Spiritual care as perceived by Lithuanian student nurses and nurse educators: A national survey

    Spiritual Care As Perceived By Lithunian Student Nurses And Nurse Educators: A National Survey Olga Riklikiene, Inga Vozgirdiene, Laima M. Karosas, Mark Lazenby PII: DOI: Reference:

S0260-6917(15)00424-4 doi: 10.1016/j.nedt.2015.10.018 YNEDT 3096

To appear in:

Nurse Education Today

Accepted date:

19 October 2015

Please cite this article as: Riklikiene, Olga, Vozgirdiene, Inga, Karosas, Laima M., Lazenby, Mark, Spiritual Care As Perceived By Lithunian Student Nurses And Nurse Educators: A National Survey, Nurse Education Today (2015), doi: 10.1016/j.nedt.2015.10.018

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ACCEPTED MANUSCRIPT SPIRITUAL CARE AS PERCEIVED BY LITHUNIAN STUDENT NURSES AND NURSE

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EDUCATORS: A NATIONAL SURVEY

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Quinnipiac University School of Nursing, U.S.A

Yale University School of Nursing, U.S.A

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Corresponding author: Olga Riklikiene

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Lithuanian University of Health Sciences, Faculty of Nursing, Lithuania

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SPIRITUAL CARE AS PERCEIVED BY LITHUNIAN STUDENT NURSES AND NURSE EDUCATORS: A NATIONAL SURVEY Olga Riklikienea, Inga Vozgirdienea, Laima M. Karosasb, Mark Lazenbyc

Address: (Till 1/9/2015)

(After 1/9/2015)

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phone: +1 203-508-4080 (USA)

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152 Montowese, Branford, CT 06405, USA

Siaures av. 61-7, Kaunas LT-49234, Lithuania

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[email protected]

phone: +37061223510 (LT)

Inga Vozgirdiene

Address: Faculty of Nursing, A. Mickevičiaus str. 9, Kaunas LT-44307, Lithuania [email protected]

Laima Karosas Address: 3 Oak Gate Drive, Branford, CT 06405, USA [email protected] phone: +1 203-435-5359

Mark Lazenby Address: Yale School of Nursing, Building 400, 300 Heffernan Drive, West Haven, CT 06516, USA [email protected]

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ACCEPTED MANUSCRIPT phone: +1 860-818-6653 Word count: Text - 5 126; Abstract - 239

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ABSTRACT

Background: Political restrictions during 50 years of Soviet occupation discouraged

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expressions of spirituality among Lithuanians.

perception of spiritual care in a post-Soviet context.

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The aim of this paper is to describe Lithuanian nursing educators’ and students’

Design and settings. This cross-sectional study was carried out among student nurses

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and nursing educators at three universities and six colleges in Lithuania. Participants and methods. The questionnaire developed by Scott (1959) and

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supplemented by Martin Johnson (1983) was distributed to 316 nursing students in the 3rd and 4th year of studies and 92 nurse educators (N=408). Results. Student nurses and their educators rated general and professional values of

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religiousness equally; although students tended to dislike atheistic behavior more than

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educators. Four main categories associated with perceptions of spirituality in nursing care emerged from the student nurses: attributes of spiritual care, advantages of spiritual care,

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religiousness in spiritual care, and nurse-patient collaboration and communication. Themes from nurse educators paralleled the same first three themes but not the last one. Conclusions. Student nurses and nurse educators acknowledged the importance of spiritual care for patients as well as for care providers – nurses. In many cases spiritual care was defined by nursing students and nurse educators as faith and religiousness. Being a religious person, both for students and educators, or having spiritual aspects in students’ personal lives influenced the perception of religious reflection. Key words: nurses, student nurses, nurse educators, spiritual care, values, religiousness, spirituality, Lithuania.

INTRODUCTION When health care providers support patients’ spiritual needs, patients with advanced disease use fewer health care resources with less aggressive treatment (Balboni et al., 2013). Awareness of patients’ spirituality allows nurses to support patients as individual persons, drawing upon patients’ approaches to coping with complex health conditions. This holistic

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ACCEPTED MANUSCRIPT paradigm guides nurses in performing careful whole-person assessment and responding to the place of spirituality in patients’ coping skills repertoir. Nevertheless, providing spiritual support can be foreign to health care professionals in

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training and practice (Penman, 2009). Both student and practicing nurses report a lack of knowledge and skills vis-a-vis providing spiritual support patients (Stern & James, 2006).

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Perhaps this is due to the ambiguity of the meaning of spirituality (McSherry and Cash, 2004; Sessanna, 2007). There is no consensus on a formal definition of «spirituality,» or even if the

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term should be defined at all (Lazenby, 2010). However, for the purposes of this study, we understand spirituality to be the meaning or purpose a person ascribes to life. Likewise, we

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understand spiritual support as facilitating the patient’s search for meaning or purpose that will help them cope with the life disruptions or distractions of illness (Ferrell, Smith, Juare &

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Melancon, 2003); or to find meaning or purpose and preparing for the end of life. Although many people express their spirituality in their religious practices, not everyone who is spiritual has a religion: anyone who searches for ultimate meaning or purpose in life can be

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said to have a spirituality (Sulmasy, 2002). In Lithuania, a former Soviet Union (FSU)

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country, the concept of spirituality is complicated by a history of enforced atheism, severely inhibiting spiritual expression of the general population for whom spirituality is intertwined

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with their religious practices.

BACKGROUND

The integration of spirituality into health care practice is challenging for historical, ethical, practical and conceptual reasons (Balboni et al., 2014). In nursing practice in Lithuania, this integration was complicated by the past tradition of governmentally enforced atheism. In the atheistic period of Lithuania‘s history, the approach to health care practice focused on practitioners‘ duty to provide technically competent medically focused care, outside of any considerations of patients as whole people with spiritualities. However, in Lithuania nursing developed as an academic discipline within the university in the subsequent spiritual and religious freedom period. This has allowed nursing to think of patients as whole people, with spiritualities that assist them in coping with illness. But with no tradition to draw upon, academic nursing in Lithuania is now left to develop new approaches to teaching and practice that integrate spirituality. The nursing profession in Lithuania maintains traditions in a framework of moral values. Karosas (2003) described Lithuanian nurses as demonstrating a Christian ethic of caring and self-sacrifice during the turbulent World War 2 (WW2) period of 1934-1945. The 3

ACCEPTED MANUSCRIPT end of WW2 ushered in 50 years of Soviet occupation during which all religious expression was forbidden and replaced with atheistic propaganda. Openly expressing spirituality or engaging in religious practices often resulted in persecution and punishment. The law forbade

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priests and chaplains to enter hospitals and to perform religious rituals. After Lithuania regained independence in 1991, religious practice was not only

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allowed, but viewed as a sign of a person‘s virtue and national loyalty; for some, it was even considered fashionable. As with open religious practice, spiritual care was previously taboo

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in the Soviet era, but today, it is increasingly explored in nursing practice, education and research (Seskevicius, 2010).

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Around the same time as independence, palliative care developed as a health care discipline in Lithuania. Palliative care has developed since then such that, in 2007, Lithuania

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adopted the Law on Palliative Care, which established in-patient palliative care services, introduced outpatient palliative care consultations, formalized evaluation of palliative care services, and provide for undergraduate and continuing professional training in palliative

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care. In 2012, the first 14-bed hospice was established. This development of pallaitive care is

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important, as 1 of the 8 domains of palliative care that all palliative care services and training must reflect is „spiritual, religious, and existential aspects of care“ (National Consensus

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Project, 2013).

Over the last 2 decades of socio-political changes in Eastern Europe, Lithuanian nursing has been rapidly evolving away from socialist principles of sceintific and technical materialism (Blazeviciene and Jakusovaite, 2007). For example, as a condition for membership in the European Union, nursing education was elevated from a diploma- to a university-based system, and nursing research and policy development were expanded (Karosas and Riklikiene, 2008). As nursing education transitions away from a strongly biomedical, technical approach towards a more sensitive, patient-centered holistic approach, the nursing curriculum must be informed by socio-cultural, religious and spiritual customs and practices. Nurse educators can affect the development of students’ values regarding nursing care (Haigh and Johnson, 2007). Stern and James (2006) highlighted the importance of nursing education emphasizing sensitivity to patients‘ understanding of their spirituality. However, students‘ spiritual, religious, cultural, or humanist values may direct their call to the health professions (Puchalski et al., 2014), that is, their career choice of serving other and attending to the whole patient - body, mind, and spirit (Balboni et al., 2014). It is, thus,

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ACCEPTED MANUSCRIPT equally improtant to consider students‘, not just educators‘, perspectives when thinking about nursing curriculum and spirituality, especially in post-Soviet Lithuania. The aim of this paper is to describe Lithuanian nursing educators’ and students’

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perception of spiritual care in a post-Soviet context.

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METHODS Design

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A descriptive, cross-sectional national survey design assessed nursing educators‘ and students‘ general and professional values regarding religiousness and the provision of

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spiritual care.

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Ethical considerations

The Center on Bioethics issued permission to conduct the study (2010-09-27, No. BCK3(M)-06). Participants received written information about the aim of the survey and gave

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their informed consent by returning the questionnaires. Data confidentiality was guaranteed

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Setting and sample

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by anonymous answers.

The study sample consisted of all possible nursing programs in Lithuanian colleges (N=6) and universities (N=3). The survey included nursing students and nurse educators. The sample included: (1) student nurses who were enrollment in a full-time nursing program at a college or university and in their third or final (fourth) year of study, and (2) nurse educators from nursing departments at colleges and universities. Nurses who were educators in other departments within colleges or universities (that is, non-nursing departments) were excluded.

Instrument The questionnaire developed by Scott (1959) and supplemented by Martin Johnson (1983) was used to investigate nursing students’ and educators’ general and professional values (Haigh and Johnson, 2007). We chose this instrument because it was the only one specific to nursing students and their educators. As well, it had an open-ended question that allowed for context-specific answers, which we viewed as important given Lituanian nursing’s historical context. Written permission to use the survey instrument and instructions for decoding the data was granted by the survey author (MJ).

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ACCEPTED MANUSCRIPT The 57-item questionnaire assesses general (that is, more personal) and professional values on a five-point Likert-type scale. Thirty seven items assess general values. Respondents were asked to decide whether they ‘always dislike’ (1) or ‘always admire’ (5) a

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behavior in some other person – anyone but not necessarily someone they knew. Some of the items reflected a negative or less desirable behavior of a person, which were coded in reverse

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for data analysis. Twenty items assessed professional values by asking nurses about values that ought to guide nurses in their work (‘strongly disagree’ = 1; ‘strongly agree’ = 5). The

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last survey question was open–ended and asked nurses a specific example of spiritual care provided to the patient. The questionnaire was translated into the Lithuanian language and

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back-translated into English following methodological considerations (Maneesriwongul and Dixon, 2004). Internal consistency was strong (Cronbach α = 0.72). In this paper, we only

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analyze, report upon, and discuss survey results regarding general and professional values of religiousness and respondents’ perceptions of spiritual care. Respondents‘ socio-demographic characteristics were collected with an invesitgator-

Data collection

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developed form.

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The researcher visited higher education institutions and met with nursing program managers or their representatives. After introducing the study, questionnaires were distributed to all student nurses and educators in the nursing department. At a set time, the researcher picked up the completed questionnaires from the nurse managers. In two cases, questionnaires were returned by post or courier delivery in sealed packages.

Analysis

Data was recorded and analyzed in the Statistical Package for Social Sciences (IBM SPSS Statistics) version 13.0. Descriptive statistics and non-parametric tests for two and more than two independent samples (Mann-Whitney and Kruskal-Wallis) were used; p<0.05 was considered significant. For data reduction and clearer representation of the results, the answers on the general value scale were re-categorised so that ‚always admire‘ and ‚usually admire‘ were combined and ‚always dislike‘ and ‚usually dislike‘ were combined. Similarly, the answers on the professional values scale were re-categorised: ‚strongly agree‘ was combined with ‚slightly agree‘ and ‚strongly disagree‘ with ‚slightly disagree.‘ In a Lithuanian context, particularly in the post-Soveit era, spiritual matters may be associated with religion and practice of faith; thus, for the purposes of this paper, we analyzed student 6

ACCEPTED MANUSCRIPT nurses’ and their educators ratings of their general (5 items) and professional (1 item) values of religiousness (table 1). Qualitative data were processed using thematic content analysis. Three researchers

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(principal researcher [OR], researcher [IV], and consulting researcher [LK]) independently coded, interpreted and grouped students' and educators' separate responses according to their

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meaning. Codes and their groups were constantly compared for consistency. Themes emerged. Respondent quotations confirmed and exemplified each theme. Analysis of

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qualitative data was done in Lithuanian up to the moment of drafting the manuscript, when the qualitative data were translated into English. The principal researcher, native in

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Lithuanian and fluent in English language, accomplished the translation in collaboration with the consulting researcher [LK], a native English speaker fluent in Lithuanian. We linked the

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quantitative data with the open-ended question about spiritual care.

RESULTS

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Four-hundred eight respondents participated: 316 nursing students in the 3rd and 4th

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year of studies and 92 nurse educators. The response rate for students was 80.0% and for educators 69.7%. One hundred eighty-three respondents – 148 (46.8%) students and 35

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(38.0%) educators – completed the open-ended question about spiritual care. The length of answers to each question varied from one word to twenty five words. The mean age of nursing students was 24.39 (CI 23.84–25.34) years. Nursing students were 97.8% female, as were 82.6% of nurse educators. Twenty percent of nurse educators had more than 21 years of teaching experience (Table 1). Quantitative data analysis revealed that the majority of student nurses (65.5%) and educators (63.0 %) always/usually admired the religiously devout person. Both groups of respondents expressed equal admiration of those who regularly attend religious services. Students and educators, alike, were neutral regarding atheism. Less than half of student nurses (41.2%) disagreed with the statement that ‘nurses ought to have a religious faith,’ while half of educators (51.1%) had no clear opinion about that statement (Table 2). There were no significant differences between groups (students and educators) regarding attitudes towards general and professional values (p>0.05); however, students tended to dislike atheism more than educators (p<0.034). Correlation analysis displayed weak but positive correlation between student nurses‘ ratings of general and professional values of religiousness (r = 0.344, p<0.01) where the stronger perception of personal value of

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ACCEPTED MANUSCRIPT religiousness was more likely to support the professional value of religiousness. Such a relationship in nursing educators was not found (Table 3). With sociodemographic characteristics, significant differences between two groups of

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respondents were determined. Yet analysis revealed that those students and educators who considered themselves religious persons expressed significantly more admiration and

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agreement with one‘s general (p<0.01) and professional (p<0.001) religious behavior as compared to students and educators who considered themselves atheists or were unsure about

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their religion (Table 4).

Students responsed more positively than educators (p = 0.030) to the general value

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question ’Do you have spiritual aspects to your life?’ Furthermore, students (but not educators) who reported having spiritual aspects in their lives more often supported the

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expression of religiousness in others both as a general or professional value (p ꞊ 0.002 and p ꞊ 0.010, respectively) (Table 4).

Nurse educators agreed with the notion that religion has no relationship with a

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spiritual way of life (p ꞊ 0.028), whereas students did not. Students who reported being

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religious more commonly having spiritual aspects in their personal lives than students who were not religious (p<0.001).

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Qualitative data analysis revealed categories of student nurses‘ and their educators‘ perceptions of spiritual care. Nursing students’ perceptions of spiritual care coincided with those of nurse educators in three categories: 1) attributes of spiritual care, 2) advantages of spiritual care, and 3) religiousness in spiritual care. Descriptions and examples given by student nurses resulted in an additional theme categorized as nurse-patient collaboration and communication in spiritual care, a theme that was not present among nurse educators‘ responses.

Category 1: Attributes of spiritual care Students and educators listed essential attributes of a nurse‘s professional skill and behavior regarding the provision of spiritual care. Students. To students, spiritual care included personal features such as honesty and respect, tolerance and responsibility. According to nursing students, spiritual care was being “sincere and kind care,“ showing „goodness, tenderness,” “with respect to another person, [respecting] dignity and [valuing] independence,” “respect[ing] their faith and values.” The professional skill and behavior of a nurse in delivering spiritual care integrated moral norms and values, according to nursing students: “there are very important values in nurses’ work 8

ACCEPTED MANUSCRIPT such as compassion and comprehension,” the provision of “spiritual care is manifested by mercifulness.” A nurse being nonjudgmental and altruistic in providing spiritual care “doesn‘t take into account her personal attitudes and personalities but provides holistic care being kind

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and patient.” Students perceived spiritual care as providing “help and comprehensive support“ and linked it to the primary responsibilities of professional nurses and inner

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strength, saying that spiritual care “needs unending patience, endurance, love and understanding.” At the same time, providing spiritual care “helps to understand the person

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better.” This notion of mutual understanding or comprehension of the patient was common in students’ responses. As well, the autonomy and individuality of a client are, to student nurses,

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important in providing spiritual care: “it is essential to listen to the patient and consider desires, principles of humanity and autonomy,” ”each person is an individual.”

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Educators. Nurse educators emphasized the importance of respect and human dignity, humanistic values and spiritual beliefs, including warmth, tenderness and love: “respect to people, their dignity, individuality,” “loving people as they are,” “hands ought to

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be tender in taking care – no ambiguity!” Educators did not emphasize patience and

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understanding as much as students but included new concepts such as empathy and humanity: “it is more empathy,” “a nurse not only takes care of a patient’s body but maintains his/her

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humanity,” “humanity ought to be the foundation of nursing philosophy.” On the other hand, educators associated the traditional personal characteristics of a nurse with the delivery of spiritual care: “attentiveness, selflessness, professonal responsibility, mercifulness as well.“ The educators, being trained in deontological ethics, strongly suggested that in thinking about the deliver of spiritual care, “it is necessary to follow ethical rules for a thorough understanding of professional ethics“ and “to assure the understanding of the provision of professional ethics.”

Category 2: Advantages of spiritual care Study respondents demonstrated the greatest consensus in describing the advantages of spiritual care for patients and providers. From the patient perspective, spiritual care would guarantee equality and humanity. As one student said, “[the nurse] delivers care without regard to the social status of the patient.” Spiritual care “saves human lives.” Students. Students described a patient‘s sense of being safe and cared for: “every person has a right to support and caring.“ One student nurse said that “the patient has to feel safe in talking with a nurse and not alone with their problems; for example, when I went to the operating room with a patient who was very worried and I calmed her down.” Moreover, 9

ACCEPTED MANUSCRIPT students linked spiritual care with end-of-life care. Hopefulness and inspiration were the right nursing attitudes in spiritual care: “to believe in a patient‘s recovery and in the ability to help him feel better”, “to bring relief and hope to dying patients.” According to students,

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providing spiritual care was advantageous not only for patients but also for nurses in their duties: “a person with spiritual values has compassion and helps the weak and ill,” “it helps

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to comprehend patients‘ problems and empathize with them,” “[a nurse] will cope with difficulties at work more easily and feel assured in various situations.“

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Educators. Nurse educators supported students‘ opinions that spiritual care involves patients‘ feeling of safety and wellbeing: “a stronger feeling of safety makes it easier for the

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patient to cope with infirmity.” Nurse educators thought that the acts of nursing extending beyond physical care to include spiritual care: “nursing is not just physical help, it is most

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important to help the soul.” They also emphasized the link between the existential attitudes of nurses and patients‘ inner-lives: “using an existential perspective to help the patient preserve the harmony between body, mind and moral state; seeing the person‘s internal world,

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assuring that patients understand and accept the spiritual world, not necessary religion, but

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[that which] may involve existential issues.” As with students, to educators spiritual care was required in palliative care: “hope and trust for the patient even in difficult situations,” “a

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nurse has to maintain [a] patient‘s faith and hope for recovery or a dignified death, when death is inevitable.” And as with students, educators thought that providing spiritual care benefited the nurse, not just the patient: “a spiritually strong nurse is more concentrated on work and more gentle.”

Category 3: Religiousness in spiritual care Students. Nursing students considered a patient‘s relationship with religion as a clear dimension in providing spiritual care. According to them, nurses are led by “basic moral rules which could also include the Ten Commandments.” Spiritual care was related to religious resources and “help for the soul.” Students discussed freedom from religious prejudice and that “a nurse has to respect a patient‘s religion and cannot criticize religious beliefs, sometimes it is better to encourage...to give one hope.” They thought a nurse should be “aware of many religions and able to adapt to patients and their religious views.” Student nurses suggested that a nurse has to pay attention to a patient‘s religion, as “human life depends not only on medicine, but God is the higher power – He will always help and make things better.” At the same time, student nurses recognized that “religion can interfere with nursing care and medical practice.” The spiritual care link with religion, especially at end of 10

ACCEPTED MANUSCRIPT life, was clearly presented by students: “religious support and understanding is especially necessary at [the] end of life for patients and their relatives.” A practical suggestion from a student was that a nurse has “to pay attention to whether the patient is Catholic or Muslim or

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any other denomination because much may depend on religion.” Educators. Nurse educators agreed with students that “faith helps a person;

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sometimes it is good to know, especially for children, that life is not over after death.” They supported patients‘ practices and beliefs through encouraging clergy‘s participation in patient

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care with services and rituals. Educators viewed it the nurse‘s responsibility to obtain these religious-specific services for patients: “presence of clergy, relatives near, lit candles, respect

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and help for the dying.” One educator, in particular, shared an experience about her provision of universal spiritual care, care appropriate even for spiritual but not-religious patients: “I

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suggested to the patient to pray in order to find peace for the soul.”

Category 4: Nurse-patient collaboration and communication

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Students, but not educators, considered spiritual care as inherent in the process of

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nurse-patient collaboration and communication. Nurse-patient communication, reciprocal understanding and interrelationship were three main themes of interaction between nurses

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and patients. Spiritual care is not “just working with patients, but also includes understanding and interaction.” From the students‘ point of view, spiritual care was an interaction, and even possibly, a therapeutic intervention for the patient’s mental health. Students wrote: Often going into the patient‘s psychological problems, it is interesting how he accepts the changes in health and [the nurse] seeking to help the patient feel less pain and psychological distress by listening to him, sharing his burden....

And: If a nurse sees a patient suffering from depression, he/she must talk with the patient, explain to him/her that life is beautiful, not everything is so bad and he/she has to love [life]. Spiritual care in nursing, to students, was “not simply mechanical work, but activity based on spiritual collaboration.” Students adopted the attitude of “a healthy spirit in a healthy body” and believed that “sometimes interaction, sincerity, good words, faith and hope are enough for patients to feel better and to recover faster.” A student nurse described providing spiritual care as the Golden Rule: “treat others as you would like them to treat you.“ 11

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Divergent opinions separating acts of providing spiritual care from nursing acts A small number of student nurses (n = 7; 4.7%) and nurse educators (n = 6; 17.1%)

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expressed divergent opinions that separated acts of providing spiritual care from nursing acts per se. Several students argued that even “spiritual values in care are very important, but the

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professionalism in practical matters cannot be forgotten.” Another responded that “it is an obligation of a nurse to be compassionate and console but it is not compulsory to pray for a

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patient;s health, this is nonsense!” Other statements of educators indicated that nursing care has to be strictly separated from spirituality and moral values: “spiritual values are important

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but not a priority“; and: „nursing care is not related to spiritual values at all.” A few answers were used to express strongly divergent opinions; for example, a nurse educator strictly

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interpreted spirituality as religion: “I think that religion, as separate from state institutions, should never be a topic in questionnaires.”

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DISCUSSION

In this study two interrelated groups – student nurses and nursing educators – found

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the notion of providing spiritual care as meaningful in a society where the term ‘spirituality’ is a new and increasingly explored concept today. According to the vast majority of student nurses and nurse educators, spiritual care is a complex mix of character, behaviors and social skills, supported by particular values and attitudes. Generational differences with the experiences of political events may impact or explain differences in perceptions between younger student nurses, who grew up in a post-Soviet environment, and older nurse educators, who developed professionally under the Soviet regime‘s restriction on religious and spiritual expressions. Personal characteristics cited by nursing students and their educators composed a portrait of a typical nurse and provided a base for spiritual care. These findings reflect spiritual engagement associated with ‘human values of love, compassion and altruism,’ ‘maintaining relationships,’ ‘participating in religious practices’ and ‘culture,’ as described by Penman et al. (2013). Both groups in our study attributed spiritual care to personal moral, belief systems. The meaning of spiritual care among students entailed respect, independence, support, and the preservation of human life, according to the ethical principle of respect. Educators also cited respect but more so the duty to care. This is consistent with Kant’s deontological description of duty or moral obligation to others, which was consistently 12

ACCEPTED MANUSCRIPT expressed by Lithuanian nurse educators in this study. Nurse educators mentioned the importance of professional ethics, which is consistent with their training in medical deontology. Younger students, born after Lithuanian independence, have no experience with

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this training and have internalized the importance of the ethical principle of autonomy. Another difference between nursing students‘ and educators‘ perceptions of spiritual

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care emerged in patient-nurse communication and collaboration. Although nursing students treated interaction, reciprocal understanding, and human relationships as elements of

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spirituality, nurse educators did not cite these in their perception of spiritual care. They did not support ’relationship’ as the most common element in the provision of spiritual care.

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Students’ responses reflected the meaning of care as being present to the patient and listening to his or her story – the physical, emotional, social, and spiritual story as one human story.

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Within the context of the nurse-patient relationship, student nurses perceive the aim of care as not only to fix but rather accompany patients as they share their stories (Balboni et al., 2014). This understanding suggests that, to students, nursing is an art as well as a science.

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This perception of nursing as an art and a science may be explained by a change in

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health care education in the post-Soveit era that emphasizes interaction and communication as a crucial part of nursing process. Almost all nurse educators were prepared in the

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biomedical model in which certain individualistic but also Marxian materialistic values were priorities, not just honesty, responsibility, and professionalism, but also technical, scientific advancements. In this more technocratic model, the nurse-patient relationship was not characterized by equality, but rather, paternalism, in which the nurse or physician dominate every decision related to patient health care. Numerous statements by our respondents revealed the importance of spiritual care for humanistic, ethical and high quality patient care. There are generally speaking 4 domains in quality of life: physical, psychological, social, and spiritual, according to the Quality of Life model (Ferrell et al., 1991). The spiritual domain includes meaning, religiosity, and hope, among other qualities. The whole-person care perspectve (Balboni et al., 2014) combined with the biopsychosocial-spiritual model of care (Sulmasy, 2002) should guide the formation of a nurse through scientific and intellectual as well as personal and spiritual development. Providing spiritual care is important in order to ensure quality care (Wittenberg et al., 2015). As well, the acts of providing spiritual care can be seen as integrating ethical principles into health care practice. For example, a spiritual assessment conveys respect for the patient and assures his/her autonomy in decisions and choices. In our study, student nurses and educators discussed the benefits for themselves of providing spiritual care: a nurse is inspired and 13

ACCEPTED MANUSCRIPT empowered by inner-peace and mindfulness, mercifulness and increased professional responsibility, all of which become more apparent to them through the acts of providing spiritual care.

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Descartes‘s dualistic philosophy separated body from soul. However, a more holistic philosophy restores the spiritual dimension. Spirituality is an integral component of nursing

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since, for the body to be healthy, the soul must first be healthy. Engaging in spiritual discourse continues to be an important element for some people at the end of their lives

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(Penman, 2009) which both nursing students and educators in our study agreed with. Many scholars equate spirituality with religious belief (Baldacchino and Draper,

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2001; Rumbold, 2003). In Lithuania, a country in which Christianity is largely practiced, spiritual matters would be associated with religion and the practice of faith. Most of the

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students and educators acknowledged the strong influence of religion and the practices of faith on spiritual values and linked spirituality with religiousness. Students and educators shared the same opinion that nurses ought to possess a religous faith. Although student

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nurses’ perceptions about atheism were not positive, they did show more positive attitudes

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toward personal religiousness, in comparison to educators. Additionally, student nurses’ and nurse educators’ linked their personal sense of religiousness with the general and professional

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values of religiousness: those who considered themselves religious more often expressed their admiration for others’ expression of religious faith in daily life and in nursing. However, spiritual foundations are not necessarily religious. Students (but not educators) who applied spirituality in their lives accepted the values of religiousness more than those who did not. Spirituality may be related to religion for certain individuals, but for others, such as atheists, it may not (Tanyi, 2002). Otherwise, a religious person may also be spiritually strong and uphold particular values. This perception confirms the approach that spirituality is much broader than religion and needs wider interpretation and comprehension. The students’ and educators’ liberal perception of spiritual care was important to understand. Patients who refuse spiritual assessment or intervention should be free to do so without pressure or adverse effect on the rest of their care. Internationally, as nursing education necessary becomes more technical and uses the latest advances in technology, such as similation and on-line learning, there is a risk of minimizing the spiritual domain of nursing care, which is often passed down from educator to student in apprenticeship style. Our study revealed that student nurses and educators find the spiritual domain an important aspect of nursing care. Nursing program managers and faculty

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ACCEPTED MANUSCRIPT need to recognize the importance of nurses‘ professional training in all areas of care, including the spiritual doman. Limitations. This national survey of a large sample limits the credibility of the

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qualitative analysis, as we could not use representative focus groups to verify the analysis. Moreover, we recognize that using one open-ended question to develop qualitative themes

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limits our analysis. We applied the qualitative data analytic method (content analysis) to arrive at an understanding of participants’ approach toward the provision of spiritual care,

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that is, a snapshot description of their understanding of the provision of spiritual care. Dispite these limitations, this study was a first important step on the long-term plan to investigate the

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phenomenon of spiritual care in a former Soviet country. This longer investigation can help to shape nursing education to be more holistic and patient-centered. A fuller investigation of

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spiritual care from multiple perspectives (students, educators, patients, their relatives, other health care providers) will shed more light on this poorly understood and yet multi-faced

CONCLUSIONS

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dimension of care.

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This study explored student nurses' and nurse educators' perceptions about the provision of spiritual care. The findings demosntrated that the two groups had slightly different perceptions but both, students and educators, found the spiritual domain an important aspect of nursing care. Student nurses and nurse educators believed that when patients’ care is provided in a holistic manner, patients' abilities to cope with illness are improved. Nurses also believed that providing spiritual care benefits nurses; it decreases burnout and promotes quality in the delivery of care, in their opinion. Students' perceptions of what spiritual care entails includes mutual collaboration and communication with patients. Students with stronger perceptions of the personal value of religiousness were more likely to support the need for a professional nurse to have a religious faith. According to study participants, providing spiritual care gives nurses the opportunity to discuss, debate, and express their own values. Thus, spiritual care was both care for the patient and self-care for the caregiver. The spiritual domain is an important, if not neglected, aspect of holistic, patientcentered nursing care. As perceptions of spirituality change generationally, and as technology

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ACCEPTED MANUSCRIPT changes nursing education, further research needs to explore how nursing education can shape both students‘ and educators‘ approach to providing spiritual care.

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REFERENCES: Balboni, M., Puchalski, C., Peteet, J., 2014. The Relationship between Medicine,

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Spirituality and Religion: Three Models for Integration. Journal of Religion and Health 53 (5), 1586–1598.

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Balboni, T., Balboni, M., Enzinger, A., et all., 2013. Provision of Spiritual Support to Patients With Advanced Cancer by Religious Communities and Associations With Medical

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Care at the End of Life. JAMA Internal Medicine 173 (12), 1109–1117. Baldacchino, D., Draper, P., 2001. Spiritual coping strategies: a review of the nursing

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research literature. Journal of Advanced Nursing 34 (6), 833–841. Blazeviciene, A., Jakusovaite, I., 2007. Value priorities and their relations with quality of life in the Baby Boomer generation of Lithuanian nurses: a cross-sectional survey.

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BMC Nursing 6 (10), 1–6.

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Maneesriwongul, W., Dixon, JK., 2004. Instrument translation process: a methods review. J Adv Nurs 48(2), 175-86.

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Ferrell, B., Smith, S., Juarez, G., Melancon, C., 2003. Meaning of illness and spirituality in ovarian cancer survivors. Oncology Nursing Forum 30 (2), 249–257. Ferrell, B., Grant, M., Padilla, G., 1991. Experience of pain and perceptions of quality of life: Validation of a conceptual model. Hospice Journal 7(3), 9-24. Haigh, C., Johnson, M., 2007. Attitudes and Values of Nurse Educators: An International Survey. International Journal of Nursing Education Scholarship 4 (1). Karosas, L., 2003. The interrupted development of Lithuanian nursing. Doctoral Dissertation. University of Connecticut Storrs, CT. Karosas, L., Riklikiene, O., 2008. Gender and the interrupted development of professional nursing in Lithuania. Acta Medica Lituanica 15 (4), 235–238. Lazenby, M., 2010.

On “spirituality,” “religion,” and “religions”: A concept

analysis. Palliative and Supportive Care, 8 (4), 469–476. McSherry, W., Cash, K., 2004. The language of spirituality: an emerging taxonomy. International Journal of Nursing Studies 41 (2), 151–161. Penman, J., Oliver, M., Harrington, A., 2009. Spirituality and spiritual engagement as perceived by palliative care clients and caregivers. Australian Journal of Advanced Nursing 26 (4), 29–35. 16

ACCEPTED MANUSCRIPT Penman, J., Oliver, M., Harrington, A, 2013. The relational model of spiritual engagement depicted by palliative care clients and caregivers. International Journal of Nursing Practice 19 (1), 39–46.

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Puchalski, C., Blatt, B., Kogan, M., Butler, A., 2014. Spirituality and health: The development of a field. Academic Medicine 89 (1), 10–16.

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Puchalski, C., Ferrell, B., Virani, R., et al., 2009. Improving the quality of spiritual care as a dimension of palliatve care: The report of the Consensus Conference. Journal of

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Palliative Medicine 12 (10), 885–904.

Rumbold B., 2003. Attending to spiritual care. Health Issues 77, 14–17.

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Seskevičius A., 2010. Given Hope: 15teen years of Lithuanian Society of Palliative Medicine (1995–2010). Kaunas: Naujasis lankas (In Lithuanian).

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Sessanna, L., Finnell, D., Jezewski, M., 2007. Spirituality in Nursing and HealthRelated Literature. Journal of Holistic Nursing 25 (4), 252–262. Stern, J., James S., 2006. Every person matters: enabling spirituality education for

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nurses. Journal of Clinical Nursing 15 (7), 897–904.

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Sulmacy, D., 2002. A Biopsychosocial-Spiritual Model for the Care of Patients at the End of LifeThe. Gerontologist 42 III, 24–33.

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Tanyi, R., 2002. Towards clarification of the meaning of spirituality. Journal of Advanced Nursing, 39 (5), 500–509. Wittenberg, E., Ferrell, B., Goldsmith, J., Buller, H., 2015. Provider Difficulties With Spiritual and Forgiveness Communication at the End of Life. Am J Hosp Palliat Care. Jul 2. pii: 1049909115591811. [Epub ahead of print]

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ACCEPTED MANUSCRIPT Table 1. Demographic and social characteristics of study sample. Characteristics

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131 (41.5) 116 (36.7) 69 (21.8)

76 (82.6) 16 (17.4)

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309 (97.8) 7 (2.2)

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47 (51.1) 45 (48.9)

18 (19,6) 21 (22,8) 25 (27,2) 22 (23,9)

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Age in groups (years) Students 20 – 21 22 – 24 25 – 55 Educators 25 – 45 46 > Gender Female Male Work experience as educators (years) 1–5 6 – 10 11 – 20 21>

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n (%)

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ACCEPTED MANUSCRIPT Table 2. Distribution of frequencies of student nurses’ and educators’ ratings of general and professional values of religiousness.

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121 (38.3)

30 (32.6)

155 (49.1)

90 (28.5)

17 (18.5)

120 (38.0)

207 (65.5)

58 (63.0)

15 (4.7)

5 (5.4)

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24 (26.1)

50 (54.3)

40 (12.6)

12 (13.1)

44 (47.8)

106 (33.5)

31 (33.7)

31 (33.7)

17 (5.4)

3 (3.3)

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85 (26.9)

92 (29.1)

226 (71.5) 75(81.5) 75 (23.8) 12 (13.1) Professional value of religiousness N(%) Strongly/slightly agree Not sure Strongly/slightly disagree 72 (22.8) 10 (10.9) 113 (35.8) 47 (51.1) 130 (41.2) 35 (38.0)

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Nurses ought to have a religious faith

General value of religiousness Depends Ussually/Always dislike Students Educators Students Educators N(%) 167 (52.8) 56 (60.9) 64 (20.3) 12 (13.0)

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Always living one’s religion in daily life Attending religious services regularly and faithfully Encouraging others to attend services and lead religious lives Being devout in one’s religious faith Being an atheist

Always/Ussually admire Students Educators

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Items

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ACCEPTED MANUSCRIPT Table 3. Comparison of student nurses’ and educators’ ratings of general and professional values of religiousness (*Mann–Whitney U tests). Students Items

Educators

Mean (SD)

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General value of religiousness

p*

1- always dislike 5-always admire

3.88 (0.91)

3.80 (0.80)

3.07 (0.91)

3.17 (0.79)

0.423

2.89 (1.02)

2.78 (0.86)

0.095

3.22 (0.78)

0.084

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daily life Attending religious services

services and lead religious lives 3.30 (0.90)

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Being devout in one’s religious

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regularly and faithfully Encouraging others to attend

faith

5- always dislike

3.27 (0.77)

1-always admire

3.09 (0.59)

<0.034

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Being an atheist

0.232

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Always living one’s religion in

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Nurses ought to have a religious faith Correlation between ratings in groups Student nurses (316) Nurse educators (92)

Professional value of religiousness Mean (SD) p*

1- always dislike 5-always admire

2.60 (0.96)

2.72 (1.05)

Spearman-Brown r,

0.327 0.086

0.220

p

<0.001 0.414

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ACCEPTED MANUSCRIPT Highlights •

Students and educators perceived spiritual care as a mix of character, behaviors and social skills. Spiritual care was defined by student nurses and nurse educators mostly as faith and

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•

religiousness.

Students’ spiritual aspects in personal lives appeared more commonly among

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•

religious students.

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Students nurses tended to dislike atheistic behavior more than educators.

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•

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