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The Exploration of Reflection Teaching in the Course of

Spiritual Nursing with Respect to Nursing Students’ Spiritual Status

and the Abilities of Spiritual Nursing Care

Ya-Lie Ku, Assistant Professor

Man-Hua Shen, Instructor

Department of Nursing, Fooyin University

Ta-Liao District, Kaohsiung City, Taiwan

Abstract

Nursing is the profession of holistic care, including physical, psychological,

social, and spiritual care. However, nurses often lack the ability to give spiritual care a

skill that should be cultivated starting during nursing education. The effectiveness of

spiritual nursing education has been identified in the literature. The purpose of this

study was to use reflection teaching to help nursing students improve their grasp of

how to practically apply concepts of spiritual nursing. This study was conducted with

46 nursing students who took a course on spiritual nursing from September, 2010 to

January, 2011. This reflection teaching was accomplished by having nursing students

write their reflections in a journal each week responding to probing questions for each

teaching unit in the course. It was projected that through using reflection journals,

nursing students would enhance both their individualized learning experiences as well

as group assignments. Results showed that more than 90% of the 46 nursing students

improved in their reflection levels to become critical reflectors, with themes such as

realization, adjustment, changing, adaptation, positivism, and application, which

intertwined with the themes generated from the weekly reflection journals. Both

quantitative and qualitative data from this study have empirically validated the

effectiveness of reflection teaching in spiritual nursing for promoting nursing

students’ spiritual status and spiritual care abilities through improving their reflection

levels.

Keywords: Reflection, Spiritual Nursing

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Introduction

Spiritual nursing started in the 1960s, but nursing education put little emphasis

on spirituality. Many studies also identified that nursing students were not competent

in spiritual care because they were not prepared by what they had learned about

spiritual care (Caranzaro, & McMukken, 2001; Keefe, 2005; McSherry, 2006; Ross,

2006; van Leeuwen, Tiesinga, Post, & Jochemsen, 2006). American Association for

College of Nursing (AACN) in 1998 and United Kingdom Central Council (UKCC)

in 2000 both have proposed that nursing education should instruct nursing students on

how to assess and care for the spiritual problems of patients; nevertheless, Meyer

(2003) identified that less than 6% of nursing curricula included spiritual topics.

Lemmer (2002) investigated nursing teaching plans in 132 universities and found that

few nursing faculties could define their spirituality and have enough knowledge to

teach nursing students about spiritual knowledge and interventions. Taylor, Mamier,

Bahjri, Anton, and Petersen (2008) again reported the lack of an evidence-based

nursing educator to teach nursing students about spiritual care. They found that it was

not clear as to the correct and appropriate ways and skills to instruct nursing students

about spiritual care; therefore, nursing students expressed difficulty in describing their

own spirituality accurately and felt a lack of preparation in being able to care for the

spiritual needs of the patients (Moss, 2007).

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Literature has indicated the need for spiritual nursing education; however,

Granham (2008) found spirituality has seldom been listed in the development and

graduation criteria in nursing, or as part of the evaluation standard in nursing

practicum. Nevertheless, the effectiveness of spiritual nursing education has been

identified in the literature. van Leeuwen, et al. (2006) reviewed nine research articles

about spiritual education in nursing and identified the influence of spiritual education

on the spiritual care competence for health care professionals. Additionally, the

spiritual care competence of 97 nursing students was shown to have improved after

six weeks of spiritual care training (van Leeuwen, et al., 2006); the spiritual attitudes

and knowledge of nursing students were significantly different when compared before

and after taking a spiritual education course (Lovanio & Wallace, 2007). Furthermore,

Taylor, Mamier, Bahjri, Anton, Petersen (2008) used a quasi-experimental study

which identified significant improvement in the spiritual care attitudes, abilities,

experiences, and knowledge of 84 nursing students and 91 nurses after using

self-learning spiritual education materials.

Wallace, et al. (2008) developed a curriculum for spiritual nursing and integrated

it into 13 different nursing curricula, and they identified that the spiritual knowledge

and attitudes of 34 senior nursing students improved significantly after taking the

integrated curriculum. Similarly, Shih, Gau, Mao, Chen, and Kao Lo (2001)

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empirically validated a teaching course on spiritual care for a Masters nursing

program in Taiwan over 18 weeks, including classroom lectures, field trips, clinical

implications, and presentation-appraisal. Results identified four ways the Masters

nursing students were helped by the course: in identifying the symbolic meaning and

impact of religious rituals, clarifying the concepts of spiritual care, enabling the

students’ self-discovery of their personal values and spiritual needs, and providing the

culture-bonded spiritual care plan. Despite the evidence in the literature indicating the

usefulness of spiritual nursing education, Ku (2010) investigated 39 nursing

universities in Taiwan and found that the majority of spiritual courses were merged

into hospice nursing as a teaching unit, with only 12 schools having spiritual nursing

(30.8%) as an independent course. However, spiritual nursing is different from

hospice nursing, and while spiritual characteristics and abilities must be a prerequisite

for a hospice nurse, these qualities are important for other areas of nursing, as well.

The author has taught a course on spiritual nursing since 2006 in 10 different systems

of classes. The majority of the nursing students were interested in the spiritual nursing

course, and evaluations of the course were satisfactory overall. However, nursing

students in the spiritual course often complained about not understanding how to

apply what they had learned about spiritual care to help patients in clinical settings.

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Purpose of the Study

The purpose of this study was to use reflection teaching to help nursing students

improve their grasp of how to practically apply concepts of spiritual nursing.

Literature Review

Chien (2008) emphasized that the importance of reflection teaching is for the

educators and learners to reflect their own teaching and learning process through

continuous reflection with the spiral circulation of improvement process. Literature on

reflection teaching included the impact on learning for both clinical nurses and

nursing school students. Liu, Lu, and Jeng (2004) invited 56 clinical nurses to view

the video depicting characteristics of a good nurse and had them reflect and discuss

the meaning of being a good or bad nurse. They identified six characteristics of being

a good nurse, such as being able to communicate, autonomic, being respectful, able to

have empathy for the patient, helpfulness, and honesty. Additionally, Shiau, Chang,

Rong, and Kang (2010) led eight psychiatric nurses in participating in a 3C (concern,

care, compassionate) growing group to explore therapeutic relationships, and results

indicated two themes - listening to the inner voices of the patients and helping patients

cope with difficulties. Finally, Chiang, Chen, and Sue (2006) applied reflection skills

in leading clinical nurses to think about ethical difficulties for SARS patients, and

Chiang (2006) also applied reflection skills in leading clinical nurses to think about

ethical issues concerning sexually violent predators.

Concerning classroom learning for nursing students, Kuo, Lee-Hsieh, and Wang

(2007) applied reflection teaching strategies in developing a caring curriculum and

had nursing students review their caring experiences to learn by reflection and

revision. Hu (2008) led students in a long-term care program covering areas such as

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dementia, nutrition, activities for elders, and groups of nurses learning how to work

together to help the patient to increase self-learning by using reflection journals to

make them reflect on their own learning process and evaluate the extent of

approaching the education goals of this curriculum. Also in the area of elder care

courses, Barber (2008) conducted a phenomenological study with 11 senior nursing

students participating in a spiritual conference to explore their realization of

spirituality, and four interpretations from this study included listening to others’

stories, understanding the extent of spirituality, realizing the influence of the spiritual

conference on the nursing students themselves, and providing spiritual care.

Baldacchino (2008) suggested that the practice of self-reflection, consideration of case

studies, and small group discussion as non-traditional ways for nursing teachers to

improve nursing students’ understanding of spiritual care to accomplish holistic care.

Concerning practicum teaching strategies, Furtado (2005) used inspirational and

phenomenological studies to help nurses and nursing teachers develop their spiritual

practicum teaching skills through photography, drawing, and reviewing interview data

that identified areas in their personal lives and practicum behaviors that were

consistent. The study is seeing if those three types of reflection teaching helped the

teachers know and communicate about themselves better so they can teach better.

Catanzar and McMukken (2001) proposed that daily journal records in a community

nursing practicum course can improve the spiritual sensitivity of nursing students.

Rankin and DeLashmutt (2006) assigned 188 nursing students to a community crisis

center to conduct a faith-based community practicum through small group meetings,

and discussion revealed support for integrating reflection skills into the clinical

practicum. The nursing students expressed that use of reflection skills in the practicum

process helped them to find themselves and understand spiritual maturing. Mitchell,

Bennett, Manfrin-Ledet (2006) developed a spiritual care map for nursing teachers to

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use as the spiritual protocol for nursing students when caring for terminal patients,

and this map included three main themes for a spiritual assessment tool as self

spiritual assessment, trauma and self-healing, and power, peace, and security.

Overall, reflection teaching in nursing emphasizes value, nurse-patient

relationship, ethical issues, cultivating caring, and how to approach learning goals.

Additionally, teaching strategies in spiritual nursing education include self-reflection,

journals, a spiritual care map, small group meeting with a lecture format, photography,

drawing, interviews, life-review, oral history, conferences, case study, and small group

discussion being each group member sharing with the others. Although reflection

teaching has been applied to spiritual nursing education, no specific level of reflection

was identified in the literature for nursing studies. Boud, Keogh, and Walker (1985)

used reflection as the basis to derive six levels of reflection process, including

attending to feelings, association, integration, validation, appropriation, and outcome

of reflection. Attending to feelings means that a person could feel any experience

happened around him/her. Association means that a person could relate the new

experience with that was already known before. Integration means that a person could

view the relationship between various experiences. Validation means that a person

could determine the truth ideas and feelings that have results. Appropriation means

that a person could produce own knowledge. Outcome of reflection means that a

person could change his/her bad characters, and promote his/her spiritual status

merging into daily lives with compromising acting behaviors. Wong, Kember, Chung,

and Yang (1995) used the Boud, Keogh, and Walker (1985) reflection model as the

basis for Hong Kong registered nurses to take a 30-hour education course, which

involved writing in reflection journals. Results identified that 13.3% were

non-reflectors, 75.6% were reflectors (level 1, 2, 3), and 11.1% were critical reflectors

(level 4, 5, 6) through the analysis of 100 reflection units.

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The reflection teaching in this study used probing questions in each teaching unit

as the core of the spiritual nursing course. Nursing students who took the teaching unit

wrote in reflection journals weekly in response to the probing questions to enhance

individual learning experiences. Reflection evaluation was conducted before and after

the spiritual nursing course by following the Boud, Keogh, and Walker (1985)

reflection model. Additionally, six groups of nursing students conducted a case

analysis to assess the spiritual problems of a patient and designed literature, music,

nature, or art spiritual nursing interventions to help solve the patient’s spiritual

problems to approach the goal of applying the spiritual nursing process.

Methodology

Research Design and Sampling

This study used reflection teaching and evaluation at the same time in a course

on spiritual nursing. Students were from the two-year BSN nursing program and

elected to take the course from September, 2010, to January, 2011. The 51 students

taking the class were offered a book of 100 coupons as an incentive to participate in

this study, and 46 accepted. The following is the course description, and the seven

teaching topics with principles and the probing questions designed for use with the

weekly reflection journals.

Description of Course on Spiritual Nursing

This course mainly facilitated the students’ ability to experience their own

spiritual status through self-reflection and understanding of spiritual definitions and

theories, and the development process of human beings. Additionally, this course had

students analyze their own and others’ spiritual status in three dimensions of

relationship - with themselves, others, and with respect to faith, enhancing their

spiritual assessment skills using case analysis and applying literature, music, nature,

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and art as spiritual nursing interventions to the nursing process of the patient to solve

his/her spiritual problems. This reflection teaching research merged into the course of

spiritual nursing required each nursing student to reflect and write in their reflection

journal weekly according to the seven teaching topics with principles and the probing

questions listed in Table 1.

Table 1: Teaching Topics with Principles and Probing Questions

Topic Teaching Principles Probing Questions

Definitions of

Spirituality

-Clarify values

-Origins of life

-Definitions of spirituality

from literature and experts

‧Write down your own definition of spirituality. Ask

another person (your family member or friend) to write

down his/her definition of spirituality. Compare the

similarities and differences between your definition of

spirituality, that of your family member or friend, and

from literature and experts.

Developing

Process of

Spirituality

-Human beings development

stages/inner healing /spiritual

duties

-James Fowler - faith

development stages

-Erik Erickson - human beings

development stages and duties

Reflect on your own life development process. Which

duties have you accomplished? Which duties do you

perform best? Which duties do you perform worse?

What kind of hurtful experiences have you encountered

and how did you heal yourself?

Spiritual

Assessment

Skills

-Sensitivity

-Listening

-Empathy

-Mediation

-Accompany

‧Accompany your family member or friend without

saying anything and write down how you felt during this

exercise.

‧Try to talk with a family member or friend and analyze

the words he/she used, what was communicated without

using words, and any spiritual words

Your

Spirituality

Items of Assessment

-Life philosophy

-Meaning and purpose of life

-Submission/acceptance

-Forgiveness/love

-Hope/joy/peace

-Encouragement/coping

‧What do you think are the most important and valuable

things?

‧What is the purpose of your life?

‧What are your feelings when you hear about criticism

or negative rumors said about you behind your back?

‧What characteristics do you dislike about yourself?

‧What are some faults you cannot forgive yourself for?

‧What ways do you use to make yourself feel peaceful

and stable?

‧What ways do you use to help you love yourself and be

happy?

‧What are your wishes for yourself?

‧What things do you fear the most and how do you

overcome them?

‧Which coping mechanisms should you focus on and

enhance? How can you improve them?

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Spirituality

and Others

Items of Assessment

-Relationships with family

members

-Relationships with friends

-Relationships with neighbors

(strangers)

-Relationship with your

spiritual mentor

‧Who is the closest and nicest to you among your

family members?

‧Who do you have the most difficult relationship with

among your family members? Do you want to repair your

relationship with him/her? How could you repair it?

‧Who is the closest and nicest to you among your

friends?

‧Who do you have the most difficult relationship with

among your friends? Do you want to repair your

relationship with him/her? How could you repair it?

‧Who is your neighbor (stranger)? How is your

relationship with him/her?

‧Who is your spiritual mentor? How is your relationship

with him/her?

‧Write down the things you did to hurt others or others

did to hurt you on a piece of paper. Tear it up, and at the

same time decide to forgive him/her.

Spirituality

and Faith

Items of Assessment

-The God of your faith

-Your relationship with God

-Rituals of faith

-Experiencing God and

obtaining help from Him

Who is the God of your faith?

What is your relationship with God?

What are the rituals of your faith, such as praying,

reading religious verses, worship that your religious

leader leads?

What is the process for experiencing God and obtaining

power and help from Him?

Spirituality

and Grief

-Definitions and assessment of

grief

-Caring and services for the

bereaved

-Individual and group grief

counseling

‧What are your experiences of having a family member

or friend die?

What was your grief process?

‧Make your own living will.

Research Process and Data Analysis

This reflection teaching research was conducted in three stages. First, the

investigator taught about seven spiritual topics with principles and listed the probing

questions for the nursing students to write about weekly in their reflection journals.

Then, using a case study, the researcher demonstrated the process of identifying the

spiritual problems the patient had by assessing three dimensions of relationship - with

self, others, and faith, and she designed spiritual interventions for each spiritual

problem using literature, music, nature, or art. Lastly, the 46 nursing students divided

into six groups and each group conducted a case analysis using the spiritual nursing

process the investigator had demonstrated.

Data analysis of this reflection teaching research consisted of three parts. The

first was to compare the results of the nursing students own evaluation about spiritual

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status and spiritual care abilities before and after taking the course on spiritual nursing.

The nursing students evaluated themselves using both a 1-10 visual scale and the

Boud, Keogh, and Walker (1985) reflection model with six levels, including levels

1-3 (attending to feelings, association, and integration) as the reflectors and levels 4-6

(validation, appropriation, and outcome of reflection) as the critical reflectors. In

addition to the quantitative data, the qualitative data in the Boud, Keogh, and Walker

(1985) reflection model consisted of the reasons the nursing students reported as to

why they were or were not able to approach a particular reflective level. Finally,

content analysis was conducted in the seven different teaching units from picking out

the journals of 46 students for identifying the different types of themes.

Results

Quantitative Data

A total of 46 nursing students (90.2%) completed evaluations of their own

spiritual status and spiritual care abilities before and after taking the course on

spiritual nursing. The first method of evaluation involved using a 1-10 visual scale.

The scores on the self-evaluation of spiritual status improved from 4.7 to 7.2, and the

level of spiritual care abilities improved from 4.4 to 7.1. A significant improvement

was identified in the scores for both spiritual status (p<.001) and spiritual care

abilities (p<.001) for the nursing students after taking the course on spiritual nursing.

Table 2 contains the study results.

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Table 2: Spiritual Status and Spiritual Care Abilities of Nursing Students

Range Mean SD

Paire-t df Sig pre post pre post pre post

Spiritual Status 2-8 5-9 4.7 7.2 1.7 0.9 -9.083 45 .000**

Spiritual Care Abilities 1-8 4-9 4.4 7.1 1.8 1.1 -9.765 45 .000**

P*<.05; p**<.001

Regarding the Boud, Keogh, and Walker (1985) six levels of reflection

evaluation model, the percentage of nursing students who achieved levels 1-3

increased from 52.2% to 97.8%. Similarly, the percentage of students achieving levels

4-6 improved from 21.7% to 95.7%. Conversely, the percentage of students not

achieving levels 1-3 decreased from 47.8% to 2.2% and was reduced from 78.3% to

4.3% of those not achieving levels 4-6. Table 3 shows the study results.

Table 3: Boud, Keogh, and Walker (1985) Six Levels of Reflection Evaluation

Levels/Testing Level 1-3 Level 4-6

Achieved Non-achieved Achieved Non-achieved

Pre

self-reflection

52.2%

(N=24)

47.8%

(N=22)

21.7%

(N=10)

78.3%

(N=36)

Post

self-reflection

97.8%

(N=45)

2.2%

(N=1)

95.7%

(N=44)

4.3%

(N=2)

Qualitative Data

There were three types of qualitative data gathered in this study. Firstly, the

themes from the reasons written by the nursing students as to why they did or did not

achieve the different levels of reflection included realization, adjustment, changing,

adaptation, positivism, and application. Secondly, the themes generated from a sample

of seven reflection journals from among the 46 nursing students were that there was

no universal definition of spirituality, the shadows from different stages of

development and healing from these wounds, empathy through accompanying people

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and listening to them, understanding oneself and others, forgiveness, repairing

relationships, understanding and developing faith, loss and sorrow. Finally, the six

groups of nursing students designed the literature, music, nature, and art interventions

for a case during the spiritual nursing process. For each unique spiritual nursing

intervention, the group first set the goal for the intervention according to the patient’s

spiritual needs and then searched for appropriate reading materials, songs, plants, and

pictures to draw for the case. The groups demonstrated the process of conducting

spiritual nursing interventions for the case in the classroom, and the investigator gave

suggestions to think about for further revision of the nursing interventions to better fit

the spiritual needs of the patient.

Discussion and Conclusion

Concerning quantitative data, this reflection teaching study with reflection

journals using probing questions showed that the nursing students improved

significantly in spiritual status and spiritual care abilities after taking the course on

spiritual nursing as indicated by self-evaluation using a 1-10 point visual scale. This

finding is similar to the results of several studies. The spiritual care competence of 97

nursing students improved after six weeks of spiritual care training (van Leeuwen, et

al., 2006); the spiritual attitudes and knowledge of nursing students were significantly

different when compared before and after they took a spiritual education course

14

(Lovanio, & Wallace, 2007); 84 nursing students and 91 nurses showed significant

improvement in spiritual care attitudes, abilities, experiences, and knowledge after

using self-learning spiritual education materials (Taylor, Mamier, Bahjri, Anton, &

Petersen, 2008); and the spiritual knowledge and attitudes of 34 senior nursing

students improved significantly after taking an integrated curriculum of spiritual

nursing (Wallace, et al., 2008).

Additionally, regarding the Boud, Keogh, and Walker (1985) six levels of

reflection evaluation model, the percentage of reflectors (level 1-3) for nursing

students increased from 52.2% to 97.8%, and improved from 21.7% to 95.7% for

critical reflectors (level 4-6). It seems that before taking the course on spiritual

nursing more than half of nursing students evaluated themselves as reflectors, but less

than one-third considered to be critical reflectors. Nevertheless, both groups of

nursing students were processing into more than a 90% improvement in reflection

levels after taking the course on spiritual nursing. In other words, more than 90% of

nursing students who take the course on spiritual nursing could become critical

reflectors.

Concerning qualitative data, themes generated from nursing students’ reasons

about achieving or not achieving the various reflection levels included realization,

adjustment, changing, adaptation, positivism, and application. Additionally, themes

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generated from seven reflection journals from among nursing students’ writings were

that there was no universal definition of spirituality, the shadows from different stages

of development and healing from those wounds, empathy through accompanying

people and listening to them, understanding oneself and others, forgiveness, repairing

relationships, understanding and developing faith, loss and sorrow. Similarly, in the

literature, Shih, Gau, Mao, Chen, and Kao Lo (2001) identified four ways Taiwanese

Masters nursing students were helped by a teaching course on spiritual care, which

were in identifying the symbolic meaning and impact of religious rituals, clarifying

the concepts of spiritual care; enabling the students’ self-discovery of their personal

values and spiritual needs; and providing the culture-bonded spiritual care plan.

Barber (2008) reported four interpretations from 11 senior nursing students

participating in a spiritual conference - listening to others’ stories, understanding the

extent of spirituality, realizing the influence of the conference on the nursing students

themselves and providing spiritual care. Shiau, Chang, Rong, and Kang (2010)

indicated two themes expressed by eight psychiatric nurses participating in a 3C

(concern, care, compassionate) growing group as being to listen to the inner voices of

the patients and to help patients cope with difficulties.

In conclusion, reflection teaching in the course on spiritual nursing helped 46

nursing students improve their own spiritual status and spiritual care abilities, with

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more than 90% becoming critical reflectors by the end of the class. Themes such as

realization, adjustment, changing, adaptation, positivism, and application intertwined

with the themes generated from the weekly reflection journals from the 46 nursing

students. Both quantitative and qualitative data from this study have empirically

validated the effectiveness of reflection teaching on spiritual nursing for promoting

nursing students’ spiritual status and spiritual care abilities through improving their

reflection levels.

Acknowledgment

The author wishes to thank the 46 two-year BS nursing students for their

participation and cooperation. Most sincere thanks are extended to the six group

leaders for the 46 nursing students who assisted in the spiritual nursing process during

the case analysis.

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