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Nursing Students’ Perceptions of Spirituality and Spiritual Care; An Example

of Turkey

Article  in  Journal of Religion and Health · February 2018

DOI: 10.1007/s10943-017-0416-y

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J Relig Health
DOI 10.1007/s10943-017-0416-y

ORIGINAL PAPER

Nursing Students’ Perceptions of Spirituality

and Spiritual Care; An Example of Turkey

Safak Daghan1

Ó Springer Science+Business Media New York 2017

Abstract This descriptive survey study aimed to explore how nursing students perceive
spirituality/spiritual care and investigate the variables acting on their perception. Data were
collected using the Spirituality and Spiritual Care Rating Scale with 500 students from the
Faculty of Nursing. The students’ median score regarding their perception of spirituality
and spiritual care indicates a ‘‘conceptual confusion’’ related with these concepts. Female
students have higher scale scores than male students (z = 2.19, p \ 0.05). Students’
awareness of spirituality and related concepts, and their acquisition of spiritual care skills
will allow them to provide spiritual care after graduation.

Keywords Nursing students  Perceptions  Spirituality  Spiritual care

Introduction

Nursing philosophy revolves around the concept of holistic care, (Barnum 2010; Gülnar
et al. 2015; McSherry 2006). The holistic model of health care suggests that people are
composed of physical, psychological, social and spiritual dimensions (McSherry 2006;
McSherry and Ross 2010). Nurse researchers in particular have affirmed and considered
spirituality and spiritual care to be fundamental aspects of a holistic nursing care approach
(McSherry and Jamieson 2011; Ramezani et al. 2014; Zehtab and Hajbaghery 2014).
Since the late 1980s, there has been an increasing interest and exploration of the
spiritual dimension in nursing (Mcsherry and Jamison 2011). The NANDA framework for
2015–2017 identified spiritual distress as an essential domain that needed to be addressed
in order to reduce suffering and promote well-being (Herdman and Kamitsuru 2014).

& Safak Daghan

[email protected]
1
Department of Public Health Nursing, Faculty of Nursing, Ege University, 35100 Bornova, İzmir,
Turkey

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 J Relig Health

‘‘Spiritual distress’’ is a diagnosis established after a comprehensive spiritual assessment.

The literature suggests that, spiritual awareness is necessary for spiritual assessment (Pesut
2008; Timmins and Neill 2013; Tiew and Drury 2012), and specific education on spiri-
tuality provides a broader view of diverse beliefs (Tiew and Drury 2012) and enabled
students to grow in terms of sensitivity to their personal spiritual agendas (Lewinson et al.
2015; Ross et al. 2014; Zehtab and Hajbaghery, 2014). However, spirituality and spiritual
care receives little attention in nursing education across the globe (Kalkim et al. 2016;
Lewinson et al. 2015 Ross et al. 2014; Timmins and Neill 2013). McSherry and Ross
(2002) found that only 15% of the participants reported significant learning opportunities
about spiritual interventions during their nursing education. Some authors suggest that
inadequate preparation may contribute to nurses’ perceptions of incompetence and
avoidance of spiritual matters in practice (Baldacchino 2006; Callister et al. 2004;
Ozbasaran et al. 2011). Baldacchino (2006) provides insight regarding the fact that nurses
generally focus more on tasks, and less on the spiritual aspect of care, mostly due to a lack
of education regarding spiritual care. Gant (2016) and Wu and Lin (2011) also found that
because there is a lack of education about spiritual care, nurses lack the confidence to
provide such care. According to Burkhart and Schmidt (2012), there is not an adequate
amount of spiritual care education in nursing curricula, which further magnifies the
problem of nurses feeling unprepared to provide spiritual care. Studies in both western
countries (Gant 2016; Timmins and Neill 2013; Ross et al. 2014) and East Asia (Wu et al.
2012; Tiew et al. 2013; Wu and Lin 2011; Wong et al. 2008) agree about the importance of
teaching spirituality to nurses. However, the conceptualization of spirituality in most
studies was western in origin. To fully understand and describe the meaning of spirituality
and spiritual care, further research should include culturally and religiously diverse sam-
ples and perspectives. It is also possible that the new generation of students may have
different worldviews, cultural beliefs and values about spirituality and spiritual care from
those of current nurses (Catanzaro and McMullen 2001; Ross et al. 2014). There is a need
to understand students’ views and how their spiritual development is shaped in order to
inform content and learning experiences offered in pre-registration education (Zehtab and
Hajbaghery, 2014). Although some Nursing boards responsible for programme accredi-
tation do encourage the inclusion of spiritual care as a core competency for nurses (Bal-
dacchino 2007; Cockell and McSherry 2012; Labrague et al. 2015), this is not the case in
all countries, and currently does not occur in Turkey. Although spirituality and related
concepts are not systematically included in the curriculum of graduate programs in Turkey,
they are presented to students through a two-hour separate course within the curricula of
the faculty where the research was conducted and through related subjects within the scope
of the integrated curricula (Ozbasaran et al. 2011). However, the method of education
follows class-based activities. In the literature, it is stated that individual reflection, spir-
itual guidance, experiential activities and in-depth discussion in small groups in the clinical
setting may be more effective learning strategies than theoretical education offered in a
classroom setting (Callister et al. 2004; Barnum 2010; Lewinson et al. 2015; Tiew et al.
2013). It is often said that Turkey is a ‘‘bridge between East and West.’’ Therefore, this
study is of significance in terms of reflecting the cultural perception of student nurses and
the full comprehension of the concepts of spirituality and spiritual care in the case of
Turkey which incorporates eastern and western culture. The purpose of this study was a) to
describe how nursing students perceive spirituality/spiritual care b) to describe how
component effect nursing students perceive spirituality/spiritual care.

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J Relig Health

Methods

Design and Sample

This descriptive and survey design study was carried out between October and December
2015 at an Ege University Faculty of Nursing in Izmir, Turkey. The population consists of
1325 nursing students. Sample has been selected randomly by multi-clustered stratified
sampling method. It was used the formula
N  t2  p  q
N¼
d2  ðN  1Þ þ t2  p  q
to determine the number of sampling (Sumbuloglu and Sumbuloglu 1998), where N is the
population size, p the probability of occurrence, q = 1- p, and d is the effect size. The
minimum size of sample was determined to be 297. For the research sample, 500 students
were selected from first, second, third and fourth grades according to the intensity of
student numbers in classes.

Data Collection and Instruments

Study data were obtained with the self-administered paper-based questionnaires. Data were
collected with the Student Description Form and Spirituality and Spiritual Care Rating
Scale (SSCRS).

Description Form

This form includes three questions on the socio-demographic characteristics of students

(age, class, gender), two open-ended questions on the definition of spirituality and spiritual
care and 6 rank-order questions that identify students’ awareness of the significance of
spirituality-spiritual power and spiritual care (Timmins and Neill 2013; Tiew et al. 2013;
Ozbasaran et al. 2011).

Perceptions of Spirituality/Spiritual Care (SSCRS)

SSCRS was selected to measure students’ perceptions of spirituality and spiritual care
(McSherry et al. 2002). It is a 17-item tool with a 5-point Likert-like scale format. The
instrument items ask respondents to choose an answer from strongly disagree (1) to
strongly agree (5), on the basis of their opinion about the item, It is a valid and reliable
measure of spirituality/spiritual care with the intended sample. The Turkish version of
SSCRS carried out by Ergul and Temel (2007) was used in this study. The Turkish SSCRS
demonstrates satisfactory validity and reliability in different studies (Yılmaz and Okyay
2009; Çetinkaya et al. 2013). The Cronbach Alpha Coefficient was 0.76 in this study.

Data Analysis

The data were entered into SPSS version 22 (SPSS Inc., Chicago, IL, USA) and analysed.
Descriptive statistics were used to explore the sample profile and scores of SSCRS.
Normality of the SSCRS score was examined by the Kolmogorov–Smirnov test and the
SSCRS score did not demonstrate a normal distribution (The Kolmogorov–Smirnov

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statistics = 1 ± 0.71, p \ 0.05). Therefore, as non-parametric tests, Mann–Whitney U and

Kruskal–Wallis tests were used to assess associations between scores and categorical
variables. The level of significance was set at 0.05.

Results

Students’ Socio-demographic Characteristics

The majority of the students were female (81.8%) and more than half (58.0%) was 21–23
age group (Min/Max: 18–35). Of the participants, 37.0% were first-year, 30.0% were
second-year, 19.0% were third-year and 14.0% were fourth-year students.

Students’ Awareness of the Descriptions of Spirituality and Spiritual Care,

and the Significance of the Concepts Related with Spirituality

The students were asked to describe the meaning of ‘‘spirituality’’ and ‘‘spiritual care’’. The
findings are given in Table 1. In this context, 76.8% of the students could not fully describe
the concept of ‘‘spirituality’’ while the concept was mostly described as ‘‘What people feel
spiritually and psychologically, not related to materiality’’ (n = 69). Similarly, 72.2% of
the students could not describe ‘‘spiritual care’’.
While 69.8% of the students thought that spirituality and spiritual power were very
important in human life, a small group of students (2.8%) expressed that they did not
find these concepts to be significant. Those who thought that the spiritual potential of

Table 1 Students’ description of the concepts of spirituality and spiritual care (N = 500)
n %

Description of spirituality
What people feel spiritually and psychologically, not related to materiality (Psychological 69 13.8
and spiritual aspect)
It is a religious concept. Individual’s belief in a creator and maintaining their life accordingly 16 3.2
(Description through religion)
A set of values an individual possesses including customs, mores and traditions.(Description 10 2.0
with values)
Abstract concepts which guide an individual’s conscience without being dependent on any 21 4.2
religion. (Description with the concept of conscience)
I cannot describe the concept of spirituality.(Cannot describe) 384 76.8
Description of spiritual care
Care which aims at ensuring the inner peace of a person in terms of their emotional, spiritual 83 16.6
and psychological state. (Care aimed at the inner peace of an individual)
Care provided to support the religious beliefs of patients (Care for the support of religious 34 6.8
beliefs)
Care provided to patients by nurses as part of their profession without any commercial 22 4.4
concern or expectation of benefit. (Care that should be provided as part of professional
ethics)
I cannot describe the concept of spiritual care. (Cannot describe) 361 72.2
Total 500 100.0

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patients had an impact on the healing process were of the majority (84.0%). The
majority of the students (70%) expressed that taking spiritual values into considera-
tion while providing care was very important. While the students stated that the
concepts of spirituality and spiritual care were not included in course contents at an
adequate level, 74.4% demanded a higher inclusion of these concepts in courses
(Table 2).

Students’ Perceptions of Spirituality and Spiritual Care

Median and interquartile range were calculated for the score of each item in the scale and
total scale score. The median of scale items was 3.60 (IQR = 3.55–3.82). The highest
median value indicating the perception of students regarding spirituality and spiritual care
was (item 2); ‘‘I think that nurses can provide spiritual care by acting in a compassionate,
concerned and positive manner while giving care’’ (5, IQR = 4–5). The two items with the
lowest median value were (item 1); ‘‘I think that nurses can provide spiritual care by
inviting a religious official to the hospital on patient’s demand’’ and (item 5); ‘‘I think that
spirituality is not concerned with belief in God or a supreme power and worship’’ (3,
IQR = 2-4) (Table 3).

Table 2 Students’ awareness regarding the significance of the concepts of spirituality

n %

Significance level of spirituality and spiritual power in human life

Very 349 69.8
Moderate 137 27.4
Little 10 2.0
None 4 0.8
Belief in the impact of spiritual potential on the healing process of diseases
Yes 420 84.0
No 80 16.0
Significance of taking into consideration the spiritual values of individuals while providing
care
Very 350 70.0
Moderate 130 26.0
Little 13 2.6
None 7 1.4
Adequacy level of the concepts of spirituality and spiritual care in course contents
Very 68 13.6
Moderate 259 51.8
Little 141 28.2
None 32 6.4
Higher inclusion of the concepts of spirituality and spiritual care in course contents
Yes 372 74.4
No 128 25.6
Total 500 100.0

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Table 3 The median scores for the SSCRS* (N = 500)

Spirituality and spiritual care rating scale items Median
[IQR]**

1. I think that nurses can provide spiritual care by inviting a religious official to the hospital 3 (2–4)
on patient’s demand
2. I think that nurses can provide spiritual care by acting in a compassionate, concerned and 5 (4–5)
positive manner while giving care
3. I think that spirituality is only concerned with a need to forgive and be forgiven 4 (3–4)
4. I think that spirituality involves only going to a place of worship (mosque/church) 4 (4–5)
5. I think that spirituality is not concerned with belief in God or a supreme power and 3 (2–4)
worship
6. I think that spirituality is concerned with finding meaning in the good and bad events of 4 (3–4)
our lives
7. I think that nurses can provide spiritual care by allocating time for patients to support 4 (3–5)
them in time of need
8. I think that nurses can provide spiritual care by helping patients in finding the meaning 4 (3–4)
and causes of their illnesses
9. I think that spirituality is concerned with having hope for life 4 (4–4)
10. I think that spirituality is about living one’s life ‘here and now’ 4 (3–4)
11. I think that nurses can provide spiritual care by giving patients enough time to explain 4 (4–5)
and discuss their fears, worries and sorrows, and listening to them
12. I think that spirituality is a unifying force which enables one to be at peace with oneself 4 (4–5)
and his or her environment
13. I think that spirituality does not involve areas such as art, creativity and self–expression 4 (4–5)
14. I think that nurses can provide spiritual care by showing respect for the privacy, dignity, 4 (4–5)
religion and cultural beliefs of a patient
15. I think that spirituality involves personal friendships and relationships 4 (3–4)
16. I think that spirituality does not apply to those who do not have a belief in ‘‘God/ 4 (3–5)
Supreme Power’’
17. I think that spirituality is a concept that includes morality 4 (4–5)
Total SSCRS 3.60
(3.55–3.82)
*
SSCRS indicates spirituality and spiritual care rating scale
**
Interquartile range, Q1–Q3

Relationships of Independent Variables with SSCRS

The relationships of selected independent variables and SSCRS scores are presented in
Table 4. The median scores of students who could not describe the meaning of spirituality
or spiritual care are the lowest in both groups (KW x2 = 10.94, p \ 0.05; KW x2 = 18.63,
p \ 0.01).
As students’ awareness of the significance of spirituality and spiritual power in human
life increases their scale scores also increase (KW x2 = 27.31, p \ 0.01). According to the
degrees of taking into consideration the spiritual values of individuals in nursing care, there
is a significant difference between the scale scores of the groups (KW x2 = 44.47,
p \ 0.01). In comparison, female students have higher scale scores than male students
(z = 2.19, p \ 0.05), and those who believe in the impact of spiritual power on the healing
process have higher scale scores than those who do not (z = 4.32, p \ 0.01). Similarly, the

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Table 4 SSCRS scores and selected independent variables (N = 500)

Variables Scores median Kruskal–Wallis test

x2 p

Class
First 3.65 4.79 0.188
Second 3.59
Third 3.53
Fourth 3.53
Description of spirituality
Description with the psychological and spiritual aspect of 3.65 10.94 0.012**
the individual
Description through religion 3.79
Description with values 3.74
Description with conscience 3.82
Cannot describe 3.59
Description of spiritual care
Care aimed at the inner peace of an individual 3.76 18.63 0.001*
Care for the support of religious beliefs 3.82
Care that should be provided as part of professional ethics 3.35
Cannot describe 3.59
Significance level of spirituality and spiritual power in human life
Very 3.65 27.31 0.001*
Moderate 3.53
Little 3.21
None 3.24
Significance of taking into consideration the spiritual values of individuals while providing care
Very 3.65 44.47 0.001*
Moderate 3.59
Little 3.62
None 3.53

Mann–Whitney U test

z p

Gender
Female 3.59 2.19 0.029**
Male 3.53
Belief in the impact of spiritual power on the healing process of diseases
Yes 3.65 4.32 0.001*
No 3.41
Higher inclusion of the concepts of spirituality and spiritual care in course contents
Yes 3.64 4.45 0.001*
No 3.41

* Significant at p \ 0.01; ** significant at p \ 0.05

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students who demand higher inclusion of the concepts of spirituality and spiritual care in
course contents have higher median scores (z = 4.45, p \ 0.01).

Discussion

Findings provide insight into nursing students’ perceptions of spirituality and spiritual care
in Turkey. Spirituality is acknowledged to be elusive and subjective because nursing
leaders like McSherry and Ross (2010) and Pesut (2008) believed that it is universal and
innate. Findings of the present study with socio-culturally diverse sample contribute to our
understanding of the universality of spirituality. Significant research have revealed that one
of the major causes of nurses’ failure in providing spiritual care was lack of information on
the concepts of spirituality and spiritual care as well as lack of clarity regarding the
concepts (Ramezani et al. 2014; Timmins and Neill 2013; McSherry and Ross 2010). For
example the study by McSherry (2006) confirmed that spirituality is often so inappropri-
ately defined and poorly understood to such an extent that many nurses do not consider
spiritual care as part of their role or responsibility. Shores (2010) states that determining
the perspectives of nursing students regarding the concept of spirituality will provide a
basis for their adoption of a holistic approach in providing care. Individuals know that
spirituality is real, yet they may have a difficult time articulating a definition or analyzing
the concept. In the experience of researchers, nursing students may possess very narrow
definitions; similarly, it is of notice that the majority of the students could not describe the
concepts of either spirituality or spiritual care. On the other hand, their awareness of the
positive impacts of spirituality and related concepts on human life and the healing pro-
cesses of diseases is higher. Similarly, in the study of Shores (2010) the majority of the
students stated that spirituality was important in life.
Many studies identified that spiritual education was important in preparing students to
provide spiritual care in practice (Kalkim et al.2016; Baldacchino 2007; Ross et al. 2014;
Ramezani et al. 2014). On the other hand, studies investigating nursing students’ per-
ceptions on the adequacy of spiritual education reported that curricula time was insufficient
(Lewinson et al. 2015; Burkhart and Schmidt 2012; Baldacchino 2007; McSherry and
Jamieson 2011; Wu et al. 2012). Similarly, in this study, students thought that the subjects
of spirituality and spiritual care were not sufficiently included in curricula. As in the study
of Tiew and Drury (2012), this research also revealed the belief of some participants that
more spiritual education should be integrated throughout the nursing curriculum.

Students’ Perceptions of Spirituality and Spiritual Care

Nurses’ spiritual perceptions are vital when providing spiritual care (Cockell and McSherry
2012; Ramezani et al. 2014). The high mean scores of the SSCRS indicated that, the
research subjects were spiritually minded nurses and they perceived spiritual care as one of
the essential dimensions of holistic care (McSherry et al. 2002; McSherry and Ross 2010).
Nursing students’ recognition of patients’ spiritual care needs will improve overall nursing
care quality. In Turkey, the concept of ‘‘formal’’ referral for spiritual care has yet to be
established in health system. In the classroom, students are aware that spirituality is
inherent in humans; however, in the clinical setting, students are challenged to understand
clearly the importance of spirituality in relation to the delivery of nursing care. According
to the findings of this study, the median score of the scale showed as similarity with the

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deficiency of students in describing spirituality and spiritual care conceptually. The median
score for the SSCRS was 3.60, indicating that student nurses’ perceptions concerning
spirituality and spiritual care were ‘‘unclearly’’ defined in other ways says ‘‘conceptual
confusion’’. While this result shows a contrast with the study of Wu et al. (2012), it shows
similarity with the results of some other studies (Lovanio and Wallace 2007; McSherry
et al. 2008).
Specific spiritual activities that nurses can perform are not clearly outlined within the
nursing textbooks (Timmins and Neil 2013). On the other hand, research studies have
indicated that clinical nurses listened actively, spent time talking with patients, respected
patients’ privacy and dignity, and maintained patients’ religious practices while they were
providing spiritual care (Barnum 2010; Ozbasaran et al. 2011; Wu et al. 2012) The item
which students showed the highest participation was item 2; ‘‘I think that nurses can
provide spiritual care by acting in a compassionate, concerned and positive manner while
giving care’’ is of significance in terms of spiritual care skills. When the other items which
received high participation are considered, it was seen that students in our study tended to
agree with the idea that spirituality incorporates existential elements in scale. In the UK,
the study results of McSherry et al. (2008) show that most students made links between
spirituality and existentialism (meaning, purpose and fulfillment in life). This result shows
a similarity with the study of Wu et al. (2012). In SSCRS, item 1 (I think that nurses can
provide spiritual care by inviting a religious official to the hospital on patient’s demand)
and item 5 (I think that spirituality is not concerned with belief in God or a supreme power
and worship) scored the lowest. This finding possibly reflects the fact that students are not
clear about the relation and distinction between spirituality and religion. This view is
consistent with those of other studies (Ross et al. 2014; McSherry et al. 2008). On the other
hand, as students’ awareness regarding the concepts of spiritual power, relation between
spirituality and disease increases, their perception of spirituality and spiritual care also
increase. The findings of the studies conducted by Wong et al. (2008) and Shores (2010)
indicate that gender has a significant impact on the spiritual care scale. Similarly, in our
study, the SSCRS scores of female students were higher.
In conclusion; as in many other studies, it was seen that nursing students were aware of
the significance of spirituality and spiritual care in human life and their impacts on the
healing process of diseases. However, it is of notice that there is a confusion regarding the
meaning of these concepts and the related nursing skills. When the students who are the
nurses of the future cannot correctly describe the spiritual needs of the patient, they may
not provide holistic care so the healing process and results of patient care are adversely
affected. Therefore, the assessment of spirituality and spiritual care perception of nurse
students from different cultures could contribute to the development of curricula in such a
way that students would acquire spiritual care competency.

Limitations

The study was limited by the use of convenience sampling. Thus, generalization of the
study findings is weakened. As the nature of spirituality is complex and multidimensional,
exploring students’ understanding and perceptions of spirituality and spiritual care using a
questionnaire may not reflect all views.

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Acknowledgements The author received no financial support for the research. The author would like to
thank especially two students who worked undertaking data collection, namely Vesile AKTAS and Yasar
GULOGLU. And also, the author would like to thank all the participant who took part in this study.

Compliance with Ethical Standards

Conflict of interest The authors declare they have no potential conflict of interest.

Ethical Standards All procedures in this research were performed in accordance with the ethical standards
as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.
Ethical approval for conducting this study was obtained from the ethical committee of the Ege University
Nursing Faculty (Approval dated September 14, 2015, ‘‘Issue: 27344949/457-2455’’).

Informed Consent The purpose of the study and procedures were explained and questions taken. Students
were voluntary and anonymity and confidentiality were assured. Informed consent was obtained from all
individual participants included in the study.

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