1. Connors, Joan MSN, RN, FCN
  2. Good, Palmira MSN, RN, CNE
  3. Gollery, Thomas EdD

Article Content

Nurses need to assess patients and provide care that encompasses the mind, body, and spirit.1 However, in many cases, nurses may not know what to say to the patient, may be uncomfortable with silence, may not want to pry into the patient's personal life, or may feel hesitant to invade the patient's private "space."2-6 In 1 study, nurses reveal that 92% of the time, they feel inadequately prepared to meet their patient's spiritual needs.7 Nursing programs do not sufficiently prepare nurses in matters of spirituality.3,5 Little spiritual content is mentioned in nursing textbooks.4(p16)


Discussing spiritual concepts during the students' nursing program lays a foundation for the development of caring for the spiritual needs of others.8-11 There is a reliance on nursing programs to prepare students to be able to address matters of spirituality with their patients.3(p232) According to LaBine,5 "it is vital that nursing students are exposed, didactically and clinically, to the spiritual care of patients."(p16) Further studies indicate that nursing students who reflect on their personal spirituality are better able to care for the spiritual needs of their patients.3(p234),12,13 Moreover, a review of the professional literature indicates that there are limited studies on teaching spirituality in public community college nursing programs; rather most studies are conducted with private faith-based institutions.5(p27)


Various teaching methods have been used to introduce students to the subject of spirituality, including simulation, reflective journaling, and lecture. Taylor et al14 suggest that there is a "disconnect" between what the students learn and transfer to the clinical setting. Using a patient simulation is one strategy for helping nursing students learn about spiritual care.3,15,16 Blesch3 developed a simulation requiring students to respond to a patient in emotional and spiritual crisis. However, student observers documented that there was "awkward silence" during the simulation. Although some students reportedly responded by calling the chaplain or praying with the patient, many lack this intuitive response.3


To date, nursing literature provides very little information on how to teach spiritual care. The purpose of this article is to describe innovative teaching methods developed for students attending a state-supported community college associate degree nursing (ADN) program to improve competence and confidence in delivering care that addresses the spiritual dimension of nursing care. Methods included creating a spiritual simulation, interrupting the simulation at the midway point to introduce Key Phrases and Caring Behaviors(C), then restarting the simulation as the students practiced implementing the new teaching material into the simulation.


Teaching Strategies to Prepare Students for Spiritual Caregiving

There were 3 strategies used for teaching students spiritual care. The first strategy was traditional classroom instruction on the topic of spirituality and caring behaviors conducted for 11/2 hours with nursing students in their first semester. This lecture introduced the concept of caring and spirituality to students before their initial clinical rotation. After the lecture, all students were placed in small groups and were assigned to develop appropriate responses to individuals described to be in spiritual or emotional distress.


The second strategy required that all students perform a spiritual assessment on a patient while in the clinical environment and submit the completed assessment to their clinical instructor. Performing a spiritual assessment encourages students to establish a trusting relationship with their patients and provides a platform by which students may practice asking more direct questions about spirituality.


The final strategy was a spiritual simulation. After the students completed the presimulation exercise, they participated in the simulation. During the simulation activity, students were to perform an admission assessment on a stable patient who had a stroke accompanied by a distressed family member. Certain roles of ancillary staff were included to provide realism to the simulation. After 10 minutes, the simulation was interrupted, and a midpoint debriefing was conducted. The interruption was intended to allow students time to discuss actions and phrases that could have been performed. Then students were given the Key Phrases and Caring Behaviors tool containing simple statements and behaviors that include active listening and appropriate touch. These are suggestions for what one could say and do in an emotionally distressed situation. Students were then given 5 minutes to become familiar with the content of the tool in preparation for replaying the simulation from the beginning. Embedding the opportunity to practice appropriate nursing interventions midsimulation represented the final teaching innovation.


Design and Sample

To examine the effectiveness of these teaching strategies, the authors examined student competence and confidence via a survey that was administered across the 3 phases. Phase 1 was before the classroom lecture and group activity; phase 2 testing was conducted after the classroom lecture and group activity; and phase 3 testing was conducted after the student participated in the simulation experience. There were 26 first semester ADN students who participated in this quasi-experimental study, which used a repeated-measures analysis of variance design. Although the study's sample size is small, the fact that the same students were assessed on 3 occasions using the same instrument provided a sample size multiplier sufficient for the purposes of the current study. Although attendance for the 3 phases of the study was required for the class, students were not required to participate in the study. Institutional review board approval was obtained from the sponsoring institution.



The instrument used in the study to determine the perception of competence and confidence in delivering spiritual care was the Competence and Confidence Tool. The tool was adapted with permission from an instrument first introduced in the article "Enhancing the Perceived Comfort and Ability of Nursing Students to Perform a Spiritual Assessment" by Hoffert et al.9(p67) The Competence and Confidence Tool has a high degree of internal reliability ([alpha] = .91) and has 10 items scored using a Likert scale from 1 (strongly disagree) to 5 (strongly agree). The total score possible is 50.



The teaching methods were effective in improving students' perceptions of their competence and confidence in providing spiritual care across all 3 phases of the study (P < .001). The most significant change was from phase 2 to phase 3, after students had completed the simulation (t = 5.65, P < .001; d = 0.93) (Table). Students indicated that they felt prepared to provide spiritual care, could address spiritual care needs of patients, were prepared to address their physical care needs, and listen to the patient. However, students also recommended an additional simulation to better prepare them for providing spiritual care.

Table. Changes in Co... - Click to enlarge in new windowTable. Changes in Competence and Confidence by Phases

The impact of these innovative teaching methods on students' perceptions of competence and confidence in addressing the spiritual aspects of nursing care was statistically significant across all 3 phases of the study (d = 0.83, P < .001). The Table, Supplemental Digital Content 1,, reports student responses to individual questions; 6 questions exhibited significant changes after the students participated in the simulation. Students' ability to respond to someone in spiritual distress reflected the greatest single change ([eta]2 = 0.56). Students' perceptions about the benefit of participating in the simulation activity increased significantly (P = .007) across all 3 phases of the study.



When provided only with the classroom lecture on spirituality, students manifested little growth in competence and confidence in providing spiritual care. However, once introduced to the simulation scenarios, participants demonstrated significant increases in their perceived confidence and competence in addressing spiritual care, spiritual preparation, and comfort level in providing spiritual care to patients


Despite being prepared for simulation with a classroom lecture, group activity, and presimulation activity, students were visibly anxious during the simulation because they did not know what to say or do to provide comfort to patients in spiritual distress. In addition, they expressed frustration about their inability to simultaneously support and comfort the family while performing their assigned tasks. The chart of Key Phrases and Caring Behaviors(C) provides practical and tangible actions that students can do and say in response to the distressed. Students were allowed to use the chart during the simulation as a prop for cognitive rehearsal. Once introduced to this chart and given an opportunity to practice in the simulation, students' perceived competence and confidence increased. Cognitive rehearsal provides students with the opportunity to intentionally practice or role play what to say and do in stressful situations.


The current study of these innovative teaching methods was limited to only students in 1 ADN program. Studies of a broader population of nursing students should be done in the future.



Innovative teaching strategies were used to teach nursing students how to address the spiritual needs of patients. The strategies introduced the content in a classroom lecture and small group discussion. Then students completed a spiritual assessment tool and participated in a spiritual simulation activity. During the simulation, a midpoint debriefing was conducted to allow time to discuss actions and phrases that could be used. Students' perceptions of their ability to provide spiritual care improved significantly once the simulation activity was completed.




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