Carrying Hope ; Pre-Registration Nursing Students ’ Understanding and Awareness of Their Spiritual Needs from Their Experiences in Practice : A Grounded Theory Study

Spirituality is integral to health and wellbeing and a fundamental element of nursing care. Nonetheless, evidence suggests that spirituality is a frequently ignored aspect of nursing education and care. From 2008 to 2010 a Glaserian grounded theory design was used to explore and explain pre-registration nursing students’ personal understanding of their own spirituality and the relationship between experiences in clinical practice and spiritual awareness. While there is evidence that examines relevance of providing spiritual care to service users, at that time, minimal research has been undertaken to examine spiritual needs in pre-registration nursing students. A theory of carrying hope emerged from the findings to explain how pre-registration nursing students resolve clinical experiences with spiritual awareness. The findings identified that pre-registration nursing students’ awareness of spirituality can be explained in three main Basic Social Processes (BSPs): struggling, safeguarding and seeking. This study highlights the extreme personal challenge pre-registration nursing students experience as a result of their experiences in clinical practice and the impact this has upon their spiritual awareness. Recommendations from this study include the implementation of a model of pastoral care for tutors to support spiritual needs of during transition from student to registration.


Introduction
For the purpose of the study spirituality is defined as 'wider than religion, the inner 'self' that arouses feelings of love, faith, hope and trust that provide meaning, inner peace and purpose in life'; adapted from (Meyer 2003;Narayanasamy 2006).It is known that when individuals are exposed to emotional stress, illness and death; consciousness of spirituality is brought into focus (Narayanasamy et al. 2004).Standards for the education of pre-registration nursing students (Nursing and Midwifery Council NMC (2010)) recognise spirituality as a principle of person-centred care.Nonetheless, the relevance of spirituality in pre-registration nursing education is often ignored (McSherry and Ross 2002;McSherry 2010).In addition, the relationship between experiences in the clinical environment and personal spirituality, is recognised as being poorly understood (Ross 2006), particularly given that incidents can expose student nurses to the unpredictable and unexpected nature of clinical practice (Morrissette 2004).T A grounded theory study, as part of the requirements of a Clinical Doctorate (Nursing) sought to explore any interrelation between students' understanding and awareness of their spirituality and clinical experience.This paper details the findings and implications of the study.

Background
Within the UK context of health care provision and service, meeting the varied spiritual needs of patients, staff and visitors is fundamental to the care the National Health Service (NHS) provides (NHS Scotland 2009;NHS England 2015).An acknowledgement of spiritual need is often associated with mental health, subsequent therapeutic interventions and end of life care (DH 2011).
Spirituality is associated with differing meanings for differing individuals in differing contexts (McSherry et al. 2004).A number of theorists have outlined the central elements of spirituality.Carson (1989) suggests that there are vertical and horizontal elements to spirituality, the vertical being associated to a relationship with another higher 'God-like' being that transcends or goes beyond 'self'.While Florence Nightingale has been credited for associating nursing care with Christianity (Alligood and Tomey 2009); however, contemporary literature argues that spirituality within nursing is considered to be more than a religious concept (Carson 1989;McSherry 2010).Some individuals choose to celebrate their spirituality through a religious faith (DH 2011), faith becomes a framework of values and life style that link and mirror the vertical transcendent relationship with a God-like other (Carson 1989).Others may perceive spirituality in humanistic views of well-being and self-actualisation associated with personal openness, acceptance and empathy and intrinsic beliefs (Rogers 1983).As a phenomenon, whether spirituality exists or not, and the constituents or presentation of spirituality, has evaded the experts in nursing and health care.This uncertainty has led to a variety definitions of spirituality (Carson 1989;Narayanasamy 1993) and resulted in ambiguity associated with education of nurses in spiritual care (McSherry 2000).Carson (1989) is clear that the vertical element, the relationship with a 'God-like' other, is not necessarily associated with religious belief.The horizontal is associated with a framework and continuum of values that an individual chooses, consciously or unconsciously and around which life is organised (Carson 1989).This continuum reflects a various perspectives of spirituality, which are wide ranging and hold different meaning for different individuals.Resulting in a unique personal (Runcorn 2006) and often private (Gillman 2007) interpretation of personal spiritual belief.However expressed, the horizontal element of spirituality reflects deep personal meaning and belief about the way human life and society is organised and sustained (Gillman 2007;Brown and Garver 2009).
Within a nursing context spiritual dimensions are associated with caring and healing.(Nightingale 1915;Carson 1989;Watson 2008).Clark and Olson (2000) and Watson (2008) recognise that nurses hold a unique position as observers and assessors of human life.Further professional literature advises that teaching of spirituality is an essential to nurse education (Greenstreet 1999;McSherry 2000;Shih et al. 2001;Narayanasamy 2006), however, many nurses recall receiving little or no education on spiritual care during their training (Ross 1996;Narayanasamy 1993).Moreover, in contemporary nursing practice spirituality remains an off-limits phenomenon (Burnard 1998;McSherry 2010).Ross (2006) andde Souza et al. (2016) conclude that the personal emotions and experiences associated with spirituality are most appropriately explored using the qualitative paradigm.Yet, how pre-registration nursing students become aware of their spirituality and personal spiritual need, from experience in the clinical environment practice was unknown.While previous studies into spirituality and nursing have adopted both qualitative and quantitative approaches, none was identified that considered spirituality in relation to pre-registration students' clinical experience.

Methods
From a philosophical stance Mills et al. (2007) suggest that a chosen paradigm, such as grounded theory, often has fit with the researcher's own truths and beliefs about 'being' (ontology) and where and how knowledge is created (epistemology), suggesting that the researcher's ontological perspective will "shape their world" (Mills et al. 2007, p. 72).Consequently, grounded theory was identified as a meaningful way to describe and understand the complexities of pre-registration nursing students' spirituality.
Glaserian grounded theory design centres on identifying Basic Social Processes [BSPs].BSPs are fluctuating actions demonstrated by individuals as part of their interaction and relationship with an environment and between persons (Glaser 1996).The study set out to identify BSPs to describe and explain the complexities of pre-registration nursing students' spirituality in relation to experiences in clinical practice.The broad aims of the study were to:

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Explore pre-registration nursing students' personal meaning of spirituality.

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Identify how pre-registration nursing students might 'make sense' of their own spiritual needs.

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Enhance the teaching of spirituality in nursing.

Sample and Data Collection
The process of simultaneous data generation, collection and analysis is central to grounded theory.Nonetheless, as a starting position data is often gathered from a purposive sample (Birks and Mills 2011).Seven pre-registration nursing students were purposively sampled from a cohort of Diploma, Advanced Diploma and Bachelor of Nursing students at one university.Data collection was undertaken over a 2-year period in 2 stages: Stage 1: focus groups, stage 2: one-to one interviews.Of the seven students that agreed to participate, four attended each of the two discussion groups.Each discussion group consisted of two students.Data from the groups generated broad concepts about participants' belief systems and their own spirituality.Stage 2 involved individual participants in semi-structured/prompted one-to-one interviews building on data gleaned from the focus group transcripts.Interviews occurred at 4 to 6 monthly intervals.One male and six female students participated in total.Five students disclosed a personal spiritual influence or belief ranging from Christianity through to Buddhism and Paganism.

Analysis
The purpose of analysis in grounded theory is to identify a core variable that will inform a substantive theory (Glaser 1978).This study sought to explain how the participants gained an awareness of their spirituality from experiences in clinical practice.The semantics of grounded theory often differ from other qualitative research designs.Each grounded theorist uses slightly different terminology for the analysis, which can be confusing for those unfamiliar with the method (Stern 2016).Nathaniel and Andrews (2007) provide one of the clearest discussions.In grounded theory the main findings of the study are described as 'concepts' or 'categories'.Concepts and categories are in turn, made up of lesser concepts or 'properties'.The 'core category' is the central concept that pulls together concepts and properties.Properties and concepts are connected to each other and the core category by theoretical codes that provide a hypothesis, asking "How do these properties connect to these categories and how are the categories held by the core?" For a grounded theory data collection, theoretical sampling and analysis are on-going from the beginning of the study, searching for patterns within the data (Glaser 1996).An iterative analytical process was adapted from stages of constant comparative analysis (Glaser 1996).Each stage was then expanded and explored throughout the analysis, each step building on the previous.Iterative stages were described as:

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creating analytical units for coding (selective and theoretical), tentative concept formation through 'in vivo' coding and theoretical sampling • development of concepts that occurred as part of memo writing, diagramming and adopting gerunds • concept integration that involved returning to, and re-examining earlier data and expansion and classification of gerunds.
Each iteration included analysis and theoretical sampling of literature, thus further data were accumulated to develop categories.The diagrammatic representation of the analytical process in each stage can be seen in Table 1.
Table 1.Process of data analysis and integrating (Glaser 1996).

Creating analytical units
Gaining an overview of the data: Field notes, focus groups, interviews and artefacts To enable a sense of the data and participants' meanings to develop

Stage 1 Initial 'line-by-line' coding
To set in motion conceptualisation of ideas; certain codes will bring together meanings and actions from the data

Concept formation into tentative categories
'In vivo' codes identified To identify "participants' special terms" (Charmaz 2006, p. 55) Theoretical sampling To develop properties of the emerging categories

Identification of prompts for semi-structuring of interviews
To ensure that initial codes were further explored in subsequent interviews with participants

Second level coding, developing categories
To identify how various codes may or may not fit together

Memo writing and diagrams
To enhance the process and an understanding of social processes associated with spirituality and concepts that developed from coded data.

Adopting gerunds
To illuminate categories, explore basic social processes and foster theoretical sensitivity

Revisiting and re-examination of earlier data
To develop categories further and integrate data with data

Expansion of gerunds
To ensure saturation of all concepts and further explore abstraction

Developing categories through memo writing and theoretical notes
To increase the level of abstraction of ideas

Theoretical sorting
To help integrate and bring together data

Classification of gerunds using Roget's classification
To identify how a core category might be developed Using literature to develop categories An aspect of theoretical sampling that enables category development

Generating theory through writing
Initial analysis used line-by-line coding.As analysis progressed datum, including field notes were revisited to extract information that was then further blended with memo writing, facilitating further notions and ideas that could be coded and followed up or explored in subsequent data (Glaser 1978).During analysis field notes were blended with memo writing to fully explore and ask questions of the data.Field notes are flexible data and can be useful for helping a researcher to put into context different observations acquired during other data collection methods (Charmaz 2006).For this reason field notes have as much relevance and currency in the analytical process of grounded theory as accurate audio recordings (Schreiber and Stern 2001).As the transcripts were analysed, other data were sampled from literature surrounding superstitious and cultural beliefs, often practised within a health care setting (Cleary 2004).Stories of quest, myth and folklore, poetry and lyrics which have resonance with all things spiritual (Campbell 1988(Campbell , 1996) ) were identified through theoretical sampling and used to further explore the data.This theoretical sampling and analysis enriched identification of codes that were then converted into a gerund.A gerund is an English verb which ends in 'ing' but that primarily functions as a noun (Charmaz 2006).Gerunds were used to identify BSPs: for example fear became fearing, protect protecting and so forth.Where word processing could not convert a code, a thesaurus function was used to expand a code's meaning in an attempt to identify a linking gerund: for example precious became 'valued' leading to an associated gerund 'valuing'.In grounded theory it is essential that the theory should 'emerge and not be forced (Glaser 1996).Glaser (1978) advises the sorting of initial codes as an important aspect of to prevent forcing the data into inappropriate concepts.Glaser (1978) offers a selection of coding families to assist the researcher with establishing the main concepts(s) that bring the codes and categories together.Despite consideration of the coding families (Glaser 1978) to assist deeper interrogation of data, it became apparent that any attempt to sort using these families resulted in forcing the data.Consequently, consideration was given to Roget's Thesaurus as a tool to sort data.Roget's six primary classes contain numerous links to meanings and the context of words.These classes enabled theoretically sorting and conceptualisation of data, eliciting connections between codes, concepts and categories.The result was that over time a series of categories relating to nursing students' experiences and spirituality were produced, 'thus identifying the main story that revolves around a core category, [and illuminating] . . .relationships with other important categories' (Bohm 2004, p. 274).
While initial data collection with participants focused upon personal meaning of spirituality, this deeper analysis revealed that their response was to tell me about personal spiritual beliefs, fears and hopes.During analysis field notes were blended with memo writing to fully explore and ask questions of the data.Analysis of memos established that the word 'hope' featured significantly.Hope is found in Roget's Thesaurus under the classification of emotion, religion and morality (Kirkpatrick 2000) Further theoretical sampling and analysis revealed that hope is associated with 'faith, belief' and 'keeping ones' spirits up' (Kirkpatrick 2000, p. 328).
Another concept that was identified during analysis was the notion of movement.Moving through, journeying, pilgrimage and travelling are all properties that would account for a BSP that happened over time, as participants moved from one clinical area to another over the three year training.Theoretical sampling led to the gerund 'carrying'.The word 'carry' falls into several classifications in Roget's thesaurus, including motion and volition, associated with personal choice and decision (Kirkpatrick 2000).On-going analysis of data and theoretical sampling of the data identified a relationship between carrying and hope, thus establishing that carrying hope was the core problem that explained participants' attempts to resolve awareness of spiritual self with clinical experiences.Glaser (1996) suggests that a grounded theory should identify how problems relating to behaviour are resolved.The findings in this study were derived from problems relating to students' 'spiritual self' encountered while in the clinical environment and interpretation of how these problems are resolved (Glaser 1996(Glaser , 1998)).'Carrying hope' is resolved by categories identified during analysis as struggling, safeguarding and seeking.

Struggling
Struggling processes were evident in early interviews with participants.An example of this is illustrated from one participant: But I do find it's [spirituality] quite lacking, um, on the wards, like it's not really the sort of thing people discuss and um, there's a Liverpool Care Pathway and there's this whole spiritual section which normally is left blank and I struggle with that because I don't feel like I have been trained to kind of go through that section with patients but, um, to me that was the most important thing on the pathway but it's not usually addressed.Um, yes.So I just kind of want to learn a bit more about that.(R Interview 1, P3: 9-17) In the focus group students struggled to describe spirituality and when probed to define spirituality, there was a sense that it could not be defined: You can't because, you can't pin it to anything, actually.I can't pin it to anything.I wouldn't use the word, that's why it's interesting, but I feel I am in my understanding of the word and I can see other people are and I don't think other people read those things of each other.(Group 1: Student B: 3: 16-19) The category of struggling was also evident in the students grappled to reconcile and/or conceal their spirituality: Struggling was also evident as students coped with the diverse human situations they witnessed in the clinical setting: I found that incident . . .I was so angry at this man that had done that to her.I know nothing about her, nothing about him or what had gone on in their life but I was so . . .oh, it just wasn't fair.That's when I went home-all the way home I was fuming [laughs] and asking "why?"And then I started thinking, oh, my system's [Buddhist faith] failing me.Like, I'm getting angry again.(AM Interview 1: 23, 24-33) In these situations students looked to spirituality to prepare and protect from adverse experiences.As findings developed through theoretical sampling and constant comparison the BSP and category 'safeguarding' began to emerge.

Safeguarding
It became evident that students were aware of paradox in the clinical environment, identifying two opposing concepts, 'the good nurse' and the nurse who was too busy to care.
Um, and the first thing that I did was-I sort of noticed on-in-placement on my medical ward, I started noticing how people with sort of um, terminal diseases and things, especially cancer, they were sort of starting to almost resent their religion . . . . . .(AM Interview 1: 3: 29-32) . . .and the staff as well . . .If you ever got into group discussions with staff . . .Then I'd find the staff would say stuff like: "oh, how can you say there's a God when you've got all this round you?"I mean cancer and things like that.(AM, Interview 1. 4: 1-3) Um, but I found that a lot of-I don't know if I should say this . . .but a lot of the nurses didn't respect her [a dying patient] because of that decision that she'd made [to refuse medication and rely on her faith].Um, like, in private they were kind of like -um, I guess like laugh about it and think it's just ridiculous.(R, Interview 1. 5: 5-8) Students witnessed resource pressures experienced by qualified staff in busy clinical environments and believed this was why some staff 'lost' their spirituality.
Especially in some of the older staff that have been in nursing for a long long time, they seem to have lost that-I don't know what it is . . .Maybe not that they've lost their spirituality but um, they just go to work, do the job and come home.(AM, Interview 1. 19: 22-25) And-the functional nurses are really good at doing things-some things.But I think they'll probably burn out faster than the ones who have managed to come to some sort of sense of self by admitting that there is this intangible side to themselves and their work.(K, Interview 2. 17: 33-36) Students revealed certain safeguarding processes that protected their 'calling' into the profession and prevented 'losing' spirituality.Prayer was important to those who held a strong faith.
Um, I mean I'm praying for the patient really, that they're peaceful, that God can help them with their pain.Um, I mean, I don't know-my friend who was brought up as a Catholic said-he's a nurse-and he says he always prays when someone dies because, um, for protection, because he's heard that . . .spirits . . .like . . .can enter you and things like that.I'm really not sure what to think about that but I do pray for protection sometimes just in-just to make sure that like, I mean, I'm safe and the people with me are safe and that they-um-and the patient is kind of peaceful and things.(R. Interview 1. 8: 27-32 7 9: 1-2) Findings revealed that students became aware of, and could identify other nurses who were seen as 'safe' and who would recognise the need to safeguard personal spirituality and that of their patients: I've met a few other Christian nurses on placement but it's taken me a long time to actually discover that they are and it's only when I've kind of . . .hinted about my faith . . .that they've kind of hinted about theirs.It's quite secretive . . .(R Interview 1: 5: 8-11) ...And she said to me that she quite often walks around the cots at night and prays over the children.And I thought to myself, yea I do that as well but I wouldn't come out and say it because I'd think I might offend somebody.Yea.And she was saying, oh no I, I-once I did actually-one of the mums asked me what I was doing.I said-obviously it must have been visible what she was doing-and she said I just-I just told her.And she was completely fine about it.But she said to me: I don't know if I would be able to tell that to the senior people I work with.I don't know how they'd view it.And she'd been there for years.And I thought that was quite sad.(D Interview 2: 6: 30-36 and 7: 1-2) The narratives gave a sense that students were safeguarding their developing spiritual identity as they journeyed towards the end of their pre-registration programme.

Seeking
The final category revealed was 'seeking'.Students sought ways in which they could 'make sense' of their experiences to align with their spirituality.Seeking and searching are natural and instinctual human occupations connected to the spiritual (Clark 2000).Storytelling became a significant property of seeking.Using a story from practice students would attempt to explain meanings of spirituality.I called these stories 'defining stories', as when the story was told students would then seek affirmation that I understood (Table 2).The length of the storytelling process differed between students, depending upon the extent of emotional impact the event had upon them.The pattern of these stories was the same for each participant.

Trying to explain
Because the one with the flowers she was like on her last legs and . . .she'd wanted a window.She knew she was dying.She never did get to the window, be in the window.And she had her flowers.And I wasn't go to take them away

D'you know what I'm saying? Seeking affirmation
Students struggled to explain spirituality; articulating frustration and the hopelessness they experienced, particularly during the first year of the programme: ...but it's really hard if you've never experienced that, if you've never lost anybody or you've never lost like a limb or something coz I had a patient who just had an amputation and I was thinking I've no idea how to relate to that feeling so... (A, Group 1. 5: 5-8) Nonetheless, students expressed a realism of 'hope' for the present and the future as identified in this excerpt: ...being a nurse has changed the way that I live my life because, you know, it makes you realise how precious life is and how quickly it can be taken away from you.And how your family relationships are so important.I think when you're seeing that every day and you see some people with regrets-patients who have regrets or relatives with things they should have said or done, then it makes you think well at least if I stick by that rule now hopefully I won't have those regrets [laughs].(AM, Seeking processes displayed by the participants also included them identifying literature and research that related to spirituality, which helped them to make sense and reconcile their experiences of clinical practice with personal spirituality and hope.Despite linear presentation of categories in this paper, the pattern of processes exhibited by students may differ.However, struggling is an initial process that causes other processes to be called into action.Struggling, safeguarding and seeking are BSPs operating together within the single major process of carrying hope.

Discussion
This study set out to explore pre-registration student nurses understanding and awareness of their spiritual needs from experiences in practice.GT analysis identified that spirituality was difficult for pre-registration students to define within a nursing context.The participants had entered the profession, imagining a vocational and supportive context in which they would practice.When the imagined and supportive context became challenged, participants demonstrated struggling with spirituality.All they had hoped for in entering the profession was confronted and they experienced fear.Participants who identified with a belief/faith, initially kept their spirituality hidden.Like the poem 'a cross in my pocket' (Thomas n.d.).For these participants, spirituality acted as a talisman to protect them from uncertainty in the clinical environment.Their spirituality afforded dual safeguarding (for them and their patients); and needed protecting, to act as a defense in times of challenge or fear associated with the clinical environment.
Notwithstanding struggling, fearing and uncertainty surrounding revealing personal spirituality, participants understood spirituality as essential to nursing.Participants also recognised that loss of spirituality might lead to loss of hope and spiritual/professional burn out.This acknowledgment caused seeking behaviours such as storytelling that, in the longer term, supported and sustained spirituality provided resilience and augmented hope.As novices the 'hope' students carried was to become a qualified and good nurse.There were several points during the study when participants began to doubt their ability to continue and carry on their training.Suggesting that without means or method of carrying hope, there is potential for burn out and the spirit to be broken; resulting in loss of hope.
A broken, burnt out spirit and loss of hope poises a significant challenge for pre-registration nurses and those who participate in their education, particularly leaving the course, before completion i.e., attrition.While the reasons for attrition are multi-faceted and complex (Orton 2011), Last and Fulbrook (2003) suggest that personal stress and unrealistic expectations of, and experiences in the clinical environment can be a significant factor.Having identified risks to carrying hope, what support can educators of pre-registration nursing students offer?Tools, such as restorative supervision have been noted as being useful in managing anxiety and stress in the nursing profession (Wallbank and Robertson 2008), although Carver et al. (2007) advise that nursing students can hold uncertainties regarding formal clinical supervision.
An alternative to clinical supervision is the less formal concept of pastoral care.Pastoral care differs from formal supervision in not necessarily providing a solution to the issues the individual experiences (Swinton and Willows 2009).Pastoral care involves listening, supporting, and encouraging, representing a spiritual dimension of any caring professional relationship (Swinton and Willows 2009).Adequate pastoral care in pre-registration nursing programmes is an NMC (2010) requirement.In 2006 the DH advised that Higher Education Institutions who provide comprehensive pastoral care in pre-registration nursing programmes are less likely to experience high rates of attrition (DH 2006).While many personal tutors of pre-registration nursing students view pastoral support as key to their role with students, there is a tendency to focus upon academic performance and progression (Por and Barriball 2008).Yet Por and Barriball (2008) identified that next to practical academic support, students mostly require help with personal issues and problems that require signposting to appropriate counselling services.
The findings of this study suggest that storytelling played a significant role in articulating the stage of 'carrying hope' the participant experienced.Consequently, a model of pastoral care that utilises storytelling as a tool for sense making can enable personal tutors to guide students who require support to carry hope (Figure 1).This model (Figure 1) aims to assist the tutor, through the student's story, to explore with which element of carrying hope the student is experiencing difficulty.Acknowledging areas of spirituality with which the student may be struggling, the tutor could recognise an attempt to safeguard personal spirituality or that of others (colleagues, patient, carer) and assist 'seeking' behaviours.The representation of struggling, safeguarding and seeking as the colours red, amber and green; highlights which holds most risk with regard to progress through the process.Once the student begins 'seeking' they are more likely to manage carrying for themselves.This model of pastoral care highlights the spiritual needs of students and could enable a developing personal awareness of spirituality.As nurses and educators we have a moral duty to support spiritual needs and 'carry hope' for nursing students when, through fear, uncertainty and the unimagined, they are unable to do so.

Conclusions
This study used a Glaserian grounded theory design to explore and explain pre-registration nursing students' personal understanding of their own spirituality and the relationship between experiences in clinical practice.Findings identified that pre-registration nursing students' awareness of their spiritual needs can be explained in three main Basic Social Processes [BSPs]: struggling, safeguarding and seeking.When their spirit was at risk of becoming broken by negative experiences in clinical practice, then their hope to carry on was at risk and struggling, safeguarding and seeking were evident.These three concepts are integral to the theory that emerged from the findings: a theory of carrying hope that explains participants' resolve between clinical experiences and spiritual awareness.This study highlights the challenges associated with spiritual awareness for preregistration nursing students.A model of pastoral care to facilitate tutors supporting pre-registration nursing students may facilitate student's reconciliation of experiences in clinical practice to spirituality.Pastoral care could foster recognition of the link between 'hope' and 'awareness of spiritual need', not only for students but also those responsible for their education.Further empirical knowledge is required to appreciate the extent to which a model of pastoral care might enhance awareness of the spiritual need in pre-registration nursing students.
Key points for policy, practice and/or research This model (Figure 1) aims to assist the tutor, through the student's story, to explore with which element of carrying hope the student is experiencing difficulty.Acknowledging areas of spirituality with which the student may be struggling, the tutor could recognise an attempt to safeguard personal spirituality or that of others (colleagues, patient, carer) and assist 'seeking' behaviours.The representation of struggling, safeguarding and seeking as the colours red, amber and green; highlights which holds most risk with regard to progress through the process.Once the student begins 'seeking' they are more likely to manage carrying for themselves.This model of pastoral care highlights the spiritual needs of students and could enable a developing personal awareness of spirituality.As nurses and educators we have a moral duty to support spiritual needs and 'carry hope' for nursing students when, through fear, uncertainty and the unimagined, they are unable to do so.

Conclusions
This study used a Glaserian grounded theory design to explore and explain pre-registration nursing students' personal understanding of their own spirituality and the relationship between experiences in clinical practice.Findings identified that pre-registration nursing students' awareness of their spiritual needs can be explained in three main Basic Social Processes [BSPs]: struggling, safeguarding and seeking.When their spirit was at risk of becoming broken by negative experiences in clinical practice, then their hope to carry on was at risk and struggling, safeguarding and seeking were evident.These three concepts are integral to the theory that emerged from the findings: a theory of carrying hope that explains participants' resolve between clinical experiences and spiritual awareness.This study highlights the challenges associated with spiritual awareness for pre-registration nursing students.A model of pastoral care to facilitate tutors supporting pre-registration nursing students may facilitate student's reconciliation of experiences in clinical practice to spirituality.Pastoral care could foster recognition of the link between 'hope' and 'awareness of spiritual need', not only for students but also those responsible for their education.Further empirical knowledge is required to appreciate the extent to which a model of pastoral care might enhance awareness of the spiritual need in pre-registration nursing students.
Key points for policy, practice and/or research • Pre-registration nursing students' entitlement to receive spiritual care is no lesser or greater than any other individual.

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Strategies that support and nurture the spiritual needs of pre-registration nursing students and assist and support with "carrying hope" should be available in the educational or clinical environment.

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Future research is needed to explore the perceptions of pre-registration nursing students who claim no spiritual affiliation or spiritual awareness with regard to their understanding of spirituality within health care provision.

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Carrying Hope is a basic social process undertaken by human beings in times of transition.
Carrying hope includes struggling, safeguarding and seeking.Carrying hope enables individuals, groups or communities to continually accommodate a vision of the positive: expected, anticipated and imagined (all they had hoped for), when the vision threatens to morph into the negative: the unexpected, unanticipated and unimagined.If the process of carrying hope becomes too difficult, other(s)-individuals, groups or communities may need to support and assist in carrying hope.
Like . . .you can't, you can't impose your own faith on other people, um (Pause 0.03) I could pray for them in my head or when I'm not with them.I'd pray for me to know what to do, or the right words to say to them, and it's not always something that you're told or taught how to do when you're a student.

Figure 1 .
Figure 1.A model of pastoral care to support 'carrying hope'.

Table 2 .
An Example of a Defining Story from Participant B.

B Storytelling Stages and Pattern Because
. . .I wouldn't behave like that [Staff denying a patient a window bed and flowers].And I've realised you don't have to behave like that.Because I realise how important it is to a patient.