Introduction

Spirituality is a fundamental dimension of human beings and involves a variety of beliefs and practices that change according to a person’s culture and world view, with a religious or non-religious perspective. Nursing professionals who are conceptually familiar with spiritual care and its importance in people’s lives are required for health care (1). Spirituality is important in moments that change lives, such as illness, pain or death, because they are times that require nursing actions, such as listening, being present, supporting faith or promoting religious practices to help people find meaning. In this sense, expressions of spirituality must come about within compassionate relationships between the people receiving and providing spiritual care (2,3). The above is in line with the concept of care as indispensable compassion towards all created beings (4).

Two important traditions should be taken into account in understanding spirituality: eastern and western traditions. In the eastern tradition, spirituality understood as a path towards divinity, the unity of being and deliverance, and is framed in ancient religious traditions, such as Hinduism and Buddhism. The second tradition is western, which covers not only the Judeo-Christian tradition, which acknowledges God, but also secular humanist and agnostic beliefs (5).

Spirituality is not controlled. Instead, it surrounds beings and allows receiving the strength of the spirit in all cultures, regarding it from the most abstract and transcendent part of the relationship with others and oneself (5-8). From the conception of nursing, it has been defined by McSherry based on two aspects: the first is religious, which consists of historical tradition and principles, and the second is existential, which has been defined as a post-modern form of spirituality. Therefore, spirituality is considered to be multi- faceted, and people can be found in nursing care that identify with one of both forms of expression (8).

In addition, in covering spirituality as a guiding framework for practicing nursing, there are, for example the Betty Neuman systems model, which describes spirituality as a component of the basic structure of human beings, and Jean Watson’s theory of human caring, which is based on the spiritual dimension that grants the soul or spirit the power to allow human beings to achieve transcendence itself by building meaningful relationships (9) that are present in identifying the diagnostic labels proposed in the North American Nursing Diagnosis Association (NANDA-I) (10).

On an international level, studies have reported the importance of spiritual care, and nursing professionals are those who are responsible for attending to it in patients as part of comprehensive care. However, there are barriers to providing this care, one of which is a lack of education related to spiritual care (2,10).

In nursing education, it is essential to prepare students starting from recognizing their own spirituality, in order to provide spiritual care for patients (11-13), and thereby strengthen the quality of attention along with the effect spirituality has on the quality of life and mental and physical health of people (14,15).

Spiritual care is defined as the actions and behaviors of health care that nursing professionals carry out during their practice, and include listening, spending time, looking after people’s dignity and privacy, allowing religious practices and promoting finding meaning and purpose in the caring relationship (5). This makes it necessary to include this skill in nursing curricula (3,5,6), which implies knowledge and reflection on one’s own values and beliefs and life events and experiences, in order to be able to recognize that they can be different to patients’ in the framework of clinical care (2). To do this, it must start with students and nursing professionals understanding and reflecting on the concept of spirituality and spiritual care as an initial aspect to cover and assess patients and their families’ spiritual needs in the future (13,14,16).

Currently, in education, people initially spoke of the concept of spiritual skills for religious education. However, it now involves education in understanding the world views of each person. It includes the way of understanding and expressing oneself to the world, which requires health care staff, including nurses, to learn knowledge and skills (17).

On a national level, few studies on spiritual care have been carried out. One of them has researched spiritual well-being in nursing students, in which the authors propose providing the necessary tools to implement strategies that promote spiritual well-being within the university (18). Another study evaluated the effect of an intervention to strengthen spiritual care for people with chronic diseases. The results showed improvements in learning and the perception of spiritual care (5).

Due to the above, the importance of introducing spiritual care in nursing education and allowing students to cultivate their own spirituality to be able to address spiritual care for others is evident (1,17). For this reason, the objective of this study is to understand the perceptions and attitudes towards spirituality and spiritual care of a group of nursing students, as part of an initial phase of a pedagogical strategy that seeks to strengthen the spiritual care skills. The above was based on a review of previous studies that describe a framework of skills for spiritual care, which have guided nursing educators to help students be competent in spiritual care (19,20).

This work can be considered a first step towards integrating this topic into nursing courses and programs in Colombia.

Methodology

A study with a qualitative approach that leads to describing and interpreting what is essential about experiences through a content analysis, applicable to the educational and social field, as proposed by Andreu (21). The sample is comprised of 20 fourth- semester university students from the Nursing program of a higher education institution in Santander. It is a program made up of 10 semesters, in which students begin their practices in their second semester of education. Participants were selected intentionally through convenience sampling, asking them whether or not they wanted to participate in the study. The main inclusion criteria was experience in clinical practice and interactions with patients and families in health care institutions, based on theoretical criteria according to the results of reference studies that indicate that nursing students with practical experience with patients and families have a greater capacity to reflect on spirituality themselves and integrate spirituality into health care (10,19,20,22). The theoretical saturation of the sample was considered when no new topics appeared, according to the criteria of Guba and Lincoln (23).

Techniques, Data Collection and Qualitative Analysis. The data was collected in October 2021 in 3 sessions with participants. A semi-structured interview was held with 10 questions focused on exploring the conceptions of spiritual self-knowledge and spiritual care, using the theoretical concepts proposed by McSherry as a reference (24). The semi-structured interview was held during this first meeting, with anecdotes about difficult times in their lives, asking them to talk about the experience, how they faced it and where or in whom they found support to get through it. Google Forms was used for the questions related to sociodemographic aspects. This session lasted a total of 2 hours and 19 minutes.

During the 2 subsequent sessions, 2 focus groups were held, which were comprised of 8 students participating in the interview. They started with telling their experiences with the topics of the interviews’ questions and sought to deepen their understanding of the topics addressed on the perception of spirituality based on the experience of relationships with patients. This was done through a remote synchronous connection, using the Google Meet application. Group focus sessions lasted 2 hours and were video recorded and transcribed for subsequent analysis.

DataAnalysis: The data analysis was initially performed inductively by reading transcribed texts and listening to audio. The information was triangulated using different sources of data. With help from the Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires (IRAMUTEQ) software, which is open source, a lexicometric or textual-statistical analysis was carried out (seeking regularities and correlations in a corpus) (25). 4 phases proposed by Andreu were taken into account, as follows:

Phase one: clarity in the assumption, which was based on the conceptions of spirituality and spiritual care from the disciplinary tenets proposed by McSherry.

Phase two: collecting the accounts of experiences through interviews and focus groups.

Phase three: determining the coding system for the structural stage. The first structuring was carried out from the thematic axes that arose from analyzing the transcribed texts, with the help of the IRAMUTEQ software. An analysis was carried out in which the first concurrencies between each one of the codes were drawn, generating the word tree with them. Subsequently, phrases with fundamental meanings were selected from the experience, regarding spirituality and spiritual care.

Phase four: determining the category system and a complete description of the concepts of spirituality and spiritual care, based on the themes analyzed in the previous phase.

As part of the general ethical guidelines of the qualitative research, respect for patients’ values, thoughts and guidelines was encouraged. Participants were considered social subjects, not depositories of information. Written informed consent was applied, and the ethical and bioethical aspects of the study were approved by the Ethics Committee of Universidad de la Salle.

Results

Table 1 shows the characteristics of the population of students of the Nursing program who participated in the study. Most were female (85%), with an average age of 20, and most were in stratum 3 (40%), catholic (45%) and living with their mothers (85%).

Table 1. Sociodemographic characteristics of the participants.

Table 1
Table 1. Sociodemographic characteristics of the participants

* SD standard deviation. * IR interquartile range. SMLV: minimum current legal wage (for its abbreviation in Spanish)

* SD standard deviation * IR interquartile range SMLV minimum current legal wage for its abbreviation in Spanish

Table 1. Sociodemographic characteristics of the participants.
Characteristic	%(n)
	-20
Sex
Female	85.00 (17)
Male	15.00 (3)
Age. Average ± SD	20 ± 2.40
Socioeconomic level:
1	25.00 (5)
2	15.00 (3)
3	40.00 (8)
4	20.00 (4)
Religion
Catholic	75.00 (15)
Christian	15.00 (3)
None	10.00 (2)
Family Income
1-3 SMLV	60.00 (12)
4-5 SMLV	35.00 (7)
Live with
Mother	85.00 (17)
Father	40.00 (8)
Siblings	40.00 (8)
Aunts/Uncles	10.00 (2)
Friends	5.00 (1)
Grandparents	10.00 (2)
Spouse	5.00 (1)
Alone	5.00 (1)
* SD standard deviation. * IR interquartile range. SMLV: minimum current legal wage (for its abbreviation in Spanish)
Source: Prepared by the authors.

* SD standard deviation. * IR interquartile range. SMLV: minimum current legal wage (for its abbreviation in Spanish)

Source: elaborated by the authors

The analysis of the interviews included 21 texts, which yielded 662 codes and 3,883 occurrences. The Hapax number was 343 and the average occurrences by texts was 184.90. The focus groups were comprised of 8 texts, which yielded 7,911 occurrences, 871 codes, a Hapax number of 411 and average occurrences by text of 988.88.

Similarity Analysis (Focus Groups): it allowed seeing the relationships between different codes, in which 6 nodes were identified, each one comprised by codes and strong co-occurrences between the professor, spirituality, person, religion, patient and thought codes. This analysis will help students approach the concept of spiritual care in the identified categories (Figure 1).

Figure 1shows the similarity tree, which presents a connection between the codes: professor-spirituality, religion, though, person, patient and religious. Students consider that the center of knowledge on spiritual care is the professor. They see them as counselors and references for the topic of spiritual care and how to carry out spiritual assessments. This code is affected by professors’ participation throughout the course, which has led them to rethink the concept of spirituality and what it is, as can be observed in the following Elementary Context Unit (ECU): “Professor, I have a question. There are no interventions for that in the NANDA. The thing is, there is a question that says religion is a part of life in the domain ten assessment form that says vital principles” (FE2).

In this sense, some students’ differentiation between the concepts of religion and spirituality is evident, as can be observed from the following ECU: “Religion is a dogma created by human beings and spirituality is like finding yourself, transcending both the material and spiritual aspects, if I may hand, some students have perceived the expressions of spirituality and religion for spiritual care as a barrier because they believe it is very personal and should not be questioned. However, they highlight the PCIENTE code as something unique that makes each approach and meeting with a patient unique and differentiating: “It depends on the patient, because one cannot start telling them god will save them when they do not believe in religion” (FE2).

It was also observed that, from learning with professors, the THINK code helps identify the differences and thoughts regarding their own beliefs, seeking benevolence towards the patient: “Because if you have no idea of the person’s religion, you can mess up or make them uncomfortable, reason why I think it is very important”(FE4). THOUGHT comes about as a way to establish relationships with others and assess patients as unique, recognizing different beliefs can exist to those express from religion and belief in a god.

Figure 1
Figure 1. Text corpus similarity analysis: focus groups. Relationships between the different codes in wich 6 nodes and co-occurrences were identified
elaborated by authors with the IRAMUTEQ software.

Figure 1. Text corpus similarity analysis: focus groups. Relationships between the different codes in wich 6 nodes and co-occurrences were identified.

Source: elaborated by authors with the IRAMUTEQ software.

Students consider spirituality an intrapersonal dimension that must be respected, generates curiosity and is something private that should not be questioned. They perceive the difference between the concepts of spirituality and religion. However, they state they complement each other.

Analysis of the Reinert method (semi-structured interview): through a descending hierarchical classification (dendrogram), 2 thematic axes were identified, the first with 4 classes and the second with one, leading to the 5 categories described later. The greatest percentage of co-occurrences was in class 3 of thematic axis 1. In addition, Figure 2 shows the axes, classes and codes with significance calculated by Chi2 (X2) with p<0.05 and of interest for the study (Figure 2). These 5 categories are explored below.

Figure 2
Figure 2. Dendrogram and thematic structure of the classes generated from the interview by descending hierarchical classification. Significance calculated by Chi2 (X2) with a p<0.05 and interest of the study.

Figure 2. Dendrogram and thematic structure of the classes generated from the interview by descending hierarchical classification. Significance calculated by Chi2 (X2) with a p<0.05 and interest of the study.

Source: elaborated by authors with the IRAMUTEQ software.

Category 3. Learning from Crises to Develop Personal Spirituality

In this category, students talk about their dreams versus the crises they have faced and how they have faced these crises. They visualize their goals and project themselves towards the future. Being able to complete their professional degrees and practice as professionals is important. Therefore, learning is part of building their futures. This learning is also reflected in problem resolution throughout their lives. They also learn about their errors and those of other in this way.

“Yes, I have learned a lot from difficult times about how to grow as a person and face my problems better each time. Working hard on my studies, graduating and becoming a great professional” (EE13).

They see themselves as subjects of care and personal realization. Parents and families have supported their dreams and are the fundamental basis for facing crises. This has helped them learn and reflect, as support for developing their own spirituality.

Category 2. Intrapersonal Happiness towards the Future

The code is the result of a life project and activities carried out to fulfill it. It is recognizing the now with what they are and have. This projection comes about in a space they call the future, and it is recognized as the imaginary where they want to be by themselves and in relation with families, giving them happiness and personal satisfaction.

“Improving my relationships with family members to be closer to them and take advantage of each moment. Being very happy with everything I have and am, recognizing I can improve” (EE11).

This continuum helps identify provision, which means how they provide safety to patients and how they receive protection from their loved ones, which makes them feel safe.

Parents play a very important role for students, recognized as those with whom they related to positively or negatively within the family. How relationships with parents from childhood can affect the development of family functionality and students’ projections towards the future were identified through expressions.

In this category, SEEING presents itself as the help that makes sense when you see the values and beliefs that act and provide support for their life projects, related to well-being and family reunions. There are also the farewells they have had to say to some family members in light of death, such as one student stated upon the loss of a loved one due to COVID-19: “Saying goodbye in an observable way to be able to let that person go” (EE9).

Category 1. Religious Spirituality

In this category, students recognize religion as a form of expressing spirituality from people’s ways of acting, which maintains a relationship with a god and helps them in providing care and connecting with their vocation for service.

“I consider myself a spiritual person, since I consider and believe in a powerful being. I also like having a calm, harmonious and peaceful relationship with myself and those around me” (EE12).

Spirituality and religion are seen as a whole, in communion, not separately. Only one student stated people should be more spiritual and less religious. This leads them towards a purpose through meditation, self- reflection and inner strength and allows believing in that superior spiritual being called god, who connects them from their being to spirituality and gives them the strength to follow their values and face difficult situations. They also recognize god as a spiritual being to whom they must be faithful, and is present now and in the future, since god is in their projections and dreams.

Category 4. Spirituality and Religion from a Physical Point of View

Students refer to the relationship between the spiritual and corporeal, recognizing the importance of self- care for their bodies for a good mental state, where spirituality helps them connect to religion and be at peace. Religion is seen as an institution created by humans for social control, which has brought about death and wealth. On the other hand, it is also seen as the beliefs that facilitate a connection with spirituality, or activities that demonstrate the actions of people, where decisions are important as actions of change, in order not to fall and reconsider their actions. Feeling, based on a self-perception of spirituality and religion as a belief, is considered vitally important. This feeling gives them peace and calm of the spirit. They state it must be maintained as that continuous capacity for bodily well-being, to facilitate maintaining a mental connection with spirituality.

“What’s most important to me is my family’s well- being. I do consider religion and spirituality help me find that peace and maintain a good physical and mental state, as well as calm” (EE13).

Although they divide what is spiritual and physical, they recognize that they make a whole.

Category 5. Finding Oneself through Nature

Students seek for a place where they can find peace, calm, life and health, belief in themselves, with spirituality and the pursuit of happiness. Some find the agreement with that finding difficult, but still consider it important to continue that constant search. Nature is a space, an open site that allows people to find calm through a good connection. They recognize that, though they are from the city and do not like the outdoors, they state the need to care for nature and love animals. They connect to nature through that which is alive. They see the outdoors as a synonym of nature, mostly referenced by students from rural areas, with families there. This allows them to find spaces and connections again, accompanied by their families.

“By connecting with nature, I feel mental peace and a passion to protect, love and take care of any living being. Breathing fresh air gives my happiness” (EE18).

Calmness, faith, life, health, love and the search attained when one connects internally with the self, nature and god, always in search of mental peace as a dimension in which there must be health, is achieved through those connections. Caring is seen as love, protection and maintaining that which is alive, nature and outdoors. Happiness is the state transmitted through a connection with nature, searching for a goal and gaining achievements.

Discussion

Students state that it is important to differentiate between spirituality and religion, respect the beliefs and values of each person and understand how they experience spirituality. The recognize that they have occasionally been shy when delving into this topic due to the complexity of searching within people. This demonstrates that students identifying the spiritual needs of patients is a topic they have somehow been developing. However, it requires guidelines that facilitate training to make assessments with more security. In this sense, Oliveira and other authors explained that a nursing team needs to be trained to identify and provide spiritual care by developing clear pedagogical strategies that help students recognize spirituality as part of the holistic health care that must be provided (26,27).

All of the above facilitates perceiving that students understand the concept of spirituality beyond religion, which could come from them and their awareness of their own spirituality. According to the study by Lewinson (19), it is necessary for nursing professionals to be spiritually aware to acquire spiritual skills.

With respect to the category “Learning from Crises to Develop Personal Spirituality,” this involves real life situations of students and their own experiences, to help them visualize a starting point for developing spiritual care skills. This is based on reflections, exchanging life stories and other methods, which were proposed by Ross and Baldachino as coordinating axes of learning (11,22).

“Intrapersonal Happiness towards the Future,” as a category, is part of the universal dimensions of spirituality. Manifestations that allow seeing the intrapersonal and transpersonal relationship that define spiritual needs and resources as the search for meaning, connection and belonging in life can also be observed (13,26).

The concepts of spirituality and religion are identified in the category of “Religious Spirituality,” which are represented by the traditions proposed by McSherry and differentiated by the students’ expressions (28). Moreover, the spirituality mentioned by McSherry and Vargas-Escobar as that which surrounds the being and is immersed in culture and relationships is evident (8,24,28).

In terms of the code “person,” here students recognize themselves as beings of action and values, who take action. This recognition by students allows visualizing some of the domains proposed by Ross et al. For education on spiritual care in nursing, such as self- awareness, assessment and the application of spiritual care (11,22).

In the category “Spirituality and Religion from a Physical Point of View,” it is important to rescue some attitudes towards the well-being of students, which Niu mentioned as strengthening self-compassion and the capacity for self-awareness (29).

The category “Finding Oneself through Nature” has codes that allow identifying factors that also appear in Ross’ study (22) and contribute to spiritual care skills, as with the perception of spirituality as a broad view of being. This implies a starting point for gaining spiritual care skills. It also admits the harmony expressed between the expressed meaning and experiences, also manifesting some personal values, similar to what was mentioned in the Delphi study carried out in Europe for the framework of spiritual care skills for nurses and midwives (30).

Finally, finding oneself, relationships with others and discovering others as unique beings in the framework of spiritual care stand out. All these important elements applied in a study on intervention for palliative care patients (31), can be applied in other spiritual care interventions, as mentioned by first-year nursing students of Noruega (32).

A framework of reference that allows developing spiritual care skills for students and nurses in training is recommended, with a defined pedagogical model or strategy that facilitates learning based on life experiences.

Conclusions

Students consider that, though there is a difference between religion and spirituality, both concepts are important and must be personally assessed based on the transcendence of human beings and the energy people use spiritually to take care of themselves.

The spiritual care category, perceived as understanding others, observing beyond, and seeing differences framed within an interpersonal relationship, allow students and patients to share experiences reciprocally upon recognizing the importance of people’s beliefs and values when it comes to approaching the patient’s spiritual perception.

It is possible to strengthen students’ personal spirituality as a strategy for acquiring spiritual skills during nursing education, promoting a greater awareness of themselves, with greater levels of awareness of the spirituality of the subject under their care when providing nursing care.

Conflicts of interest

The authors declare that there is no conflict of interest.

Funding

No external funding was provided to the authors for this study.

Ethical responsibilities:

Protection of people: This study is considered risk-free due to its nature. It was approved by the Institutional Ethics Committee.

Confidentiality of data: The authors declare they have followed their work center’s protocols on the publication of patient data.

Right to privacy and informed consent: The authors have obtained the informed consent of patients and/or subjects mentioned in the article. This document is in the possession of the corresponding author referred to in the article.

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Author notes

Claudia Consuelo Torres Contreras. Universidad de La Salle. Av. Circunvalar 35-117 Bulevar del Cacique Casa: 50. Bucaramanga, Santander, Colombia. Email. ctorres67@unisalle.edu.co

Additional information

How to reference.: Torres-Contreras CC, Vargas-Escobar LM, Triana-Rodríguez JY. Spiritual Care in Nursing Students: Qualitative Study. MedUNAB [Internet]. 2022;25(3):430-440. doi: https://doi.org/10.29375/01237047.4330

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