal and inspiring people I know is my husband, Bob. When I reflect and recall how Bob has helped me in this journey, it brings forth both laughter and tears. Bob is the best husband I could wish for. He is not only my constant motivator, listener, prayer partner, housekeeper, but also my research assistant and transport coordinator ferrying me to various research study sites to recruit and conduct interviews. I will remain grateful to Professor Debra Creedy, my principal supervisor, who has been very patient supervising, guiding, and encouraging me throughout this journey. Also Associate Professor Edward Poon, friend and colleague, who patiently listened and helped clarify the “cobwebs” in my mind when I did not understand certain concepts in qualitative study. I would like to thank Dr Pauline Tan, Chief Nursing Officer, who is my “boss” and patiently stood by me when I was stressed and gave me the space and time to conduct my research study, writing up of the thesis and numerous presentations. Dr Chia Yen Yen, who patiently provided a listening ear when I needed to air my frustrations and doubts. There are others that equally played an important role in my study. They are Assistant Professor Vicki Drury, co-supervisor, and members of my Thesis Advisory Committee — Associate Professor Evan Lee, Assistant Professor Chow Yeow Leng, and Associate Professor Edward Poon. Professor Desley Hegney, Director of Research helped to address problems surfaced by me. Assistant Professor Chan iv Moon Fai who patiently guided and taught me all that I needed to know about biostatistics. I also extend special thanks to staff of the three educational institutions, National University of Singapore, Nanyang Polytechnic (NYP) and Ngee Ann Polytechnic (NP) for their support and assistance in helping me to recruit nursing students for my research study. Ms Rosy Tay is another supportive partner who deserves special mention. Without Rosy’s unwavering support, recruitment of participants would have been difficult. I am also grateful to Ms Pearly Yuen and Dr Ngu Wah Aung (Ngee Ann Polytechnic) who helped to facilitate data collection which enabled me to complete the research study successfully. Also appreciate the Griffins’ prayer support and thorough reviewing of this manuscript. Finally, I wish to thank the 871 students of this study. It is all of you who ultimately made this study possible and a worthwhile and fulfilling experience. v Table of Contents Dedication . ii Acknowledgements . iii Summary . x List of Tables xiii List of Figures . xiv List of Symbols xv Chapter 1: Background 1.1 Introduction 1.2 Interest in Spirituality . 1.3 Spirituality in Nursing Practice . 1.3.1 Conceptual Confusion . 1.3.2 Do Patients Want Spiritual Care? . 1.3.3. Nurses’ Spiritual Well-being 1.4 Spiritual Practice in Singapore . 1.5 Problem Statement . 1.6 Aims 12 1.7 Significance of the Study 12 1.8 Summary 14 1.9 Thesis Structure . 14 Chapter 2: Spirituality 17 2.1 Introduction 17 2.2 Search Strategy 19 2.3 Results . 19 2.3.1 Understanding Spirituality . 19 2.3.2 Attitudes 22 2.3.3 Lack of Emphasis on Spirituality in Nursing Education . 24 2.3.4 Organisational and Cultural Factors . 27 2.3.5 Individuality 29 2.4 Conclusion . 31 Chapter 3: A Review of Studies of Students’ Perceptions of Spirituality and Spiritual Care . 33 3.1 Introduction 33 3.2 Method . 34 3.3 Results: Review of the Studies . 40 3.3.1. Evaluation of a Specific Spiritual Education Unit . 40 3.3.2. Integrating Spirituality in Undergraduate Nursing Curriculum 44 3.3.3. Different Educational Strategies of Teaching Spirituality 51 3.4 Discussion 54 3.5 Conceptual Framework 56 3.6 Conclusion . 59 Chapter 4: Phase Study: Qualitative Research Method 60 4.1 Introduction 60 vi 4.2 Underpinning Paradigm . 60 4.3 Choice of Research Framework 62 4.3.1 Early Steps in Analysis 62 4.3.2 Use of Displays to Draw and Verify Descriptive Conclusions about the Phenomenon 66 4.3.3 Verifying and Validating Conclusions . 71 4.4 Phase Data Collection Procedure . 73 4.4.1 Setting and Inclusion Criteria 73 4.4.2 Sampling . 73 4.4.3 Ethical Considerations . 74 4.4.4 Interview Process 74 4.5 Approach to Data Analysis . 75 Chapter 5: Phase Study Results . 77 5.1 Introduction 77 5.2 Findings Related to Spirituality 77 5.2.1 Being Human 77 5.2.2 Spiritual Well-Being 82 5.2.3 Spiritual Awareness . 86 5.3 Findings Related to Spiritual Care 90 5.3.1 Antecedents for Spiritual Care . 90 5.3.2 Forms of Spiritual Care . 97 5.3.3 Nursing Role . 102 5.4 Factors Affecting Spiritual Care-giving in Practice . 106 5.4.1 Personal Factors 106 5.4.2 Systems factors 111 5.4.3 Patient and public factors . 115 5.5 Summary 117 Chapter 6: Discussion of Phase Study Findings . 119 6.1 Introduction 119 6.2 Participants’ Characteristics, Spiritual Understanding, and Perceptions 119 6.3 Perceptions of Spiritual Well-Being . 121 6.4 Relationship between Nurses’ Spiritual Well-Being and Spiritual Care-Giving 123 6.5 Spiritual Assessment as a Form of Spiritual Care . 124 6.6 Relationship Between Attributes and Spiritual Care-Giving . 125 6.7 Relationship Between Diverse Spiritual Understandings and Spiritual CareGiving 127 6.8 Relationship between Spiritual Education and Care-Giving 130 6.9 Perceived Barriers to Spiritual Care-Giving 133 6.10 Phase Study Limitations 135 Chapter 7: Phase Study . 139 7.1 Introduction 139 7.2 Research Design . 139 7.3 Setting 139 7.4 Sampling 140 7.5 Tool Development 140 7.5.1 Content Validity Results 142 vii 7.5.2 Face Validity Results . 142 7.6 Pilot Study . 144 7.6.1 Setting . 144 7.6.2 Sample 144 7.6.3 Ethical Considerations . 145 7.6.4 Instrument . 145 7.6.5 Pilot Study Results 146 7.7 The Main Study 149 7.7.1 Setting . 149 7.7.2 Sample 149 7.7.3 Measures . 150 7.7.4 Study Procedure 151 7.8 Ethical Considerations 151 7.9 Approach to Analysis . 152 7.10 Summary 153 Chapter 8: Phase Study Results . 154 8.1 Introduction 154 8.2 Results . 154 8.2.1 Descriptive Statistics . 154 8.2.2 Internal Consistency of the SCGS 155 8.2.3 Factor Analysis of the SCGS . 158 8.2.4 Concurrent Validity . 165 8.2.5 Results of Spiritual Care-Giving Rating Scale (SCGS) 167 8.2.6 Relationship between SCGS and Sample Characteristics . 170 8.3 Summary 174 Chapter 9: Discussion of Phase Study Findings . 176 9.1 Study Limitations . 176 9.2 Psychometric Evaluation of SCGS . 177 9.2.1. Constructs of the Spiritual Care-Giving Scale (SCGS) 179 9.2.2 Spiritual Care-giving Scale (SCGS), Spirituality and Spiritual Care Rating Scale (SSCRS) and Students Survey of Spiritual Care (SSSC) . 185 9.3 Participants’ Views and Understandings about Spirituality, Spiritual Care, and Factors Influencing Spiritual Care 187 9.4 Age and Spirituality . 192 9.5 Dynamics between Spirituality, Education Programme, Ethno-Cultural Factors, and Institution . 193 9.6 Summary 196 Chapter 10: Conclusion and Recommendations 198 10.1 Introduction 198 10.2 Significance of Study . 198 10.2.1 Spirituality Described 199 10.2.2 Spiritual Care Described 199 10.2.3 Factors Influencing Spiritual Care in Practice 200 10.2.4 Relationship with the Conceptual Framework 200 10.2.5 The First Locally Developed Multi-dimensional Spirituality Scale (SCGS) 201 10.3 Implications for Nursing . 201 viii 10.3.1 Implications for Nursing Education . 201 10.3.2 Implications for Nursing Management . 203 10.3.3 Implications for Nursing Regulators 204 10.4 Recommendations for Future Nursing Research . 204 10.5 Conclusion . 206 Bibliography 207 Appendix 1: Examples of Codes for Spirituality Construct . 239 Appendix 2: NUS IRB Approval Letter . 241 Appendix 3: Approval from Nanyang Polytechnic to Conduct Research Study 243 Appendix 4: Approval from Ngee Ann Polytechnic to Conduct Research Study . 245 Appendix 5: Participant Information Sheet and Consent Form for Phase Study . 247 Appendix 6: List of Proposed Questions for Phase One to One interview. . 251 Appendix 7: List of Questions from Phase 1, Literature Review and Published Instruments. . 253 Appendix 8: Content Experts Panel Review Form. . 259 Appendix 9: Pilot Study Instrument: Participant Demographic Details and SCGS 266 Appendix 10: Participant Information Sheet for Phase Study (Pilot Study) 271 Appendix 11: Main Study Survey Instrument: Participant Demographic Details, SCGS, SSSC & SSCRS . 274 Appendix 12: Approval Letters from Authors of Published Instruments Used in the Main Study: SSCRS and SSSC 282 Appendix 13: Participant Information Sheet for Phase (Main Study) . 285 ix Summary Background Spiritual care, a central element of holistic and multidisciplinary care, is not often integrated into practice. In order to assess the ability of the nursing profession to offer spiritual care, one could begin with student nurses as the next generation of clinicians. However, there has been little exploration of student nurses’ perceptions and attitudes towards spirituality and spiritual care. Purpose This exploratory study investigated nursing students’ perceptions and attitudes about spirituality and spiritual care. Method A mixed-method study was conducted over two phases. In-depth interviews with a convenience sample of 16 final-year students were conducted. Findings from the interviews and a systematic literature review were used to construct a tool to survey a representative sample of final-year student nurses (response rate of n=745, 61.9%). Results Phase revealed three emerging themes for each major concept. Themes relating to spirituality were being human, spiritual well-being, and spiritual awareness. Themes of spiritual care were antecedents for spiritual care, forms of spiritual care, and nursing role. Themes relating to factors influencing spiritual care in practice were personal attributes, system factors, and patient factors. x 272 273 Appendix 11: Main Study Survey Instrument: Participant Demographic Details, SCGS, SSSC & SSCRS 274 275 276 277 278 279 280 281 Appendix 12: Approval Letters from Authors of Published Instruments Used in the Main Study: SSCRS and SSSC 282 283 284 Appendix 13: Participant Information Sheet for Phase (Main Study) 285 286 287 [...]... perceived and understanding will be used to explore participants’ attitudes towards spirituality and spiritual care Specifically, the aims of the study were to: 1 Describe and examine final-year pre-registration nursing students understanding of spirituality and spiritual care 2 Describe and examine final-year pre-registration nursing students perceptions of factors facilitating or hindering the integration... in relation to students perceptions of spirituality and attributes to deliver spiritual care Students participating in interviews perceived spirituality as universal, innate, an important aspect of being human Survey findings indicated that students demographic details, programme type, and academic environment influenced their perceptions and attitudes about spirituality and spiritual care The results... is a need to explore the views of students and nurses about spirituality and spiritual care There is also a need to gain insights into student nurses’ understanding and concerns about spirituality and spiritual care (McSherry et al., 2008) Gaining insights into how our future generations of nurses perceive this dimension of care could help to inform and shape practice and education There is some evidence... between spirituality and practice The search produced 410 papers, of which 40 were included in this review 2.3 Results Five main recurring themes were deemed to affect nurses’ delivery of spiritual care: (1) understanding of spirituality; (2) attitudes; (3) lack of emphasis on spirituality in nursing education; (4) organizational and cultural factors; and (5) notions of individuality 2.3.1 Understanding Spirituality. .. samples and perspectives (Conner & Ellen, 2004; Creel, 2007) Insights into how nurses perceive spirituality and spiritual care could help to inform and shape practice and education Studies conducted in Hong Kong and Taiwan 9 indicated perceived differences in Western and Chinese cultures, religions and beliefs that may affect how the Chinese perceive spirituality, spiritual needs, and desired spiritual care. . .In Phase 2, the Spiritual Care- Giving scale (SCGS) was developed and tested to be valid and reliable (α=0.96), comprising five factors: Attributes for Spiritual Care, Spirituality Perspective, Defining Spiritual Care, Attitudes to Spiritual Care, and Spiritual Care Values Concurrent validity showed moderate correlation with two other theoretically relevant scales, Spirituality and Spiritual Care. .. and nurses are aware of their own spirituality and have mutual understanding and agreement about this concept; and (2) patients and users of healthcare services expect to have their spiritual needs addressed Possible factors underpinning the lack of integration of spirituality in practice are explored in the following sections and include conceptual confusion, perceived needs of patients, nurses’ spiritual. .. practise, observe, and respect one another’s religious, cultural and spiritual beliefs Little is known about spiritual practice in healthcare, magnitude of patients’ spiritual needs and support they obtained from healthcare professionals Through observations, anecdotal evidence and conversations with nursing and healthcare colleagues, conceptual confusion regarding spirituality and spiritual practice appeared... hindering the integration of spirituality in practice 1.7 Significance of the Study In Singapore, studies on spirituality are scarce There is only one nursing study conducted in Singapore that explored patients’ experiences of spiritual care (Lang, Ang, Poon, & Devi, 2006) There is little research on nurses’ perspectives and understanding about spirituality and spiritual care 12 Given the paucity of... spiritual wellbeing and perceptions of spirituality 3 1.3.1 Conceptual Confusion There is confusion surrounding the meaning of spirituality and how it is interpreted and understood by both nurses and patients (McSherry & Cash, 2004) Tan, Braunack-Mayer and Beilby (2005) suggested that this confusion could be due to language and terms used when defining and discussing spirituality As spirituality is . NURSING STUDENTS PERCEPTIONS AND ATTITUDES ABOUT SPIRITUALITY AND SPIRITUAL CARE IN PRACTICE TIEW LAY HWA B. Nursing, (La Trobe), Grad Dip Advanced Nursing, (La Trobe), M.Sc.(Training). Participants’ Views and Understandings about Spirituality, Spiritual Care, and Factors Influencing Spiritual Care 187 9.4 Age and Spirituality 192 9.5 Dynamics between Spirituality, Education. Constructs of the Spiritual Care- Giving Scale (SCGS) 179 9.2.2 Spiritual Care- giving Scale (SCGS), Spirituality and Spiritual Care Rating Scale (SSCRS) and Students Survey of Spiritual Care (SSSC)