An Investigation of the Perceptions and Practices of Nursing Students Regarding Spirituality and Spiritual Care

The aim of this research was to determine Turkish nursing students’ knowledge, practices and perceptions of spirituality and spiritual care and to investigate the relationship between their perceptions and their demographics. This study was a descriptive survey conducted at a nursing school providing degree-level education in the city of Manisa, in the western part of Turkey. The sample of the study consisted of the 400 nursing students. A nursing student sociodemographic form, a form on nursing students’ knowledge and practices of spirituality and spiritual care, and the Spirituality and Spiritual Care Rating Scale were used to collect the data. Half of the students could meet patients’ or individuals’ spiritual needs, and the spiritual care that they gave was most frequently listening, empathy, and psychological support. The research findings were that nursing students’ perceptions of spirituality and spiritual care were “sufficiently” although not “very sufficiently” defined. Being female, being in the second year of education and seeing spiritual care education as necessary were determinants of their perceptions of spirituality and spiritual care.


Introduction
Today, all branches of science support the idea of the "holistic" approach to people, and consider a person as a whole. Holistic care is the response to a person's physical, psychological, social and spiritual needs [1]. Holistic nursing care includes attention to the spiritual needs of patients and their families. The health team must have the skills to see these needs, answer them, and discover them [1][2][3]. One of the basic principles of nursing is to provide adequate care in accordance with the spiritual needs of patients and their families [2]. Developing spiritual health and holistic health care has brought nurses into a leadership role in the creation of spiritual care plans [3]. Care must be planned around patients' religious and spiritual interests, beliefs and thoughts, whatever these may be. It is therefore seen as necessary that space should be given to the topics of holistic care and spiritual care as part of nursing care, and that research be carried out in this area so as to draw attention to the subject.

Background
People are biopsychosocial beings, and there is constant interaction between their biological and psychosocial needs. A problem arising in the physical area can affect the social and psychological areas as well. Also, events in the emotional-spiritual area can bring about some pathological changes in the body. For this reason, when a person is being assessed, he or she must be taken as a whole, with the biological, social, psychological, cultural and spiritual dimensions [1]. With the introduction of important changes in the health care system, nurses use the concept of holism in patient care, and the spiritual aspect of health care is steadily gaining importance. It is known that spirituality and spiritual care are of great importance as fundamental principles in health care. For this reason, varying interpretations of the term "spiritual" can affect the quality of care [1,4]. The word spirituality comes from the Latin "spiritus", meaning to breathe, or to be alive. In a broader definition, it means to feel life. The broad definition of the word spiritual includes spiritual needs and thoughts about the unexpressed topics of the practice of a religion or any kind of belief. "Spiritual" and "religion" are often used interchangeably but spirituality does not always imply excessive religiosity [2]. Religion is defined as one aspect of spirituality. Even without a leaning towards traditional religion, a person's spiritual side can be an important part of his or her needs. Spirituality does not need to be linked to religious traditions. It brings meaning and purpose to a person's life and carries the broad meaning which expresses a person's life. Spirituality contains not only religious feelings, but also those of anxiety, hope and belonging [1,2]. Spiritual care has been defined as including all nursing care which supports a patient's religious practices and personal beliefs and values. For this reason, religion is a basic part of the concept of spirituality [2]. Within the scope of a study, spiritual care was defined as the care nurses provide to meet the spiritual needs and/or problems of patients [5]. On the other hand, in the conclusion of Milligan's study it was explained that identifying spiritual needs is regarded as difficult and nursing students found giving spiritual care to patients are evenly divided over how easy or difficult it is [6]. Cleda reported that many nurses in the work place feel inadequately prepared to provide spiritual care due to various reasons, including lack of adequate time to build a rapport, uncertainty about their personal spirituality, the belief that spiritual care should be left to chaplains, and insufficient education about providing spiritual care [7]. The study has documented findings that the inadequate awareness of nurses concerning spiritual care is a reason for their lack of success in providing holistic care [8]. Other reasons for the failure to provide spiritual care are shortage of time, a feeling of inadequacy on the part of nurses in providing spiritual care, and a lack of education [9]. Although studies on this topic in Turkey have been limited, those which have been conducted have shown that most nurses do not have knowledge of spirituality and spiritual care [10][11][12][13][14], that nurses' awareness of spirituality and spiritual care is not at an adequate level [11][12][13][14], that they have not had adequate education in spiritual care [15], and that this care is not given to an adequate extent [12]. On the other hand, it has been reported in some studies that nurses' awareness of spirituality and spiritual care is high [10,15].
It has been emphasized in studies in this country and abroad that a lack of education is an important factor among the reasons for nurses not meeting the spiritual needs of individuals [5,8,16,17]. Also, McSherry reported that the concept of spirituality and spiritual care in nursing remained theoretical in the fields of organization, management and practice, and that going beyond this is necessary [18]. For these reasons, it has been emphasized that it is important and necessary to accommodate the topics of spirituality and spiritual care in nursing education programs [11,12,19].
It is seen in the literature that studies of spirituality and spiritual care are often conducted with nurses [10,11,13,17]. In a review of papers on perceptions toward spirituality and spiritual care published from 2000 to 2012, 138 articles were identified, but only nine studies involved preregistration nursing students. A critical examination of these studies identified descriptions of spirituality content in curricula [6,16,20] and the impact of specific spiritual education modules or teaching strategies on students' spiritual perspectives [5]. In a review of the literature by Lewinson et al., it was reported that nurses were aware of their lack of knowledge, understanding and skills in the area of spirituality and spiritual care, and desired to be better informed and skilled in this area. As a result of this study, it was reported that nursing education played an important role for nurses in raising spiritual awareness and facilitating competence and confidence to support the spiritual dimension of their role [21]. In Turkey, also, studies of spirituality and spiritual care conducted with nurses were encountered [10,13,15], but no studies conducted with students were found.
Although nursing education in Turkey was integrated at the university level in 1955, it has not been possible to standardize it. In Turkey there are two groups of nurses, those who are university graduates and those who qualified from vocational high schools. Nurses with these two different educational backgrounds have to share the same professional title and the same responsibilities [13]. In Turkey, spirituality and spiritual care are generally taught in one single class in nursing university education, and the concepts of spirituality and spiritual care are integrated into topics throughout education.
Nursing students, who will form the next generation of nurses, will have very different world views, cultural beliefs and values from the present generation, and therefore their perception of spirituality and spiritual care will be different. For this reason, it is felt that a determination of students' perceptions of spirituality and spiritual care will meet needs on this topic and thereby develop spiritual care.

Aim
This study was conducted with the aim of determining the perceptions of spirituality and spiritual care of Turkish nursing students who were studying for a university degree.

Objectives
The three specific research objectives were: (a) to describe nursing students' sociodemographic characteristics, knowledge and practices of spirituality and spiritual care (b) to determine their perceptions of spirituality and spiritual care (c) to investigate the relationship between their perceptions and their demographics.

Research Design and Sample
This study was a descriptive survey conducted at a nursing school providing degree-level education in the city of Manisa, in the western part of Turkey. The nursing school where the study was conducted was chosen by the purposive sampling method as one which was accessible to the researchers. This school was one giving a four-year degree program in the field of nursing following high school. The population of the study consisted of the 521 nursing students who had performed clinical practice in patient care before the survey was conducted between November 2015 and January 2016 and who were registered in the second year (n = 214), third year (n = 220) or fourth year (n = 127). The criteria for inclusion in the study were (a) being a student in the nursing department where the study was conducted; (b) having clinical experience to determine the students' perceptions of spirituality and spiritual care to patients providing care; (c) being willing to participate in the study; (d) having Muslim religion to provide homogeneity of the study; (e) speaking Turkish; and (f) being present in the school during the research period. A total of 161 students were excluded from the study, 23 for non-attendance of classes, three because they filled in the questionnaires incompletely, five because they did not wish to take part in the research, and 130 because they could not be contacted during the period of data collection. A response rate of 71% was achieved, with 400 students completing the questionnaires.

Instruments and Data Collection
A structured self-reported questionnaire was used to collect the data. It consisted of three tools: a nursing student sociodemographic form, a form on nursing students' knowledge and practices of spirituality and spiritual care, and the Spirituality and Spiritual Care Rating Scale (SSCRS).
Nursing Student Sociodemographic Form: This form was prepared by the researchers [13,16,[22][23][24], and consisted of 12 questions on such things as the students' age, gender, marital status, educational level, working as a nurse, place of longest residence, family type, experience of stress in life, health perception, life satisfaction, academic and liking for the profession.
Form on Nursing Students' Knowledge and Practices of Spirituality and Spiritual Care: This form was prepared by the researchers after an examination of the relevant literature [13,16,[22][23][24] and consisted of 11 questions on the students' concept of spirituality and practices concerning spiritual care and spirituality.
Spirituality and Spiritual Care Rating Scale: It was developed by McSherry et al. [25]. The SSCRS measures spirituality by quantifying participants' perceptions of the extent to which they hold certain spiritual views and engage in certain spiritually related activities. The tool is composed of 17 items rated on a five-point Likert-type scale. In general, higher scores indicate a higher level of perception of spirituality or provision of spiritual care. The Turkish version of SSCRS was used in this study. Validity and reliability study of the Turkish version of the scale was carried out by Ergul and Temel in Turkey [26]. The Turkish version of SSCRS demonstrates satisfactory validity and reliability, and the Cronbach's alpha coefficient was 0.76. The alpha coefficient reported for this study was 0.82.
The tools were handed out to the students after class, in a classroom environment, and were collected back by the researchers in a face-to-face interview after they had been answered. It took approximately 10 minutes to complete these forms.

Ethical Considerations
Ethical approval for conducting this study was obtained from the management of the Health School of University and the Ethics Committee of University Medical Faculty (Approval No: 20478486-380). The intervention formed part of the curriculum, and student participation in the research was neither burdensome nor risky. The director of the nursing school consented in writing to this research. Informed consent was obtained orally and in writing from the nursing students taking part in the study. The information included the purpose and procedures of the study, the voluntary nature of their participation and the option to withdraw at any time.

Data Analysis
Data were analyzed using the SPSS for Windows, Version 21.0. Descriptive statistics were used to describe nursing students' sociodemographic characteristics. Independent t-test and one-way analysis of variance (ANOVA), Pearson's product-moment correlation, Mann Whitney U, Kruskal Wallis analysis were used to assess associations between scores and socio-demographics variables. Multiple linear regression analysis was used to identify the impacts of variables on their perceptions of spirituality and spiritual care. Level of significance was set at 0.05.

Demographic Characteristics of Nursing Students
The students' ages ranged from 18 to 36 years (with a mean age of 20.93˘1.79 years). Females accounted for 71.8% of the students, most (96.8%) were single, and nearly half (41.8%) were in their second year of education. Table 1 shows the other socio-demographic characteristics of the students.

Nursing Students' Knowledge and Practice of Spirituality and Spiritual Care
Fifty percent of the students (n = 200) stated that they had knowledge of spirituality and spiritual care, and more than half (56.5%) had obtained this knowledge from school. Fifty-three percent of the students thought that this knowledge was insufficient. Most of them (94.3%) stated that spiritual care was necessary within nursing care, and 32.8% said that they had been directed by a teacher or a responsible nurse to give spiritual care. It was found that half of the students (50.7%) could meet patients' or individuals' spiritual needs, and that the spiritual care that they gave was most frequently listening (87.3%), empathy (75%), and psychological support (59.8%). Factors which prevented students from giving spiritual care were mainly lack of time (67.3%), lack of knowledge (58.3%), lack of a suitable place (54%), and giving priority to physical problems (45.8%). Most of the students saw education in spirituality and spiritual care as necessary, and 83.3% wanted more information on the topic (Table 2).  Table 3 shows the students' own spiritual practices. Among the most frequent of their daily spiritual practices were prayer (74%) and listening to relaxing music (56.3%), and the most frequent among their weekly practices were practice of religion (26.8%) and relaxation in nature (18.8%).

Nursing Students' Perceptions of Spirituality and Spiritual Care
The mean scores for the SSCRS are given in Table 4. The highest three mean scores were for item 2; 'I think that nurses can provide spiritual care by acting in a compassionate, concerned and positive manner while giving care' (mean 4.41˘0.88), item 14; 'I think that nurses can provide spiritual care by showing respect for the privacy, dignity, religion and cultural beliefs of a patient' (mean 4.10˘0.98) and item 17; 'I think that spirituality is a concept that includes morality' (mean 4.06˘0.94). The items with the lowest mean were item 5; "I think that spirituality is not concerned with belief in God or a supreme power and worship" (mean 2.82˘1.40), item 3; "I think that spirituality is only concerned with a need to forgive and be forgiven" (mean 3.42˘1.11) and item 13; "I think that spirituality does not involve areas such as art, creativity and self-expression" (mean 3.46˘1.23).

Associations between Independent Variables and SSCRS
Statistically significant relationships were found between nursing students' perceptions of spirituality and spiritual care and their age (r =´0.127, p = 0.01), gender (t = 3.143, p = 0.002), year of study (F = 3.333, p = 0.037), health perception (F = 3.178, p = 0.043), liking for the profession (t = 2.260, p = 0.024), state of knowledge of spirituality (t = 2.091, p = 0.037), view of spiritual care as necessary (Z =´2.737, p = 0.006), and view of education on it as necessary (t = 2.980, p = 0.003). The younger the students, the greater their mean scale scores were. Female students, second-year students, those who perceived their health as good, those who liked their profession, those who had knowledge of spirituality, and those who saw education in spiritual care and spirituality as necessary all had higher scale scores.
No statistically significant relationship was determined between the mean scale score and marital status, employment status, longest place of residence, family type, experience of stress in life, health perception, satisfaction with life, academic success, liking for the profession, direction by a teacher or responsible nurse to give spiritual care during practice, or the ability to meet the spiritual needs of patients or individuals (p > 0.05).

Variables Related to Nursing Students' Perception of Spirituality and Spiritual Care
Multiple regression analyses were calculated in order to explore the relationships between nursing students' perceptions of spirituality and spiritual care and variables. Assumptions of homogeneity of variance, linearity, normality, singularity, multicollinearity and heteroscedasticity were all tested and were found to be valid. Multiple regression showed that the combination of sociodemographic and spirituality-related variables was significantly related to nursing students' perceptions of spirituality and spiritual care (F = 4531, p < 0.001, R 2 = 0.09). Significant predictors of nursing students' perceptions of spirituality and spiritual care included gender, educational level and seeing spiritual care education as necessary (Table 5).

Knowledge and Practice of Spirituality and Spiritual Care
Insufficient knowledge of spirituality can cause nurses to perceive themselves as inadequate in spiritual care and to avoid spiritual care within nursing care [27,28]. In the present study, more than half of the students (53%) had the view that their knowledge of spirituality and spiritual care was inadequate. Similarly, it was determined in a study by Lopez that nursing students acted by relying on their own experience and intuition in applying spirituality-related practices [29]. This inadequacy of knowledge in relation to spiritual care in nursing students may be related to educational programs not according enough space to this topic or ignoring it. In support of this idea, previous studies have emphasized that spirituality is inadequately represented in nursing education [22,30,31]. As well as according a place to spirituality in nursing education as theory, nursing educators have important responsibilities in integrating spirituality into the educational program, in guiding the provision of spiritual care by students, and in providing role models [6,30]. However, it was found in this study that two out of three nursing students had not been directed by a teacher or responsible nurse to provide spiritual care.
In the literature, it has been reported that even though students have spiritual awareness of those to whom they are providing care, in practice they ignore spiritual care [32]. In this study, it was found that half of the students were able to meet the spiritual needs of patients or individuals in need of spiritual care, and that in meeting these needs they mostly listened, provided empathy, or gave psychological support. When assessed in this way, it can be said that the practices which nursing students apply to meet the spiritual care needs of patients were ignored when meeting individuals' needs in this dimension. Studies have determined that factors hindering nurses' provision of spiritual care are lack of knowledge, lack of clarity of their role in providing spiritual care, lack of time, a feeling of inadequacy in providing spiritual care, lack of education [4], burden of work, inadequacy of resources, and seeing it as low priority [7,33]. The barriers found in this study to nursing students providing spiritual care (lack of time, lack of knowledge, inadequacy of a place to carry it out, and giving priority to physical problems) are in accordance with the findings of previous studies. In the health system in Turkey, reasons such as pressure of work and the large numbers of patients to look after mean that spirituality is ignored in nursing care. It is seen that students are affected by this.
McSherry reported that spiritually active nurses were more sensitive to patients' spirituality [18], and Leeuwen and Akerman [17] and ve Shores [34] found that those who carried out religious activities had greater spiritual perception than those who did not. It is seen in many studies that the personal spirituality perception of nurses and nursing students and their self-spiritual practices have an effect on perceiving patients' spiritual needs, identifying them, and on how practices should be planned and applied [5,35,36]. In this study, the personal spiritual practices frequently carried out by the nursing students included prayer, listening to relaxing music and religious practices. In a study by Shores, 44% of students took part in religious activities once a week and 22% once a month [34]; it was reported in a study by Ross et al. that 60% of nursing and midwifery students prayed regularly daily or weekly, and 51% took part in religious gatherings [36]. These findings show that the spiritual practices of nursing students focus primarily upon religious practices [36]. It is thought that the differences in study findings are related to the culture, religious beliefs, and views and perceptions of spirituality of the nursing students.
Most of the students saw education in spirituality and spiritual care as necessary, and almost all of them stated that spiritual care should be part of nursing care. Also, a majority wanted information on the topic. In the same way, students in studies by Hsiao et al. [22] and McSherry et al. saw education in spirituality and spiritual care as necessary in the education program [37]. In a study by Tiew et al., however, few students thought that there should be spiritual care throughout nursing education [24]. When education in spirituality and spiritual care is integrated into the nursing students' education program or education is carried out on this topic, it is seen that knowledge of spirituality and spiritual care increases [5,20], spiritual awareness increases [6,8,19], attitudes toward spirituality improve and practice increases [5,20]. There is also an increase in the planning of spiritual care-giving [7], they write better about spirituality and a patient-centered approach is developed better [19], and the capacity of spiritual care-giving increases [38]. In Turkey, the concept of spiritual care in nursing education is included in the dimension of human needs in the philosophy of holistic care. Some schools offering nursing education have begun to teach the concept as a separate subject. However, changes in practical application have so far been inadequate [14]. Also, in the school where this study was conducted, spirituality and spiritual care are not taught as a separate subject and this topic is only mentioned in a few lessons, and it is thought that this is the reason why students feel the need for education on spiritual care and ask for information on it.

Perceptions of Spirituality and Spiritual Care
It is of great importance for nursing educators to know the spiritual perspectives of their students in order to ensure a connection between education and practice in spiritual care. It is emphasized in the literature that students who have spiritual awareness are more sensitive and better at giving spiritual care [34]. In this study, nursing students' perceptions concerning spirituality were "sufficiently" but not "very sufficiently" defined (mean 3.77˘0.54). These findings were similar to those of studies in the literature evaluating students' perceptions of spirituality and spiritual care: Wu in a study in Taiwan with 239 students found the items mean scores 4.00˘0.58 [31], and Ross found the items mean scores 3.99˘0.37 in a study with 531 students in four European countries [36]. In this regard, it can be said that nursing students have a need for information on spiritual care. When this need is met, students will realize the spiritual needs of the patients to whom they are providing care and the quality of nursing care will be improved [31].
It is noticeable that the two highest mean scores for the SSCRS of the nursing students in this study were for spirituality and spiritual care, while their two lowest scores were for religion. This result can be thought of as arising not only from the students' family, society and other elements, but also from the understanding of individual care which the students acquired in their education, and as showing that they regarded spirituality and spiritual care as important. However, the fact that the lowest scores were for religion does not show a similarity with previous studies carried out with nurses. In some studies, nurses equated spirituality with religion [4,33,39]. Wong and Yau, and Ross reported that when nurses were giving spiritual care they tended to focus on religious needs [4,40]. Yılmaz and Okyay explained this by saying that nurses emphasize the religious aspect of spirituality [14].

Variables Related to Perception of Spirituality and Spiritual Care
In this study, the variables which explained nursing students' perceptions of spirituality and spiritual care were found to be being female, being in the second year of education, and seeing spiritual care education as necessary. In the same way, Shores found that the spiritual perspective of female students was higher [34]. This finding was related to the idea that females tend to share their love more. It is known that low clinical experience results in a low spiritual care score. However, in this study, the scores of second-year students were found to be higher. This can be explained by their open perceptions and high awareness, because this was their first experience in clinical practice. It is to be expected that, along with these variables, the perceptions of spirituality and spiritual care of those who saw spiritual care education as necessary would be high.

Limitations
The findings of this study need to be considered in the light of several limitations. Firstly, the study was conducted with a small number of students, and thus generalization of the results to students in this country is weak. Secondly, although the students had spiritual awareness, it is true that they ignored spirituality in practice. For this reason, it is a limitation that spiritual practices were asked about in a limited way and were not observed. Finally, because there are few scales on spirituality and spiritual care which have been tested for validity and reliability in this country, findings on the topic were obtained in the study using one scale.

Conclusions
The research findings were that nursing students' perceptions of spirituality and spiritual care were "sufficient", although not "very sufficient". Being female, being in the second year of education and seeing spiritual care education as necessary were determinants of their perceptions of spirituality and spiritual care.
Even though these findings are limited, they provide a view of the perceptions of nursing students in Turkey. It is recommended that a comparison should be made of these findings with nursing students studying in other parts of Turkey or with nursing students in other countries. In addition, it is recommended that other variables apart from the findings of this study, which determine nursing students' perceptions of spirituality and spiritual care, should be demonstrated in future quantitative and qualitative studies. It is recommended that changes be made to educational curricula in order to improve nursing students' perceptions of spirituality and spiritual care, and to develop their spiritual care.