1. Introduction

Like many nurses, we are uncomfortable with the notion of providing spiritual care. You might feel like the nurse who said, “When a patient brings up a spiritual need, the only thing I know to do is call the priest or I worry that I’ll say the wrong thing.”

Historically, the notion of approaching individuals as bio-psychosocial and spiritual beings has been renowned within the nursing profession. Twenty-six nursing theories were examined by Taylor (2002) [1] to determine whether nurse theorists actually acknowledge the spiritual domain in their conceptual frameworks. The investigation revealed that 12 of the 26 theories appear to acknowledge the impact of spiritual nursing care on the quality of patient care delivered within the dynamics of holistic nursing care. There is literary evidence that historically, nurses incorporated ‘attention to the soul’ which implied caring for the spiritual dimension as part of their clinical practice (Taylor 2002) [1]. Clinical nursing practice refers to actual observation and treatment of sick, ill or injured persons as distinguished from theoretical or experimental observations (Taylor 2002) [1].

In order to meet the needs of patients holistically and to assist them in making sense of their circumstances, spiritual nursing care should be considered as equally important as physical, emotional and social care dimensions. Therefore, the concept of holistic nursing care requires that nurses should understand the interconnectedness of the physical, psychological, emotional, social, cultural and spiritual realms and treat their patients accordingly (Freshwater & Maslin-Prothero 2005; Govier 2000:; Meyer 2003) [2-4]. Nurses who appreciate this interconnectedness are likely to ensure that the spiritual component is evident in their patient care practices (Callister et al. 2004) [5].

Spiritual nursing care entails activities that facilitate a healthy balance between the bio-psychosocial and spiritual aspects of the person, thus promoting a sense of wholeness and well-being (Taylor 2002) [1].

According to McEwen (2005) [6], varied themes of spiritual nursing care in the literature represent a variety of worldviews and the opinions of people from diverse backgrounds. Smith and McSherry (2004) [7] posit that the human spirit unifies the whole person and potentially promotes health in a very real sense, by ensuring inner harmony or ‘shalom’, a feeling of peace caused by God-centered human wholeness. The descriptions of spiritual nursing care in the literature range from general conceptions of a caring presence to religiously orientated interventions such as prayer or reading religious texts in relation to God’s intervention and his healing powers (Sawatzky & Pesut 2005) [8].

Currently, there is a renewed emphasis on spiritual nursing care with a growing awareness in the literature about issues related to its contribution to quality of patient care and attainment of holistic patient care (Tjale & Bruce 2007) [9]. Spiritual nursing care is closely associated with terminal illnesses; however, as humans are spiritual beings, they all have spiritual needs. Hermann (2007) [10] adds that spiritual nursing care is related to maintenance of hope in patients and helping them find meaning and purpose in their pain. Koslander and Arvidsson (2007) [11] view spiritual nursing care as recognition of patient’s dignity and showing them love and acceptance in order to assist them to attain emotional well-being and inner peace. Although spiritual nursing care seems not to fit well with the understanding of science and what constitutes scientific truth, Awara and Fasey (2008) [12] argued that spiritual care brings to clinical practice spiritual gains that result in full or partial transformation of the individual, serving to promote hope and regeneration of faith in patients and caregivers alike.

The renewed emphasis on spiritual nursing care as an inherent facet of holistic nursing care presents nurses with a significant challenge to understand what this care entails. This understanding is necessary in the light of the confusion about the meaning of the concepts ‘spirituality’ and ‘spiritual nursing care’ and the practical implications specifically of the latter concept in clinical nursing practice. McEwen (2005) [6] contends that if nurse educators and researchers do not attempt to make the existence and importance of spiritual nursing care explicit in the domain of holistic nursing care, the nurse practitioner who is directly involved in the delivery of patient care, will not do so either.

It is a noted fact that technological and scientific advances in medicine have increased the quality and effectiveness of health care. However, the focus on science and technology has increasingly overshadowed the concerns for spiritual and humanitarian needs, and this increases the risk of de-personalizing ill individuals. With the numerous advances in scientific and medical technology, nursing has become more complex and sometimes even mechanistic. As a result, the relevance of spiritual nursing care tends to be compromised and lost (Sawatzky & Pesut 2005) [8].

Although theoretical and empirical literature addressing spiritual care as it relates to nursing practice are increasing and emerge as important bodies of knowledge, spiritual nursing care is still not well understood nor applied meaningfully in practice. It seemed therefore necessary to obtain a contextualized view of spiritual nursing care by drawing upon the views of those persons who render such care in the clinical context. The findings on what spiritual nursing care is and is not by differentiating between emotional, psychological care versus spiritual nursing care would enhance understanding on holistic patient care. The findings could also serve as a framework for incorporating spiritual nursing care in the curriculum as well as in-service education programs not only for nurses, but for other health professionals as well for quality patient care. The findings could also have far reaching impact on policy makers and important accreditation bodies such as the World Health Organization (WHO), the Department of Health and Commission on Higher Education on the training and education of nurses and adoption of clinical protocols that entails provision of spiritual nursing care to improve the quality of patient care.

The central theoretical question which guided this study was: ‘What do you understand by spiritual nursing care and how do you provide such care to your patients?’

I believe that Spiritual care is a natural part of total care which fits easily into the nursing process of assessment, nursing diagnosis, planning, implementation and evaluation. Placing spiritual need and spiritual care within the framework of the nursing process has proven to be very helpful, for both philosophical and practical reasons. First, spiritual care can become more tangible as well as more assessable. Second, the types of knowledge utilized by the Nursing Process - practice wisdom, ethics of practice, and scientific knowledge are all relevant in assessing spiritual needs and planning spiritual care. It can also be documented in nursing care plans, to ensure a continuity of care. Like all other areas of care, spiritual care should be a team effort. If spiritual needs are accurately assessed and documented, all staff will be encouraged to see that care is provided. Members of the team who for some reason, do not feel comfortable about providing that care themselves, will be able to use referral. Thus, spiritual care can be a natural part of holistic care.

The aim of the study was to explore and describe student nurses’ conceptualization and their experiences of rendering spiritual nursing care. The objective of the study was to explore and describe how student nurses conceptualize spiritual nursing care and render such care to their patients.

2. Methods

2.1. Study Design

The research design that was utilized is qualitative descriptive design. The researcher utilized purposive sampling. The population of this study were the fourth year students currently enrolled in the second semester of school year 2014-2015 at Benguet State University- College of Nursing.

2.2. Procedure

The data for the research were collected through unstructured in-depth individual interviews, focus group interviews, direct observation and field notes. The unstructured interview comprised of two grand tour questions which were derived from the central theoretical research questions: ‘What do you understand by spiritual nursing care and how do you provide such care for your patients?’ An interview guide was used to give direction to data collection, as suggested by Holloway (2005) [13]. It was comprised of section A for demographic data, section B for the grand tour question and section C for the list of pre-determined questions for focus group interviews as follows:

• What do you understand by spiritual nursing care?

• How do you provide spiritual nursing care for your patients?

• How do your religious values guide your care for patients as a nurse?

• What do you understand by holistic patient care?

• What difficulties or barriers do you experience when providing spiritual nursing care?

• How do you handle the identified difficulties or barriers?

All information gathered were recorded and transcribed verbatim with respect to the vernacular used. Field notes were kept during and after the interviews. These notes were both descriptive and reflective and complemented the tape recordings that were obtained during interviews and data analysis.

2.3. Ethical Considerations

Before the research began, the necessary written permission was obtained from the Benguet State University- College of Nursing to conduct the research. The student nurses who participated in the research were informed of the study’s aims and their answers are confidential.

2.4. Rigor

The trustworthiness and authenticity criteria were subjects of this study. Before analysis of data, the researcher sets aside their potential prejudices and biases, a technique in phenomenological research called bracketing (Cohen et al., 2000) [14]. Member checks were used to establish credibility. The researcher sent each participant their transcript and asked them to review and verify the transcript content. Each participant agreed with his or her transcript.

2.5. Data Management

Data were analyzed using Colaizzi's phenomenological method. First, the researcher read all participants’ descriptions of the phenomenon for a general overview. She then read each interview two times and began to color code with highlighter function the various themes for each interview. The researcher noted the following themes: the meaning of spiritual care, the nurse relationships in health care context, the provision of spiritual care and the challenges in the provision of spiritual nursing care.

The researcher read through the highlighted areas and searched for specific statements for each theme. Each statement was analyzed for its significance and where it fit, in the different theme areas. Statements from all participants that are similar were grouped together and clustered into one list of themes. Then the researcher wrote a thorough description of the nurses’ experience of giving spiritual care. This description can be found in the findings section. The researcher sent participants a copy of their transcripts along with a summary of the researcher’s perceptions of the interview for validation. No new data were revealed from the participants.

3. Findings

The following discussions present the analysis and interpretation of the identified themes, sub-categories, and validation with literature. The themes were examined in view of literature with the intent to describe the conceptualization of nurses about what spiritual nursing care means and how it was provided to patients.

Responses from participants to the questions enabled the analyst to relate what constitutes spiritual nursing care from their perspective and challenges experienced as they provided such care. The ensuing discussions were based on the identified themes, categories and subcategories.

3.1. Theme 1: Meaning of Spiritual Nursing Care

This theme explored and described the meaning of spiritual nursing care in relation to the application of the concept ‘spiritual being’ as it applies to the student nurse and to the patient. From this theme, the understanding of the interrelationship of body, mind and spirit was explored from the responses presented. Some of the participants referred to their patients as human beings with a spiritual image as exemplified in this excerpt: “ … so this is the most challenging part on daily basis that I may treat people well as human beings and as people who are created in the image of God, not a an object which will help me get my rotational duties complete by the end of the day.”

One participant suggested that relating with a patient should go beyond the status of being a patient, but as a person who is worthy of all respect, attention and consideration of the status of being a human being: ‘‘Approaching a person as a person and not as a patient, and again allowing the communication or the relationship just to be normal. I am not a nurse or she is not a patient. We are all on the same level where we are able to communicate as human beings.”

This expression showed the need to respect patients by how they are addressed as they enter the health care arena and are treated as equal partners in the provision of health care. This finding is supported by Rahner’s (1975:1620) [16] classic conclusion that behaviour of human beings can be understood in the context of which they are as spiritual beings. According to a philosophy (Blumer 1969:8) [17], this ‘self’ of the patient is interpreted on the basis of the ‘I’ who is the real person who is respected by the health care giver, as opposed to the ‘me’ which is a product of society or the health care environment where the patient is seen through the lens of the disease or sickness presented.

3.2. Theme 2: Nurse Relationships in the Health Care Context

The nurse-patient relationship was expressed in terms of how they interacted with patients and values that were attached to it. One participant explained that relating with a patient was understood to be spiritual when being conscious of those actions for serving or pleasing God. The patient was seen as a spiritual being to be treated so as implied in the following statement: ‘‘I believe more in ah! You know, doing good than in talking about faith matters with patients, I don’t know but there is something in me that makes it awkward to talk about spirituality with the clients, but I do pray a lot too. However, I believe in works rather than words. So I live my life in my faith as I relate with my patients in such a way that I aim to please God in whatever I do or say.’’

According to this finding, the physical care provided to their patients was done in the consciousness of it being a service to God. Resorting to doing things for patients in a humane way was exemplified as a regard for people as human beings that deserves to be treated with compassion and courtesy. For more clarity on this response one participant said: “I try to walk an extra mile for my patients, and all of them will say that, that I do my best even though many times I am assigned to the most difficult patients in terms of attitude. I do my best to go the extra mile with my patients through the strength that God gives me.”

Some participants suggested that having a positive attitude or thinking positively about patients and sacrificing for them demonstrated compassionate care to those in need of such care. Hegarty (2007:47) [18] argues that patients deserve to be treated courteously and with compassion as they are the lifeblood of institutions. Although most of the participants had no exposure to training on spirituality, they however, recognized the value of a nurse-patient relationship embedded in spirituality as an essential aspect of patient care.

Both the individual and focus group participants seemed to have witnessed patients being treated as objects or in a dehumanizing way which made them state that patients are often identified with diseases, pain, ailments or suffering as expressed by one participant: ‘‘Bed 2 has pain or that patient with a sore throat.’’

Hospitals are common ground for identifying patients by their diseases or hospital bed numbers and as such, be treated as objects. In this finding patients were seen through the lens of the disease they presented. Jeon (2004:250) [19] explains that ‘self’ needs should be appreciated as being situated in interaction with others. The ‘I’ is the part of self that is the real person created by God, and sickness or disease reduces its status to that of ‘me’, which depends on how others see the person. The self is never stable and is easily affected by crisis. Therefore, patients lose their self-identity and assume a self that is relevant to the health context and its language.

3.3. Theme 3: Provision of Spiritual Nursing Care

Spiritual nursing care is described by Van Leeuwen et al. (2006:881) [20] as simply actions of assisting a patient to recognise a personal unique meaning of life in times of sickness, to strengthen that person’s relationship with self, others and God and to bring an appreciation of nurse’s spiritual actions or interventions in the immediate environment of care. Spiritual nursing care interventions reported by the participants indicated as promoting transcendence, communication and consequences of provision of spiritual nursing care. Prayer was cited as the most common spiritual intervention with the highest frequency of all the suggested actions employed by nurses to care for the spiritual needs of their patients. One participant articulated that practice by stating that: “Yah … prayer is like the first thing that I would go for because, when you’re preparing a patient for surgery in a busy setting. Does praying before the surgical procedure in the OR counts? Because I do that a lot too especially when in Benguet Gen when you know, the circulating nurse does that part. Anyway, for me prayer is the easiest thing you can have right there to reassure a patient, and to ah …to make them feel that even though they don’t go to church or anything; God is looking out for them. So that’s … that’s the first thing that ah! I would do and some of my group mates as well.”

Another participant also identified that: “Prayer was the first thing I offered when the family members of a patient who was being resuscitated in the medical ward was crying while watching the doctors and nurses stumble over to revive their family member. I just hugged the wife and we prayed silently in the corner.”

One participant reported singing (with spiritual content) as a strategy to connect with God, to draw strength and courage in trying circumstances. The Concise Oxford Dictionary (Seidl 1983) [21] defines singing as ‘to utter words in tuneful succession or to provide a vocal melody’. The words and lyrics can be intentionally chosen in a song to bring hope and comfort to the singers or listeners. In this instance the participants reported singing as a way of providing comfort through the words in the song and the melody thereof, as demonstrated in the following quote: “There was nothing that could be done on that patient. Well the heart rate, blood pressure and the vital signs were very poor. The doctor decided that we throw in the towel. We had to call in the family. I suggested that we should sing and pray with them because now the patient was critical and terminally ill. So we sung a chorus and I could see the patient and relatives lighten up.”

Participants reported that although their patients were in a medically oriented environment, conversations held with patients in times of suffering included faith in God as part of the therapy for recovery. Miner-Williams (2005:66) [21], in support of this finding, are of the opinion that in many cases nurses do not discuss issues related to spirituality with patients. In a study conducted by Tanyi et al. (2006:535) [22], their findings suggest that nurses should engage in spiritual dialogue by asking direct questions that are related to issues such as faith, belief in God, prayer or Bible texts. This kind of engagement was regarded as the simplest way to incorporate the patient and family’s spirituality into their care, although in some instances, the patient may not be forthcoming with the information.

The use of touch and giving humour for patients was also emphasized by a participant by declaring that: “I’m afraid my patient will just cry if I talk more about his situation and his frustrations in life so I just stood there in front of him and tapped his back. 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 just used my charm to make his environment lively by telling him funny experiences of our batch mates and our instructors, and oh, I almost forgot, those corny jokes are still effective to them.”

According to an article entitled Meeting your patient’s spiritual need by Carol Eldridge, gentle touch is reassuring and comforting. When you touch your patient, you provide comfort, warmth, and connection. And in a 2007 study of 100 hospice patients, every patient listed laughter as a spiritual need by creating happy experiences. Caring can be communicated appropriately through touch-language. The general rules that guide all caring communication guide touch-language. It will be perceived negatively when too strong, too long, and too intimate for the occasion. It will be perceived as caring when performed with great sensitivity, honesty, and real caring.

The symbols of prayer, reading Bible texts and singing spiritual songs were used to negotiate spiritual meaning of the situations experienced. However, they were applied indiscreetly and not as a patient centered practice.

Nevertheless, patients in this study context seemed not to expect student nurses to care for their spiritual needs. It confirms the conclusion that this type of care was provided by few student nurses on their own and not as a generally accepted or expected aspect of professional patient care practice. Commonly spiritual needs are referred to the hospital chaplain or the patient’s spiritual leaders. This finding is confirmed by Van Leeuwen et al. (2006:883) [20] who conclude that nurses accept the provision of spiritual nursing care within the nursing profession as a co-incidence.

Participants confirmed that the reality in practice is that patients are not given the information they need. One participant empathized about the need for this interaction by stating that: “If I were a patient and want the doctor to involve me, and after examining me telling me what is wrong with me and how he is going to treat me. A person must be informed, and must know exactly what is wrong with him or herself.”

Sickness, injury and disease make patients feel vulnerable and often feel left out when discussions are made concerning their care. Participants in this study had picked up the importance to provide patients with relevant information that makes them feel important and of worth.

3.4. Theme 4: Challenges in the Provision of Spiritual Nursing Care

Most of the participants reported to be feeling inadequately prepared to render spiritual nursing care to patients. Most of the cited spiritual care provided was intuitive or done as part of their spirituality, and not necessarily as part of their professional training or responsibility. This feeling of inadequacy was experienced as a lack of education, confrontation with different beliefs of both patients and nurses, preferences of patients based on culture; need to have a contractual agreement with the patient and lack of time. One participant in the individual interviews expressed that lack of time is one of the barriers or aspect that makes it difficult for them to deal with the patients’ spiritual needs: “… lack of time, lack of training, concern about activity outside of physician’s area of expertise … lack of interest or awareness.”

It does seem that to provide spiritual nursing care is qualitatively different compared to other treatments given in a health care unit. Providing spiritual care is seen as something extra that needs special time to be done and not as part of the nurse’s professional expertise in clinical practice. Govier (2000) [23] comments that attending to someone’s spiritual need is time consuming and presents a challenge to the nurse who is over stretched by under-staffing and the routine demands of busy public hospitals. Van Leeuwen et al. (2006) [20] also confirm that nurses encounter varied demands and pressures in their practice.

Participants, when asked about whether they knew how to provide spiritual nursing care, indicated lack of guidelines during their basic training years on how to provide such care: ‘‘I think also that it lies within the individual on how to carry out spiritual care. We were not guided or given the spiritual principles during our RLEs, even during our lectures, I do not think that this is in our academic curriculum.’’

One would thus assume according to the above stated finding that spiritual needs of patients are not met in clinical practice as the majority of nurses are not spiritually competent.

Although inclusion of spiritual care into the education of different health professionals is already evident, there is still a need for conceptual consensus that is coherent across all the different health professions, particularly amongst nurses. Nurses still struggle to teach and integrate spiritual nursing care to nursing practice, even though some of the literature reviewed have such content (Collins 2006:254) [25].

The Constitution of the Republic of the Philippines allows people to have freedom of religious affiliation. Participants seem to have understood this right and integrated spiritual nursing care from their point of view and belief particularly of the Christian faith with however a non-judgmental attitude towards the beliefs of their patients and of their colleagues.

It seemed to be more complex for the participants to render spiritual nursing care to the patients than giving professional care or attending to the needs of other dimensions of an emotional or psychosocial nature.

4. Conclusions

Providing basic spiritual nursing care to patients does not need an agreement or consent, but may be necessary if offering spiritual nursing care which touches areas of belief systems, religious worldviews or doctrinal practices. Prayer and use of spiritual songs was the most common and simplest form of spiritual nursing care suggested by the participants. However, spiritual nursing care is not only about prayer, reading scriptures or use of sacred music, but other modes of care such as providing patients with information or appropriate referral are examples of such care, touch and humour which even non-religious nurses can practice. Approach to care focuses on recognizing a patient as a spiritual being worthy of genuine respect and dignity. Participants themselves showed confidence and ability to do so without difficulty. It was, however, a challenge as patients subscribe to different belief systems or not to any which was perceived as a barrier to providing of spiritual nursing care. In spite of the constraints identified such as lack of time, and guidance or not given with the spiritual principles during their related learning experiences and lectures, the importance of providing spiritual nursing care cannot be underestimated (Ledger 2005) [26].

In general, the findings suggest the participants identified that the outcome of their spiritual intervention had a positive therapeutic effects on their patients.

Spiritual nursing care, according to this study, was provided based on the spiritual background of the student nurses, and not necessarily as part of professional preparation of the nurse. It was intuitive care that was provided as an in-between practice depending on the ability of the student nurse to identify spiritual needs and do something about it.

Most of the scholarly findings that seem to may have valuable impact on clinical practice and improvement of patient care are mainly accessed by nurse scholars more than nurses on the ground that are to implement those findings at bedside care. Therefore, information and findings from this study and other nursing literature on spiritual nursing care should be made available to nurses in practice in various ways. The gap between available research findings and developed models of spiritual care and their implementation in clinical nursing practice is addressed.

The pilot served its purpose to explore the research process and make changes based on the experience. Two main problems discovered was the interview schedule was too long and it did not always ask the questions that described the essence of spirituality.

In cases where nurses themselves, or their loved ones become patients, the nature of their personal experience of spiritual nursing care would have a profound effect on how they would desire that such care be provided. They should be asked to write narratives of how that care was experienced and those narratives be analysed through empirical processes. However, because of the small sample size in this study, the findings are not generalizable, but recommendation is made that further research be conducted with larger samples.

ACKNOWLEDGEMENTS

The author wishes to acknowledge Ruby, Steivy, Jon, Jaay, Aubrey, Johane, Chrisa, Jesreen, Mark, Kryme, Sunshine, Ate Cess, Ashley and my whole family in group Z (Criselle, Mhems, Wyn, Aly, Vany, Ate Char, Shery, and Nophie) for their sense of humour that’s keeping me sane, and their fervour.