Issues in Mental Health Nursing, 22:593– 605, 2001

Copyright °c 2001 Taylor & Francis

0161-2840 /01 $12.00 + .00

A COMPARATIVE STUDY OF THE SPIRITUAL

PERSPECTIVES AND INTERVENTIONS OF
MENTAL HEALTH AND PARISH NURSES

Inez Tuck, PhD, RN

School of Nursing, Virginia Commonwealth University,
Richmond, Virginia, USA
Lisa Pullen, PhD, RN
Child and Family, Inc., Knoxville, Tennessee, USA
Debra Wallace, PhD, RN
College of Nursing, University of Tennessee, Knoxville,
Tennessee, USA

Spirituality is an integral part of holistic nursing practice.

Limited research has been done that explores nurses’
spirituality and the spiritual interventions they have made
with patients in their practice. Much of the extant research
has been done on nurses involved in terminal care such as
oncology and hospice nursing. This study explores spiritual
perspectives and spiritual nursing interventions in two
other nursing specialties that require holistic nursing care
as well: mental health and parish nurses. The Ž ndings
indicate that both groups report high spiritual perspective
scores and provide a variety of interventions to patients in
their practices.

From the time of Florence Nightingale, who referred to the human be-
ing in physical, psychological , environmental, and spiritual perspectives
(Nightingale , 1969 ), nurses have recognized that spiritual care is an im-
portant component of holistic nursing care. According to the American
Nurses Association (ANA, 1998 ), health is viewed not only as the ab-
sence of disease, but also as a sense of physical, social, psychological ,

Address correspondenc e to Inez Tuck, Virginia Commonwealth University, School of Nurs-

ing, 1220 East Broad Street, P.O. Box 980567, Richmond, VA 23298-0567 . E-mail: ituck@
hsc.vcu.edu

593
594 I. Tuck et al.

and spiritual well-being. The relationship of spirituality and health has

been an integral part of nursing from its inception and has gained in-
creased attention in recent years.
Numerous studies have indicated that, despite nurses’ acknowledged
belief in the value of spiritual care, they are often hesitant to provide
spiritual interventions (Cimino, 1992; Hall & Lanig, 1993; Tuck, Pullen,
& Lynn, 1997 ). Suggested reasons for this have been that nurses do not
feel educationally prepared (Narayansamy, 1993 ), that confusion exists
between the deŽ nitions of spirituality and religiousness (Emblen, 1992 ),
and that there is reluctance related to professional role deŽ nitions (Fry,
1998 ).
There are several specialties in nursing in which holism becomes a
central component of care. In addition, there are specialties in which
spirituality is commonly acknowledged as a factor for consideration in
planning care. The practice of oncology and hospice nurses often in-
volves the spiritual domain (Taylor, HighŽ eld, & Amenta, 1999 ). Like-
wise, parish nursing is deemed to have spirituality as part of acceptable
practice. Parish nursing is a growing specialty of nursing practice, which
focuses on the promotion of health within the context of the values, be-
liefs, and practices of a faith community, and which emphasizes the
relationship between faith and health (ANA, 1998 ). The intentional in-
corporation of the spiritual dimension and use of spiritual interventions
are integral components of parish nursing practice (Bergquist & King,
1994 ). In contrast, few instances of emphasis on spirituality in mental
health practice are reported. Mental health nurses wrestle with religios-
ity and spirituality while embracing the concept of holism. The purpose
of this study is to compare the spiritual perspectives of mental health
and parish nurses and describe their spiritual interventions in practice.

LITERATURE REVIEW

Although the literature supports that religion and spirituality are dis-
tinct (Emblen, 1992; Mahoney & Graci, 1999 ) with religion being related
to a speciŽ c belief system, there is some overlap in Ž ndings in relation to
health and well-being. Spirituality has been documented to be related to
health and well-being. Walton (1999 ) reported that, in patients recov-
ering from an acute myocardial infarction, spirituality provided inner
strength, comfort, peace, wellness, wholeness, and enhanced coping. In
studies of individuals living with HIV disease, spiritual well-being was
found to be signiŽ cantly related to psychologica l well-being (Coleman
& Holzemer, 1999; Tuck, McCain, & Elswick, 2001 ) and hardiness
 Spiritual Perspectives and Interventions 595

(Carson & Green, 1992 ). In a study of 121 participants, Fernsler, Klemm,

and Miller (1999 ) found that spiritual well-being helped to mitigate the
demands of illness imposed by colorectal cancer. Riley et al. (1998 )
reported that spirituality was positively related to quality of life and
life satisfaction in a convenience sample of 216 patients with chronic
illness.
The positive relationship of religion and well-being is well-docu-
mented. Koenig and Futterman (1996 ) examined 23 studies of the rela-
tionship between religiousness and well-being among older adults. In 21
studies, investigators found that persons who were more religious had
greater well-being. Strawbridge, Cohen, Shema, and Kaplan (1997 ) ex-
amined the long-term association between frequent religious attendance
and mortality over 28 years ( N D 5,283 ). Frequent attenders (more than
once a week ) had a lower mortality rate, and were more likely to stop
smoking, increase exercising, increase social contacts, and stay married.
Other longitudina l studies reported that frequent religious attendance or
religious involvement was associated with lower mortality (Hummer,
Rogers, Nam, & Ellison, 1999; Rogers, 1996 ). Ellison (1995 ), in a study
of religiosity, health status, and life satisfaction among black Americans
( N D 2,107 ), found that the association between religion and well-being
is consistent over the life course, and that greater religiosity is associated
with older age and being female, married, and Southern.
Recent studies have indicated that prayer and spiritual coping have
a positive effect on healing. In a study of 151 patients recovering from
coronary bypass surgery, researchers noted that patients who pursued
complementary approaches, particularly exercise and prayer, had better
postoperative psychologica l recovery (Ai, Peterson, & Bolling, 1997 )
and that private prayer appeared to signiŽ cantly decrease depression
and general distress in the same sample one year following surgery
(Ai, Dunkle, Peterson, & Bolling, 1998 ). Intercessory prayer was also
demonstrated to have a positive effect on 466 coronary care unit (CCU )
patients who received remote, intercessory prayer daily for four weeks
in a randomized, controlled study (Harris et al., 1999 ), even though
the patients were unaware that they were being prayed for. Compared
to a control group ( N D 524 ) who received no intercessory prayer,
prayer was associated with lower CCU course scores in the patients
who received the intervention.
Few studies have addressed spirituality in the context of mental health
nursing. Pullen, Tuck, and Mix (1996 ) found an overall high spiritual
perspective in a sample of 50 mental health nurses. Tuck, Pullen, and
Lynn (1997 ) described “being with,” “doing for,” and “encouraging the
client to look inward and outward” as categories of spiritual care reported
596 I. Tuck et al.

by mental health nurses and noted that the mental health nurses were
able to recognize spiritual needs.

PURPOSE AND RESEARCH QUESTIONS

The purpose of this comparative descriptive study was to examine

the spiritual perspectives of selected mental health and parish nurses to
identify their level of spiritual perspective and the speciŽ c interventions
provided to their clients. Spiritual perspective considers how one views a
relationship with God or a higher power and how meaningful spirituality
is in one’s life. Responses to items on the Spiritual Perspective Scale
(SPS ) indicated the importance of spirituality to the individual.
Spiritual interventions are self-deŽ ned activities performed by nurses
to meet the spiritual needs of their clients. The investigators did not
presuppose sufŽ cient knowledge existed to determine the potential range
of responses.
The following research questions guided the study: (1 ) Is there a
difference in the spiritual perspective of mental health and parish nurses
as measured by the SPS?; (2 ) What is the relationship of demographic
characteristics and SPS scores?; and (3 ) Are there differences in the
nature and type of spiritual interventions provided by mental health and
parish nurses?

METHOD

Sample

The total sample of mental health nurses ( N D 91 ) who resided

in a Southeastern metropolitan area were recruited at two data col-
lection points. All registered nurses (RNs; N D 84 ) employed at a
long-term public mental health facility were invited to participate in the
survey. A convenience sample of 50 RNs was obtained by the end of a
4-week study period, achieving a response rate of approximately 60%.
All registered nurses working in psychiatric settings at a local health
care system, including inpatient/acute care, outpatient/community men-
tal health centers, and adolescent residential facilities were also invited
to participate in the study ( N D 115 ). A convenience sample of 41 RNs
(36% response rate ) from these settings was obtained by the end of a
6-week study period.
A list of parish nurses who resided in the Southeastern United States
was obtained from parish nurse groups, educational programs, or through
a snowball technique of referral to obtain a sample of comparable size.
 Spiritual Perspectives and Interventions 597

Potential participants ( N D 236 ) were recruited by mail, with a response

rate of 48%. One hundred thirteen surveys were returned. Of these, 95
surveys had complete data and were included in data analysis.

Data Collection

Prior to data collection, protection of human participants was insured

and the study was approved by the participating institutions . Two instru-
ments were used to complete this research—an investigator-develope d
demographic survey and the SPS (Reed, 1986 ). The demographic survey
requested information about gender, age, race, education, and religious
afŽ liation. The SPS is a 10-item questionnair e using a 6-point Likert-type
scale to measure one’s spiritual perspective. This scale was developed
by Reed and has been used to study spiritual perspectives in terminally
ill, nonterminally ill, and healthy adults (Reed, 1987 ), persons living
with HIV (Tuck, McCain, & Elswick, 2001 ), and mental health nurses
(Pullen, Tuck, & Mix, 1996 ). The Ž rst four items measure the extent to
which one holds certain spiritual views; the remaining six items explore
how one engages in spiritually related interactions. Examples of items
on the scale include, “How often do you engage in private prayer or
meditation? ” and “My spiritual views have had an in uence upon my
life.” A mean score is derived for reporting purposes. Possible scores
range from 1 (low spiritual perspective ) to 6 (high spiritual perspective ).
Reed (1987 ) demonstrated criterion-discriminat e validity and reported
a Cronbach’s alpha coefŽ cient of .90, indicating high reliability.
In addition to completing the instruments, the participants were asked
to respond to three open-ended interrogative statements. The open-ended
statements were intended to elicit information about spiritual interven-
tions. In the Ž rst statement, nurses were asked to describe their percep-
tions of the “ideal” spiritual interventions that best support the needs of
patients. The second statement asked nurses to describe an instance in
which they provided spiritual care, and the third requested an interven-
tion made within the two weeks prior to survey completion.

Procedure

Mental health nurse participants were notiŽ ed of the purpose of the

study during staff meetings and offered the opportunity to voluntar-
ily participate in the study. Those consenting to participate were given
a packet including an information sheet about the study, the SPS, a
demographic questionnaire , and the interrogative statements to com-
plete. The researcher left the designated area for approximately 1 hour
598 I. Tuck et al.

while the participants completed the questionnaries . Completed ques-

tionnaires were placed in sealed, unmarked envelopes and returned
to the researcher. The process continued with small groups of nurses
in community mental health agencies over the 6-week period of data
collection.
As noted previously, data were collected from parish nurses using
mailed packets. Letters describing the study, a consent to participate
form, and the study surveys were sent to all potential participants on
the compiled list ( N D 236 ). Packets were numerically coded and, as
with the mental health nurse sample, anonymity and conŽ dentiality were
maintained throughout data collection, analysis, and reporting.

Data Analysis

Data were analyzed using the JMP° statistical software program

R

(JMP° Statistical Discovery Software, 2000 ). Descriptive statistics were

R

used to describe the sample. Data collected from the mental health nurses
from the two types of sites were collapsed into one group. Group means
and standard error (SE ) of SPS scores were obtained for the mental health
nurses and parish nurses, and results were examined for difference using
ANOVA. The total sample was divided into bivariate categories by age,
gender, race, education, and religious afŽ liation. Age was divided into
categories of 39 and younger or 40 and older, and education by pro-
fessional and technical nursing degrees. SPS scores were analyzed for
between-group variances. Finally, a linear model of demographic vari-
ables to predict SPS scores was derived as speciŽ ed by the parameters
of the JMP° software, again using the total sample.
R

The responses to the open-ended interrogative statements were re-

viewed by the investigators . These interventions were sorted by key
phrases in the responses and ranked by frequency of report. The results
of these independent analyses by the investigators were compared to
increase trustworthiness of the Ž ndings.

FINDINGS

The majority of the participants were Caucasian females. Compared

to mental health nurses, the parish nurses were older and had obtained
a higher level of education. As expected, 100% of the parish nurses
reported having a religious afŽ liation. Similarly, 98% of the mental
health nurses reported a religious afŽ liation. A full description of the
sample is provided in Table 1.
 Spiritual Perspectives and Interventions 599

TABLE 1. Demographic Characteristics of the Sample

Mental health nurses Parish nurses

N D 91 N D 95
Gender
Female 73 (80.3%) 92 (96.9%)
Male 16 (17.6%) 1 (1.1%)
Missing 2 (2.1%) 2 (2.0%)
Race
Caucasian 82 (90.1%) 87 (91.6%)
Other 9 (9.9%) 6 (6.3%)
Missing 2 (2.1%)
Religious afŽ liation
Yes 88 (96.7%) 95 (100%)
No 2 (2.1%) 0 (0%)
Missing 1 (1.2%)
Age
20 – 29 years 58 (63.7%) 2 (2.1%)
30 – 39 years 11 (12.1%) 10 (10.5%)
40 – 49 years 15 (16.5%) 24 (25.2%)
50 – 59 years 5 (5.5%) 39 (41.1%)
60 or older 2 (2.2%) 20 (21.1%)
Education
Diploma 33 (35.1%) 26 (27.7%)
A.D.N. 36 (39.5%) 17 (18.1%)
B.S.N. 15 (16.4%) 24 (25.5%)
M.S. 8 (9.0%) 26 (27.7%)
Ph.D. 0 (0%) 1 (1.0%)

Both groups reported a high spiritual perspective, although parish

nurses had a higher mean score on the SPS, with the mean being 5.31
(SE D .05 ) for mental health nurses and 5.74 (SE D .05 ) for parish
nurses. The difference in groups was signiŽ cant at p < :0001. The
other signiŽ cant group differences were age ( p < :0003 ) and gender
( p < :0005 ), though Ž ndings for gender must be interpreted cautiously
because of the small number ( N D 17 ) of males represented in the to-
tal sample. Mean spiritual perspective scores for nurses 39 years old or
younger ( N D 81 ) were 5.38 (SE D .05 ) and for nurses 40 years old or
older ( N D 105 ), 5.65 (SE D .05 ). Mean scores for females were 5.57
( N D 165, SE D .04 ) and for males, 5.12 ( N D 17, SE D .12 ). Addition-
ally, there was a variation in scores by race, with African-American par-
ticipants scoring slightly higher on the SPS (mean 5.76; SE D .13 ) than
Caucasian participants (mean 5.51; SE D .04 ), but the difference was not
600 I. Tuck et al.

TABLE 2. Comparison of SPS Scores by Category

Mean score
Group Frequency (range 1 – 6) Standard error
Nursing Specialty
Mental health nurses 91 5.31 ¤ .05
Parish nurses 95 5.74 ¤ .05
Age
39 years old or below 81 5.38 ¤¤ .05
40 years old or above 105 5.65 ¤¤ .05
Gender
Female 165 5.57 ¤¤¤ .04
Male 17 5.12 ¤¤¤ .12
Race
African American 15 5.76 .13
Caucasian 169 5.51 .04

Note: Differences signiŽ cant at: ¤ p < :0001, ¤¤ p < :0003, ¤¤¤ p < :0005.

statistically signiŽ cant in the bivariate analyses. Although these Ž ndings

may indicate a trend, the number of African-Americans represented in
the sample ( N D 15 ) was too small to provide proportionat e comparison.
See Table 2 for a summary of SPS scores by category.
The model used to predict variance in SPS scores indicated that race
( F D 4:17; p < :0426 ), and gender ( F D 5:37; p D :0216 ) are signif-
icant variables. Group membership was the most signiŽ cant predictor
( F D 29:03; p < :0001 ). These three variables accounted for 20% of the
variance in SPS scores. The JMP° program allows for unbalanced cell
R

size and corrects for bias in the noncentrality estimate (JMP° Statistical
R

Discovery Software, 2000 ).

Spiritual Interventions most frequently provided by each group were
reported for three different situations (ideal, general, and speciŽ c; see
Table 3 ). Mental health nurses believed that listening, referring, and en-
couraging were the interventions that best supported patients spiritually
(the ideal ). These interventions were included more frequently and were
often associated with others in the text. The following exemplars illus-
trate mental health nurses’ responses: “The best support to the patient
spiritually would be listening and acknowledging the patient’s concerns
or thoughts,” “When a patient is needing spiritual guidance, I will refer to
a minister, a preacher, or a priest;” and “: : : encouraging and facilitating
patients to explore their own value system.”
The three highest reported ideal interventions of parish nurses were
praying, listening, and touching: “Praying with and for members of the
 Spiritual Perspectives and Interventions 601

TABLE 3. Spiritual Interventions Reported by Mental Health and

Parish Nurses
Mental health nurses Parish nurses
N D 91 N D 95
Ideal or best
spiritual intervention Listening (18) Praying (45)
Referring (18) Listening (45)
Encouraging (12) Touching (12)
Praying (5) Being present (9)
Offering self (5) Being available (6)
Spiritual interventions
made in general Referring (11) Praying (52)
Encouraging (10) Listening (30)
Listening (9) Teaching (25)
Praying (9) Touching (12)
Spiritual interventions No intervention (21) Praying (26)
made in last 2 weeks Talking/counseling (11) Listening (21)
(speciŽ c) Praying (10) No intervention (16)
Listening (10) Supporting (12)
Note: Numbers in parentheses indicate the number of nurses who reported the
intervention. More than one response could be given.

parish is critical to spiritual care;” “: : : listening and presence, to be fully

present to each patient and to listen without judgment;” “: : : touching
the patient, holding patient, touching brow while praying.”
In general, mental health nurses reported using four interventions
more frequently: referring, encouraging, praying, and listening (see
Table 3 ). An example of referring and praying as an intervention follows:
I pray with my patients. At times (since I became Catholic) I have brought
communion, given a rosary, or arranged for another Eucharistic minister
to come and share communion with a patient. My faith and walk are now
much stronger and I don’t have the old misgivings about sharing my faith.

In this general category, Parish nurses reported praying, listening,

teaching, and touching. Teaching is illustrated by offering “programs on
healing and wholeness; healing services; newsletter articles on the re-
lationship between health/wholeness and spirituality ; [and] Bible study
on Jesus’ healing.”
Mental health nurses reported, talking or counseling, praying, and lis-
tening within the two weeks prior to completing the survey. Some nurses,
however, had provided no interventions within the past two weeks. An
602 I. Tuck et al.

example of talking as an intervention was provided by one mental health

nurse:
Talked with patient who was concerned about what she should do about
her son. Some delusional thinking was present. We talked about her spir-
itual belief and by turning her control over to her higher power, it would
take away her fears. She seemed to feel better.
Parish nurses reported their most frequent spiritual interventions in the
preceding two weeks to be praying, listening, and supporting, although
some of them had not provided any interventions during this time period.
Exemplars indicate several interventions such as visiting, listening, and
supporting as found in the following quote:
I was visiting with a woman 102C years who just within the last year had
come to know Jesus. She had some family members who did not like her
to talk about Jesus to them. I let her tell me how at night she stares up
at the ceiling and she can see Jesus there. I made the comment that this
must be comforting for her and she seemed very happy that I understood
what she was saying; she appeared relieved that I didn’t try to talk her
out of her vision as being a hallucination, etc. She held my hand for a
long time and seems more at ease now with the fact she may die soon.
Also, I said and did these things in full view of one of her family members
(a nonbeliever) so as to possibly set an example as to how she can support
the woman even if she doesn’t believe in Christ.

DISCUSSION

Mental health and parish nurses were selected from facilities in the
Southeastern United States, a region often referred to as the Bible Belt.
Virtually all (99% ) participants reported religious afŽ liation. These re-
sults may not be generalizable to all regions of the country where reli-
gious afŽ liation may not be acknowledged by all participants as in this
study. Although religious afŽ liation was high, there was no attempt to
measure the level of participation in religious activities. These nurses
reported high afŽ nity to spiritual views and connection with others as
evidenced by the scores on the SPS.
Nurses practice in patient situations in which spiritual care is a require-
ment. Mental health and parish nurses are concerned with helping people
“make meaning of their experiences,” and incorporating spirituality into
practice seems consistent with this goal. Parish nurses have chosen to
practice in an environment where spiritual interventions are expected.
Both groups of nurses reported a high spiritual perspective as measured
 Spiritual Perspectives and Interventions 603

by the SPS. A recent study by Taylor, HighŽ eld, and Amenta (1999 )
indicated that hospice nurses reported signiŽ cantly higher scores about
beliefs and attitudes of spiritual care than oncology nurses ( M D 40:5
and M D 38 respectively, p < .0001, range 10– 50 ). Although the mea-
sures are different, the Spiritual Care Perspective Scale (SCPS ) used in
the study by Taylor and colleagues and the Spiritual Perspective Scale
(SPS ) used in this study measured spirituality in groups of nurses in
those specialities in which spiritual beliefs, attitudes, and practices are
relevant.
The spiritual interventions made by the mental health and parish
nurses were similar with the intervention of prayer being reported by both
but more frequently by the parish nurses (the most frequently occurring
intervention ). However, the number of interventions reported by the two
groups are very different. In most instances, parish nurses made twice
as many interventions as mental health nurses. This is apparent with the
responses in all three situations, most notably the difference in the ideal
or best category. Analysis of data from interventions made within the
past two weeks indicate that mental health nurses are intervening less
frequently than parish nurses, with 31 interventions noted as compared
to 59 interventions by parish nurses. Referral to other professionals was
reported more frequently by mental health nurses, possibly indicating
concerns about scope of practice or spiritual intervention skills available.
These differences warrant examination in future studies.

CONCLUSION

Mental health and parish nurses reported high spiritual perspective

scores and provided a variety of spiritual interventions in their practices.
Nurses, in order to continue to provide spiritual care to patients, must
know the appropriate interventions , be able to identify interventions
that beneŽ t their patients, and select those that are suitable to the clinical
practice sites. Nurses’ acknowledgment of and comfort with their own
spirituality seems to be a critical factor in providing spiritual care. The
challenge for nursing in the future is to explore spiritual care outcomes
and to determine if nurses’ spirituality is a prerequisite for providing
effective spiritual care interventions.

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