Nurse Education in Practice 11 (2011) 47e53

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Nurse Education in Practice

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Teaching on spiritual care: The perceived impact on qualified nurses

Donia R. Baldacchino a, b, *
a
Institute of Health Care, University of Malta, Malta
b
University of Glamorgan, Wales, UK

a r t i c l e i n f o a b s t r a c t

Article history: This study unit as part of the Continuing Professional Development (CPD) programme aimed at reviving
Accepted 26 June 2010 the spiritual dimension in nursing care. This paper discusses the perceived impact of the study unit
Spiritual Coping in Illness and Care on qualified nurses. The paucity of literature demonstrates some
Keywords: benefits perceived by the learners namely, clarification of the concepts of spirituality and spiritual care,
Spirituality self-awareness of personal spirituality and their current clinical practice which neglects the spiritual
Spiritual care
dimension. The ASSET model [Narayanasamy, A., 1999. ASSET: a model for actioning spirituality and
Spiritual coping
spiritual care education and training in nursing. Nurse Education Today 19, 274e285] guided the teaching
Teaching
Impact
of this study unit. The nature of this study unit demanded an exploratory method of teaching to
Education encourage the nurses to be active participants. Qualitative data were collected by a self-administered
Post-graduate learners questionnaire from the three cohort groups of qualified nurses who undertook this study unit in
Continuing Professional Development (CPD) 2003e2004 (A: n ¼ 33), 2004e2005 (B: n ¼ 35) and 2006e2007 (C: n ¼ 35).
Learners found the study unit as a resource for updating their knowledge on spirituality in care and
increased self-awareness of their own spirituality and nursing care. They acknowledged their role as
change agents in order to implement holistic care in collaboration with the multidisciplinary team.
Recommendations were proposed to integrate the spiritual dimension in education and patient care.
Ó 2010 Elsevier Ltd. All rights reserved.

Introduction Draper, 2001). Patients may turn to others for bio-psychosocial

Literature criticised nursing care for giving minimal attention to
the spiritual dimension in patient care (McSherry et al., 2008;
Baldacchino, 2008c; Mitchell and Hall, 2007). This may be due to
lack of time, work overload, feelings of incompetence to deliver
spiritual care and lack of education in the undergraduate and CPD
curricula (Baldacchino, 2006; Keefe, 2005; McSherry, 1998).
Bradshaw (1997) argues that spiritual care is caught from role-
models in the clinical area rather than taught. However, since
spiritual care is not being given the merited attention, learning on
the spiritual dimension in care through role-modelling appears to
be impracticable.
The study unit was oriented towards spiritual coping in illness
and spiritual care. Experiences of spirituality may be derived from
within or outside formal religion (Tse et al., 2005; Knestrick
and Lohri-Posey, 2005). Thus, spiritual coping consists of
religious methods such as, prayer and non-religious strategies like,
talking to other patients with similar ailments (Baldacchino and
* Institute of Health Care, University of Malta, Malta. Tel.: þ356 21 468 227 (res.),
þ356 2340 1847 (UOM-IHC off.), þ356 2340 1571 (IHC Secretary).
E-mail address: donia.baldacchino@um.edu.mt
and spiritual support in order to cope and feel more in control of
their situation (Koenig, 2004; Baldacchino, 2003).
Through the author’s networking experience, it could be said
that although some universities in the U.K., U.S.A. and Canada are
known to teach on spirituality and spiritual care, few published
articles were traced to date on evaluation results of the study units.
Thus, this study attempts to fill in this gap by evaluating a CPD
study unit.
Aim
This paper discusses the perceived impact of the study unit on
Spiritual Coping in Illness and Care on qualified nurses.
Definitions
Spirituality is the unifying life force which integrates the bio-
logical, psychological and social components which includes or
excludes the religious component according to the individual belief
system (Baldacchino, 2010). Thus, spirituality applies to both the
believers and non-believers. While considering the individuality in
the definition of spirituality, all individuals may possess the
potential to experience spirituality (McSherry, 2006). The ultimate

1471-5953/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.nepr.2010.06.008
48 D.R. Baldacchino / Nurse Education in Practice 11 (2011) 47e53

outcome of spirituality is to help individuals to find meaning and Table 1

purpose in life (Chan et al., 2006). Study unit outline: spiritual coping in illness and care.

Spiritual care is being as opposed to doing (Baldacchino, 2010;
Halm et al., 2000; Bradshaw, 1994). Hence, spiritual care is
oriented towards therapeutic communication by the caregiver’s
availability and actual presence to patients (DiJoseph and Cavendish,
2005; Ross, 1996). Spiritual care may help patients to explore
strategies to cope with their illness to enable patients find meaning
and purpose in life (Baldacchino, 2003). Thus, research recommends
that spiritual care should be integrated in nursing education and
nursing practice as a philosophy of care in order to enable delivery of
holistic care (Sawatsy and Pesut, 2005; Baldacchino, 2010).
Conceptual framework
Following analysis of various humanistic theories of learning of
Carl Rogers, Abraham Maslow, Malcolm Knowles and Paolo Freire,
the Actioning Spirituality and Spiritual are Education and Training
model (ASSET) (Narayanasamy, 1999) was selected. The ASSET
model encompasses a tripod of structure content, process of learning
and outcome of education. This was considered the most appro-
priate as it provided a complete cycle of the teaching and learning
processes of qualified staff who tended to overlook the spiritual
needs of clients (Hubbell et al., 2006; Koenig, 2004).
The structure content and the process of teaching and learning
The study unit was developed by the author and based on the
literature, research and feedback from the undergraduate students
who had completed the study unit on ‘The spiritual dimension in
care’ (Baldacchino, 2008a). It consisted of 4 European Credits
Transfer System (ECTS) incorporating 28 h of teaching sessions
which included the four-hour seminar (Table 1). The study unit was
submitted by the CPD Curriculum Development Committee at the
Institute of Health Care (IHC). Eventually, this unit was approved by
the IHC Board and the Senate of the University of Malta.
Study unit title: spiritual coping in illness and Care 4 ECTS
Level 1
Learning objectives
By the end of the study unit, the learners will be able to:
a) define the term spirituality, spiritual well-being and spiritual care
b) increase awareness of personal spirituality
c) outline the spiritual distress-spiritual well-being continuum in illness
d) apply the existing Theories of stress/coping and research in care
e) assess the spiritual needs and coping of patients during illness
f) foresee their role as change agents for holistic care by implementing
spirituality in care
Content
1. Concept analysis of spirituality, spiritual coping, spiritual well-being and
spiritual care
2. Self-awareness exercises on personal spirituality and delivery of spiritual
care
3. Spiritual distress: impact of illness on individual’s life
4. Psychological theories of stress and coping
5. Research on ‘Finding meaning and purpose in illness’
6. Research on self-transcendence in illness
7. Research on hope in illness
8. Assessment of spiritual needs and coping of patients during illness
9. Facilitation of coping strategies used by patients during illness
10. Holistic care: meeting individual’s spiritual needs by the nursing process
11. Barriers to delivery of spiritual care.
Teaching methods
 Lessons with power-point presentations and a handout with (20e30)
minutes of exploratory work: Brain-storming, questioning, patient case
studies analysis, small group discussions, sharing of clinical experiences,
self-reflective exercises on personal spirituality and nursing practice.
 A concluding seminar for patient case study presentations.
Assessment method: assignment:
 Case study presentation in a seminar: assessment of patient’s/personal
spiritual distress and spiritual coping (50%).
 Academic write-up of the presentation and spiritual care (50%)
 Evaluation by a self-administered questionnaire on the study unit
(voluntary)
An extensive reference list was provided on published anecdotal and research
based literature and text-books. Nurses were encouraged to do further
literature search

This study unit had a monotheistic religious orientation since

95% of the local population are registered as Roman Catholics (Malta
Archdiocese, 2007) and the displaced immigrants are registered as
Christians or Moslems (Jesuits’ Refugees Services, 2007). The
learners had diverse clinical experiences (Table 2). This diversity
Table 2
enhanced their participation in the group discussions of patient case Demographic data of the three cohort groups of nurses.
studies. This gave them the opportunity to reinforce the theory
Characteristics Group A Group B Group C
learnt by identifying individual spiritual problems/needs and spir-
itual coping, supported by ways of meeting patients’ holistic needs. 2004 2005 2007b
The sessions were repeated twice weekly for twelve weeks to (n ¼ 33) (n ¼ 35) (n ¼ 35)
accommodate different duty rota. This facilitated active participa- Male 9 8 6
tion in small group discussions and sharing of experiences. The Female 24 27 29
students were assessed by means of a case study presentation Mean years of clinical 17.5 14.8 16.6
(Table 1). Precautions were taken to safeguard patients’ health by experience
Diversity in clinical Community Community Community
obtaining institutional permissions and patients’ consent. The
experience Geriatrics Geriatrics Geriatrics
Hospital Psychologist and/or the Hospital Chaplain were available Medical Medical Medical
for assistance in case of stress following the interview. Through the Obstetrics Obstetrics Obstetrics
active participation in the assessment of patients, the learners Oncology Oncology Outpatient
Outpatient Paediatrics clinics
became aware of the complexity of spiritual care and yielded
clinics Surgical
a reflective mode of learning (Jarvis, 1995). A humanistic environ- Surgical Surgical Specialised
ment was created and an active teaching and learning process was Specialised Outpatient carea
similar to the study unit delivered to the undergraduates which is carea clinics
already published (Baldacchino, 2008a). Specialised
carea
a
Literature review Specialised care may include accident and emergency, intensive therapy unit,
high dependency unit, cardiac intensive coronary unit, neurosurgical unit, cardio-
thoracic unit, coronary care unit, special care baby unit, operating theatre and
Literature suggests the importance of evaluating study units, renal unit.
modules and curricula in order to identify the extent to which b
The study unit was not available in 2006 because of exigencies of the Nursing
planned goals are achieved (McKie et al., 2008) and effectiveness of Department.
 D.R. Baldacchino / Nurse Education in Practice 11 (2011) 47e53 49

teaching (Mooney and Timmins, 2007; Harrison et al., 2004).
Although teaching on spirituality and spiritual care entails several
ethical issues such as individuality and respect for diverse religious
affiliations (McSherry et al., 2008), positive impact on learners is
documented such as increased self-awareness and knowledge of
spiritual care with personal spiritual growth (Table 3).
Teaching on spirituality and spiritual care revealed a positive
impact on the learners’ personal life, academic achievement and
professional care. Additional to the content of teaching, several factors
might have fostered learning such as teaching methods for example,
reflective exercises, small group discussions (Baldacchino, 2008b;
Bush, 1999); exposure to clinical experience (Pesut, 2002; Shih et al.,
1999) and students’ age and maturity (Hoover, 2002; Wallace et al.,
2008). Data collection method might have influenced recollection of
experiences such as journaling (Bush, 1999), freedom in expression of
experiences safeguarded anonymous self-administered question-
naires (Baldacchino, 2008b; Bush, 1999) and in-depth exploration of
experiences such as by focus group technique (Hoover, 2002).
Learning on the spiritual dimension in care may help the profes-
sionals realise their current care which may motivate them to become
change agents by implementing patient-centred care (Hoover, 2002)
and meeting patients’ needs holistically (Narayanasamy, 1999).
Research methodology
The descriptive exploratory study evaluated the study unit on
Spiritual Coping in Illness and Care by investigating the perceived
impact of the study unit on the three cohort groups of students at
the end of the study unit.
were females (Group A: 24 females, 9 males; Group B: 27 females, 8
males; Group C: 29 females, 6 males) which represents the overall
nurses’ gender ratio in Malta (Table 2).
Data collection and analysis
Evaluation of the CPD study units forms part of the Quality
Assurance Auditing, requested by the University of Malta. Addi-
tional to the general evaluation conducted by the Nursing CPD Unit,
the author collected qualitative data specifically on this study unit
since it was new to the CPD programme. Institutional and ethical
permissions were granted by the Chairperson of the Institute of
Health Care, University of Malta. Thus, on completion of the study
unit, the nurses were asked to fill in a self-administered ques-
tionnaire on voluntary basis. The questionnaire consisted of five
open-ended questions (Table 4).
The questionnaires were returned to the author, separate from
their assignment write-up to maintain confidentiality and to
enhance trustworthiness of data. An index number, not related to
their names, was given to the questionnaire solely for publication
purposes. Students consented to have their data analysed to be
disseminated in nursing journals and conferences. The high
response rate (A: 82% n ¼ 27; B: 91% n ¼ 32; C: 86%, n ¼ 30),
appeared to demonstrate the learners’ interest in this study unit.
The data underwent thematic analysis manually guided by the
procedural steps of Burnard (1991). To enhance credibility of the
findings, data were analysed independently and concurrently by
the author and the research assistant who agreed on the two
themes identified.

Sample Findings

The study unit was taught to three different cohort groups of The impact of the study unit on the learners is demonstrated by
qualified nurses (A: n ¼ 33, B: n ¼ 35, C: n ¼ 35), in Semester 2 of the following two themes and four categories which emerged from
2004, 2005, 2007 respectively (Table 2). The majority of the nurses the data (Table 5).

Table 3
Summary of published evaluation of teaching on spirituality and spiritual care.

Author, year, Sample and teaching programme Findings

country
Wallace et al. Undergraduate junior and senior  Significant differences in knowledge on spirituality and attitudes among senior-level nursing students
(2008), USA students (n ¼ unknown) (t ¼ 3.059, p ¼ 0.004).
A weekend programme on spirituality
and spiritual care
Baldacchino Final year undergraduate nursing  Increased self-awareness of their personal spirituality; counted their blessings in life;
(2008a,b,c), students (n ¼ 65)  Increased knowledge of the concepts of spirituality and spiritual care;
Malta A study unit on the spiritual dimension  Became more sensitive to patients’ needs.
in care
Bush (1999), A Group of mature nurses aged over 25  Effective teaching and learning occurred through sharing of experiences and knowledge between the
Australia years (n ¼ unknown) group members and between the educator and the group.
Teaching programme on spirituality
and spiritual care
Pesut (2002), 1st and 4th year undergraduates Similar findings between the two groups:
Canada (n ¼ unknown)  Developed a strong awareness of their personal spirituality oriented towards a relationship with a higher
Teaching on spirituality and spiritual being, reason for living, spiritual growth and the importance of community in their spiritual
care development;
 Had a high level of spiritual well-being;
 Patient-centred care was characterised by emotional presence, listening, prayer and facilitating
connections with those of similar beliefs;
 The reciprocal nature of spiritual learning in the nurse-patient relationship enhanced their spiritual
growth.
Hoover (2002), Nursing students undertaking part-  Increased self-awareness about their relationship with self and others;
Wales time degree (n ¼ 25)  Finding meaning and purpose in life;
A module on nursing as a human  Appreciated more their values in life;
caring including spirituality  Increased knowledge of the caring theory, and holistic approach to care;
 Enhanced caring practice by implementing patient-centred care.
Shih et al. (1999), Qualified nurses working in Intensive  Understood spirituality as part of holistic care;
Taiwan Care Unit (n ¼ 64)  Clarified the concepts of spirituality and spiritual care;
A lecture on spiritual care to patients  Increased awareness of personal beliefs and spiritual needs.
50 D.R. Baldacchino / Nurse Education in Practice 11 (2011) 47e53
Table 4
Study unit evaluation questions.
1. Explain how you consider this study unit relevant to you personally and to
your nursing care.
2. Explain how the various modes of teaching helped you to learn on
spiritual care (e.g. power-point presentations, small group discussions,
self-reflective exercises)?
3. How helpful was the assessment strategy (i.e. interview of a patient, write-
up, presentation in seminar)?
4. What impact did the study unit have on you?
5. Comments and suggestions on the overall organisation of the study unit.
Discussion
The discussion of these themes is supported by the learners’
excerpts and are compared with the limited published research on
teaching spirituality/caring.
Updating with knowledge on the spiritual dimension in care
Increasing knowledge on spirituality and spiritual coping in illness
Increased knowledge was reported to be about clarification
of the definition of the term ‘spirituality’ which had been
conceptualised solely with religiosity:
‘This study unit helped me understand better the nature of
patients’ spiritual needs. I learnt that spirituality incorporates
not only religiosity but any other coping strategy which may
help the individual to find meaning and purpose in life’.(B15)
A broader definition of ‘spirituality’ was applied also to under-
standing spiritual coping which includes both religious and non-
religious strategies. The importance of identifying spiritual needs
appeared to be recognised, which eventually seemed to motivate
the nurses to learn more about spirituality in order to enhance
nursing practice:
‘This study unit made me conscious of the spiritual needs of
patients. It stimulated me to search more literature about the
spiritual needs of patients. This study unit is fundamental for
nursing care as we were not exposed to the spiritual aspects of
care during my training’.(A2)
Following reflection on the clinical practice which revealed
minimal attention to the spiritual dimension of care, the learners
considered this study unit as an opportunity to update themselves
with new knowledge on spirituality in illness and holistic care.
Additionally, students demonstrated increased motivation to
further their learning. Similar findings were found in research
whereby an increase in knowledge appeared to trigger further
learning which may contribute towards holistic care (Baldacchino,
2008b; Greenstreet, 2005).
Being a small group in class and supported by a trustful collegial
relationship, the learners appeared to be comfortable to clarify
Table 5
Findings: themes and categories.
1. Updating with knowledge on the spiritual dimension in care.
1.1. Increasing knowledge on spirituality and spiritual coping in illness
1.2. Understanding the holistic impact of illness on patients’ life.
2. Self-awareness on the nurse’s role in spiritual care
2.1. Becoming aware of own spirituality and nursing care
2.2. Acknowledging the nurses’ role as change agents.
misconceptions and share their clinical experiences throughout the
sessions of the study unit.
‘My experience in this study unit has been a big eye-opener
regarding the quality time in our nursing care. When patients
have the opportunity to share their concerns with us nurses, it
can help them to cope with their illness’.(A18)
The importance of listening to patients was identified by Ross
(1997: 714) who was impressed by patients’ desire to ‘unburden
themselves through talking to someone who had time to listen’.
While admitting the limitations encountered in their nursing
practice, such as being busy with meeting medical and physical
needs, the study unit appeared to help them acknowledge the
importance of delivering holistic care. This is consistent with
research whereby undergraduates and qualified staff were found
to increase their knowledge on the spiritual dimension in care
which may clarify the concept of spirituality and spiritual needs
(Baldacchino, 2008b; Wallace et al., 2008; Hoover, 2002).
However, a difference is noted between the impact on under-
graduate and qualified nurses of the same culture in the study
conducted in Malta by Baldacchino (2008b) whereby fourth year
students equated the increase in knowledge with their academic
achievement whereas qualified nurses considered it as a resource
to help their colleagues and students to meet patients’ needs
holistically.
Understanding the holistic impact of illness on patients’ life
Assessing patients’ medical/surgical needs without addressing
the spiritual needs impairs holistic care. The study unit assessment
requested the learners to address directly the individual patient’s
spiritual distress and spiritual needs which were reported to help
them identify the impact of illness on the patient’s life:
‘This study unit helped me to have a deeper understanding of
the impact of illness on patients, especially patients with cancer,
and their ability to adapt and respond to the chaos brought
about by cancer diagnosis’.(B5)
The written assignment requested them to dedicate time for the
face to face interview. Students explored signs of spiritual distress,
methods of spiritual coping and how nurses and members of the
multidisciplinary team could deliver spiritual care. This interview
appeared to help them understand better spiritual distress and how
patients may cope with their illness:
‘It gave me insight into other people’s feelings and problems and
the various coping strategies which could be used in life. Very
often we are so much caught up with our nursing duties that we
are too busy to address the spiritual emotions of patients’.(C20)
Dedicating time to listen and reflect on patients’ statements
appeared to make them aware about the importance of giving
priority to meeting also patients’ spiritual needs which was
envisaged to enhance holistic care:
‘On considering the wholeness of spirituality in life, imple-
menting spiritual care may facilitate holistic care which may
enhance recovery of the whole person, irrespective of the
specific illness’. (C4)
Increased knowledge about the spiritual concepts of spirituality,
spiritual distress, spiritual well-being, spiritual coping and spiritual
care appeared to help the learners see the possibility of meeting
patients’ needs through the implementation of holistic care. This
study unit seemed to enable the learners to be active participants in
the learning process which motivated them to explore further the
spiritual dimension in care and analyse critically the reality of
nursing care which underestimates patients’ spiritual needs. This is
 D.R. Baldacchino / Nurse Education in Practice 11 (2011) 47e53 51

parallel with the findings of Hoover (2002) who found that nurses The new concepts of spiritual distress, spiritual well-being, self-
comprehended better the concept of caring and reported their transcendence and spiritual coping appeared to trigger the learners
willingness to implement patient-centred care. to share their experience with other colleagues. They attempted to
introduce change in patient care by liaising with the multidisci-
plinary team in order to meet patients’ spiritual needs:
Self-awareness on the nurse’s role in spiritual care
‘Very often I found myself discussing these new spirituality
Becoming aware of own spirituality and nursing care concepts with my colleagues. Nurses are to be knowledgeable
The learners’ experience of undertaking the study unit appeared enough and equipped professionally in order to start delivering
to confirm the essence of spirituality in life: spiritual care... After all, it is the nurse who is day and night
with patients... However, this needs teamwork.. The nurse
‘I have always felt that spirituality was not given the merited
may be the liaison person between the various members of the
importance when caring for our patients and this was one of the
interdisciplinary team’.(C5)
reasons why I applied for this study unit. This study unit has
instilled in me an increased awareness of the crucial role spiri- This study unit appeared to enable the nurses to consider their
tuality may have in bringing about and influencing healing of position as change agents whereby they could help their colleagues
the person as a whole’.(B6) to become aware of their status quo (Freire, 1972) and introduce
change gradually by implementing spiritual care. Additionally,
The study unit was reported to be beneficial as the learners had
apart from giving care, the personal benefit of patient care was
time to think critically about their own spirituality and their current
identified:
clinical practice:
‘Sitting by the patient talking about his experience brought me
An interesting study unit, not only in helping nurses to care for
face to face with reality. I have learnt a lot from the case study of
patients’ needs but I confess that it helped me immensely to
my assignment! In struggling with our own spiritual journeys
tackle my personal life in harmony. Very often a small amount of
through different experiences in life, such as nursing care, we
hope can be the medicine to help individuals to recover or to
can recognise that in fact we receive more than we give when
complete his/her journey into the unknown’. (C6)
we care for others’.(A1)
Self-awareness exercises appeared to enable the learners to
This study unit appeared to help the nurses acknowledge their role
reflect on their own spirituality and personal value system whereby
as change agents. Thus, transformation was apparent in the learners
they seemed to appreciate their own life better by counting their
whereby they showed commitment to address spiritual needs of
blessings in life.
patients in liaison with the multidisciplinary team. This is consistent
‘The study unit was excellent as it helped me become not only with research whereby, having undertaken study units on spiritual
more sensitive to others’ needs but also to my own spiritual care, nurses and midwives acknowledged the current neglect of the
needs by looking at my life in a different way, appreciating my spiritual dimension in care and professed their intention to provide
life better and learning to count my blessings in life’.(C9) holistic care (Wallace et al., 2008; Hoover, 2002). However, to put
theory to practice, mentorship is needed to sustain nurses to practise
Awareness of the nurses’ personal spirituality with spiritual
what they learn (Swain et al., 2003) and guide them on long term basis
growth is consistent with the findings of Pesut (2002) who found
during implementation of holistic care.
that both first and fourth year students were found to have
a stronger awareness of their personal spirituality with spiritual
growth that is finding meaning in life and importance of relation-
Limitations of the study unit
ships with their community.
Furthermore, sharing of experiences in small groups enabled
This study unit formed part of the CPD programme and thus the
learners to develop reflective skills in an attempt to recognise their
learners were qualified staff with diverse age, personal and clinical
learning and clinical practice as a reflective journey as demon-
experiences (Table 2). Whilst this diversity enhanced learning from
strated by research (Gustafsson and Fagerberg, 2004; Chapman and
each others’ experiences, the group discussions on patient case
Howkins, 2003; Glaze, 2002).
studies utilised quite an amount of time with positive outcome
Literature suggests that nursing care may be enhanced by
whereby the theory on spirituality and spiritual care could be
reflection in action when assisted by clinical supervision or
integrated into the clinical component. Time was a problem
mentorship (O’Callaghan, 2005; Clouder and Sellars, 2004).
throughout the course of the study unit! Although the teaching
However, learners could not be mentored in their clinical practice
sessions were organised twice weekly in the afternoon, the author
to reinforce the theory for various reasons such as, the nature of the
and the learners used to be tired but the various teaching methods
local current short CPD courses based mainly on theory, the limited
enhanced active participation.
number of educators with expertise in spiritual care and the diverse
The three cohort groups of learners were all Christians.
spread of clinical placements of the group undertaking this study
However, this study unit oriented teaching towards monotheistic
unit.
religions of Christianity, Judaism and Islam. This was an attempt to
address the diverse religious needs of displaced patients coming to
Acknowledging the nurses’ role as change agents
Malta from various countries. Thus, these findings should be
The study unit appeared to help the nurses to consider their
interpreted with caution as the cultural aspects were limited
responsibility of learning on spiritual care so as to become
mostly to the Maltese patients.
a resource of knowledge to their colleagues in order to facilitate
Evaluation data of this study unit were derived from open-
holistic care:
ended questions in a self-administered questionnaire. Although the
‘You can do nothing to inspire the person under your care if you use of a questionnaire enhanced anonymity, lack of supervision
do not inspire yourself. Unless the health care professionals might have influenced the findings. Had data been collected by the
become interested in holistic care and teamwork, the spiritual use of journaling, face to face interview or a focus group technique,
dimension in care will remain unnoticed.’(B1) in-depth data could have been recalled better.
52 D.R. Baldacchino / Nurse Education in Practice 11 (2011) 47e53
Future implications
These findings shed light on the positive impact of this study
unit on nurses. However, the definition of spirituality is still
undergoing exploration in research. Therefore, application of this
concept in education and clinical practice is a challenge (McSherry
et al., 2005).
Since spiritual care involves the multidisciplinary team, this
study unit may be organised inter-professionally in order to
enhance sharing of experiences, teamwork and holistic care (Stern
and James, 2006; Tucker et al., 2003).
Therefore, other members of the multidisciplinary team
including the patients may be involved in teaching. The study unit
may include other coping strategies which could be used by
patients and nurses, such as meditation and support groups, to
foster self-transcendence and harmony in life:
‘Maybe if we learn to meditate, it can help us to empty ourselves
and transcend to a higher power before starting the day’s work.
This exercise could be an effective way to motivate ourselves to
give help to others altruistically’.(C24)
This study unit was found as an eye-opener for the learners by
becoming conscious of their own spirituality which was recom-
mended as a priority in education and clinical practice:
‘I suggest that more study units of this sort be available at least
every year. If we feel good and strong spiritually, we can respond
better to patients. Eventually, we learn how to express ourselves
in a caring presence by being with the patient and providing
comfort in stressful situations’.(B4)
This study unit may be extended to a module including both
theory and practice. The practical component may request
the learners to initiate a practical change in the clinical area, such as
facilitation of a spiritual coping strategy, for example, organising
individual/group reflective exercises. Integrating theory with
practice may reinforce learning and may also facilitate collabora-
tion between the teacher, learner and practitioners (Wallace et al.,
2008).
Finally, suggestions for future study units included more self-
reflective exercises, mentorship on the clinical area and organisa-
tion of regular seminars and conferences, open to all members of
the multidisciplinary team. Since nurses are present with patients
twenty-four hours a day, the nurse was suggested to be the liaison
person for consistent care (Baldacchino, 2006).
Conclusion
The study unit on Spiritual Coping in Illness and Care was deliv-
ered to three cohort groups of qualified nurses. The positive impact
was demonstrated by the two themes which emerged from the
data namely, increase in knowledge on the spiritual dimension in
care and self-awareness on the nurse’s role in spiritual care.
The positive impact on nurses could have been due to several
strengths of this study unit. The exploratory, reflective teaching
methods triggered active participation; the learners’ maturity and
voluntary registration appeared to sustain their interest till the
end; the diversity in the nurses’ clinical experience fostered anal-
ysis of the concepts and clinical case studies; and the Christian and
Islam content orientation provided a broader perspective to the
religious dimension of spiritual care. Thus, these strengthens
appeared to outweigh the limitations encountered namely, time
constraints in the duration of the study unit (4 ECTS) which limited
discussion periods and provided short self-reflective exercises; the
learners who analysed a personal crisis situation, presented it
solely to the author or the hospital chaplain at the concluding
seminar and so this lessened learning of the entire group; and the
learners were mainly nurses which limited the discussions with
their partners in care from the multidisciplinary team.
Since the learners were qualified nurses, the study unit seemed
to help them acknowledge the neglect of the spiritual dimension in
care which inhibits delivery of holistic care (Ross, 2006;
Baldacchino, 2010). This may be due to secularisation of the
contemporary society and lack of education. Eventually, they may
change their behaviour to challenge this neglect and transform
their medically oriented care to holistic care by further education
and teamwork (Wallace et al., 2008; McKie et al., 2008).
The findings demonstrate that the objectives of this study unit
(Table 1) appeared to be achieved, whereby increased knowledge
and awareness on the spiritual dimension in care were reported.
However, literature suggests that learning may be an outcome of
a combination of what the learners were taught and the learners’
individual efforts to learn which is highly acceptable and recom-
mendable (Harrison et al., 2004).
Acknowledgement
The author appreciates the cooperation of Professor J. Rizzo
Naudi, the Chairperson, Dr Sandra Buttigieg, the Director of the
Institute of Health Care, University of Malta; Ms G.A. Jaccarini, the
Coordinator of the Nursing/Midwifery Department, Mr J. Sharples,
the Nursing Director for integrating this study unit in the CPD
Programme; Ms C. Farrugia and Ms L. Bonello for proof reading;
Family Attard for providing me with a quiet reflective seaside
environment to report these findings; and Dr L. Ross, University of
Glamorgan Wales for her invaluable feedback on this manuscript
and the two anonymous reviewers.
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