Nurse Education Today 33 (2013) 574–579

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Nurse Education Today

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Student nurses' perspectives of spirituality and spiritual care

Lay Hwa Tiew a, b, c,⁎, Debra K. Creedy d, Moon Fai Chan c
a
Alexandra Hospital, Jurong Health Services, Singapore
b
Jurong Health Services, National University of Singapore, Singapore
c
Alice Lee Centre for Nursing Studies, National University of Singapore, Singapore
d
School of Psychology, University of Queensland, Australia

a r t i c l e i n f o s u m m a r y

Article history: Aim: To investigate nursing students' perceptions of spirituality and spiritual care.
Accepted 12 June 2012 Background: Spirituality is an essential part of holistic care but often neglected in practice. Barriers to spiritual
care include limited educational preparation, negative attitudes towards spirituality, confusion about nurses'
Keywords: role, perceptions of incompetence and avoidance of spiritual matters. There is limited knowledge about
Spirituality students' perspectives of spirituality and spiritual care. Previous studies have predominantly focused on
Spiritual-care
educational approaches to enhance spirituality. The next generation of clinicians may have different world-
Perceptions
Attitudes
views, cultural beliefs and values about spirituality and spiritual care from current nurses. There is a need
Student-nurses to understand students' views and how their spiritual development is shaped in order to inform
pre-registration education.
Method: A cross-sectional survey of final-year students from three educational institutions in Singapore was
conducted from April to August 2010. Data included demographic details and responses on a new composite
tool, the Spiritual Care Giving Scale (SCGS).
Results: A response rate of 61.9% (n = 745 out of 1204) was achieved. The lowest mean score was item 9,
“Without spirituality, a person is not considered whole”. Highest mean was item 2, “Spirituality is an impor-
tant aspect of human being”. Factor 5 (Spiritual Care Values) had the lowest mean with Factor 2 (Spirituality
Perspectives) the highest. Participants considered spirituality as essential to being human; developmental in
nature; and vital for individuals' state of well-being. Attributes important for spiritual care were identified.
Multivariate analyses showed positive association between participants' scores and institution but not with
other variables.
Conclusion: Participating student nurses reported a high level of spiritual awareness that was not constrained
by age. Students affirmed the importance of spiritual awareness in order to address the spiritual needs of
patients. There was some congruence between the perceptions of students in this ethno-culturally diverse
Asian sample and responses by students in the UK and North America on the personal attributes needed to
provide spiritual care. Comparative studies using the SCGS could inform our understanding of spirituality
and best pedagogical approaches to develop spiritual awareness across the curricula and in clinical practice.
© 2012 Elsevier Ltd. All rights reserved.

Introduction importance of meaning, purpose, hope and relatedness for individuals

Health is a holistic concept that incorporates physical, social, cultural,
emotional and spiritual dimensions (Chan, 2009). Of these dimensions,
spirituality is least understood and most contested. Spirituality is a
vague, poorly defined term, but Swinton and Pattison (2010) argue
that this lack of clarity is a strength that can have powerful clinical
implications. Spiritual care in all its diverse forms can highlight the
⁎ Corresponding author at: Alice Lee Centre for Nursing Studies, National University
of Singapore, Level 2, Clinical Research Centre, Block MD 11, 10 Medical Drive,
Singapore 117597, Singapore. Tel.: + 65 9782 7309 (day time contact number);
fax: + 65 6776 7135.
E-mail addresses: nurtlh@nus.edu.sg, lay_hwa_tiew@juronghealth.com.sg
(L.H. Tiew).
experiencing illness. Over the past 30 years, there has been growing
recognition of the importance of spirituality in nursing but little exami-
nation of how spirituality is taught, understood and applied in practice
by student nurses about to embark on their professional careers.
Background
Literature related to spirituality in nursing education is sparse. The
lack of attention to spirituality in the undergraduate curriculum may
be similar to barriers often cited by nurses in practice. These barriers
include a lack of knowledge, a lack of time, failure by staff to be in
touch with their own spirituality, confusion about the nurse's role in
providing spiritual care, and fear of imposing their own philosophy
on others (Hubbell et al., 2006; Milligan, 2004). In other studies,

0260-6917/$ – see front matter © 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.nedt.2012.06.007
 L.H. Tiew et al. / Nurse Education Today 33 (2013) 574–579
nurses reported a lack of competence to deliver spiritual care
(Stranahan, 2001; Hubbell et al., 2006). Some authors suggest that in-
adequate preparation may contribute to nurses' perceptions of
incompetence and avoidance of spiritual matters in practice (Taylor,
2008; Baldacchino, 2008; McSherry, 2007).
Previous studies have predominantly investigated the challenges
faced by registered nurses in spiritual care-giving, but there is a lack
of research about pre-registration nursing students' understanding
and experiences (Chism and Magnan, 2009; McSherry et al., 2008).
Available studies with pre-registration students have focussed pre-
dominantly on educational issues. One study described teaching
strategies to enhance students' spiritual sensitivity (Cantanzaro and
McMullen, 2001), while a review of the literature identified that reflec-
tion in clinical practice was an important process to enhance spiritual
practice (Greenstreet, 1999). Another study surveyed baccalaureate
nursing programmes (n= 132) to identify how the concept of spiritual-
ity was addressed in curricula (Lemmer, 2002).
Few studies have surveyed students about their understanding of spir-
ituality and spiritual practice. Of the few available studies, it was reported
that nursing students are inclined to rely on their own experiential under-
standing and intuition about spirituality and how it may be applied in
practice (Pesut, 2002; Hoffert et al., 2007). McSherry et al. (2008)
reported that students hold diverse views about what constitutes spiritu-
ality with the majority adopting an existential, holistic and integrated
concept of spirituality. Some students had defined views about spiritual-
ity; felt that spirituality was a personal matter and that nursing lecturers
should not attempt to influence their beliefs (McSherry et al., 2008).
Most of these studies with students were conducted in either
North America or the United Kingdom with homogenous samples
and reflect a Judeo–Christian perspective (Tiew and Creedy, 2011).
To fully understand and describe the meaning of spirituality and spir-
itual care/needs, further research should include culturally and reli-
giously diverse samples and perspectives (Conner and Eller, 2004;
Creel, 2007). Studies conducted in Hong Kong and Taiwan, for exam-
ple, indicated differences between Western and Chinese cultures on
spirituality, spiritual needs, and desired spiritual care (Mok et al.,
2009; Shih et al., 2001).
It is also possible that the new generation of students may have
different worldviews, cultural beliefs and values about spirituality
and spiritual care from those of current nurses. There is a need to un-
derstand students' views and how their spiritual development is
shaped in order to inform content and learning experiences offered
in pre-registration education (Hart and Ailoae, 2007).
Of specific interest to this present study are students' perspectives
of spiritual practice in Singapore healthcare, the extent of patients'
spiritual needs, and support received from healthcare professionals
in students' development of their practice. Singapore is a multicultur-
al society. The majority of its population is Chinese, followed by
Malay and Indian with an even broader multicultural workforce. In
1990, nursing education in Singapore evolved from a hospital-based
apprenticeship system to a diploma programme and then to a degree
in nursing in 2006. Therefore, the educational preparation of nurses
in the workforce is varied and little is known generally about spiritual
education and practice in Singapore.
The Study
Aim
This study aims to explore final-year undergraduate student
nurses' perspectives of spirituality and spiritual care-giving.
Objectives
1. Describe student nurses' understanding of spirituality and spiritual
care.
575
2. Examine relationships between students' demographic character-
istics, and spirituality and spiritual care.
Design
A descriptive, cross sectional design was used.
Participants
Convenience sampling was used to recruit from the three educa-
tional institutions (two polytechnics and a university) in Singapore.
Inclusion criteria were final-year nursing students undertaking a
diploma or degree leading to nursing registration.
Instrument
The survey consisted of a demographic information form and the
Spiritual Care-Giving Scale (SCGS). The SCGS was developed because
of limitations of existing scales. There is no one composite tool that
measures all spiritual dimensions; and existing instruments were pre-
dominantly developed and used with homogenous samples and from
cultures with dominant Judeo–Christian beliefs (Tiew and Creedy,
2011). Through a critical review of the literature (Tiew and Creedy,
2011), themes drawn from a qualitative study (Tiew and Drury,
2012), and testing with a large cohort of student nurses contributes to
the ability of SCGS to assess perceptions of spirituality in a culturally rel-
evant way. This paper presents results drawn from a larger programme
of work to develop a culturally relevant spiritual assessment scale (Tiew
and Creedy, 2012).
The SCGS is a 35-item instrument with 5 factors: Attributes for
Spiritual Care (Factor 1); Spiritual Perspectives (Factor 2); Defining
Spiritual Care (Factor 3); Spiritual Care Attitudes (Factor 4); and Spir-
itual Care Values (Factor 5). The SCGS uses a 6-point Likert scale with
responses ranging from one (strongly disagree) to six (strongly
agree). See Appendix 1. The SCGS has a Cronbach alpha of 0.96 and
significant reliability (r = 0.811; p b 0.01) (Tiew and Creedy, 2012).
Data Collection Procedure
Data collection occurred between April and August 2010. The
researcher addressed each student cohort at the end of a class. The
purpose of the study and procedures were explained and questions
taken. Participants were informed of their right not to participate
and withdraw at any time without prejudice. Participants submitted
the completed survey form into a locked box located in their school
administration office.
Ethics Approval
Approval for the study was granted by the National University of
Singapore Institutional Review Board (IRB) and the three participat-
ing educational institutions.
Approach to Analysis
Descriptive statistics were used to explore the sample profile and
scores they obtained for each item. Pearson's product–moment correla-
tion, t-test, and ANOVA were used to test any significant association/
difference on the samples' average total SCGS scores to demographic
characteristics. Data were analyzed using the Statistical Package for
the Social Sciences (SPSS) 17.0 (2009) personal computer version
and significance was set at p b 0.05.
576 L.H. Tiew et al. / Nurse Education Today 33 (2013) 574–579

Results
Profile of the Study Sample
The survey response rate was 61.9% (745/1204). The majority of
respondents were female (86.4%), single (95.2%), median age 21 years,
who nominated a religious affiliation (75.2%) and were from diverse
ethno-cultural backgrounds (69.3% Singaporeans, 8.1% Malaysians,
15.6% People's Republic of China and 7.1% from other nationalities).
Most respondents (66%) were Chinese, the rest were Malays (19%),
Indians (8%) and Others (7%) (see Table 1).
Student Responses on the Spiritual Care-Giving Scale
The average item mean value on the SCGS was 4.54 (SD = 0.98)
reflecting a high level of agreement. The item with the lowest mean
was item 9 “Without spirituality, a person is not considered whole”
(mean=3.95, SD=1.36), and the highest mean was item 2, “Spirituality
is an important aspect of human being” (mean = 4.82, SD = 0.95).
Mean values were also computed for each factor. Mean value for Fac-
tor 1 was 4.63 (SD = 0.93); 4.7 (SD = 0.96) for Factor 2; 4.66 (SD =
0.93) for Factor 3; 4.35 (SD = 1.01) for Factor 4, and 4.23 (SD =
1.16) for Factor 5. Factor 2 (Spirituality Perspectives) had the highest
mean value indicating consistent agreement about the nature of
spirituality.
The highest mean score in Factor 1 “Attributes for Spiritual Care”
reflected participants' agreement that establishing a trusting nurse–
patient relationship was important for spiritual care. In Factor 2,
“Spirituality Perspectives,” the item with the highest mean score
revealed participants' view of spirituality as an important aspect of
being human. In Factor 3 “Defining Spiritual Care”, the item describ-
ing spiritual care as a process and not a one-time event or activity
achieved the highest mean score. The highest mean score in Factor
4 — “Spiritual Care Attitudes” was participants' belief that spiritual
care was important because it gave patients hope. Responses on Fac-
tor 5 “Spiritual Care Values” identified that students believed spiritual
care was an important part of holistic nursing care (see Table 2).
Associations Between Demographic Characteristics and Perceptions of
Spirituality
There was a positive but weak relationship between age and the
average total SCGS score (r = 0.088, p = 0.017). There were no signif-
icant differences on the average total SCGS score and gender (t =
0.077, p = 0.368), religious beliefs (t = − 0.334, p = 0.487), race
(F = 0.682, p = 0.564), and nationality (F = 1.019, p = 0.384). Howev-
er, there was a significant difference on SCGS score and different type
of programme. The mean SCGS score for diploma students was 168.45
(SD = 22.22), which was lower than the score indicated by degree
students (mean = 176.68, SD = 18.72; t = − 2.93, p = 0.004). The ef-
fect size between degree and diploma programme was significant at
0.375. Additionally, there was a significant difference in item mean
scores for different sites (Site A: mean = 4.54, SD = 0.61; Site B:
mean = 4.44, SD = 0.66; Site C: mean = 4.7, SD = 0.53; F = 5.557,
p = 0.004). Post-hoc analysis showed a significant difference between
Table 2
Scores of samples on the Spiritual Care-Giving Scale scalesa (n = 745).
Mean SD

Factor 1 4.63 0.928

Q27 Individual definiton_SC 4.66 0.987
Table 1 Q28 Nurses' spiritual awareness_SC 4.58 0.936
Sample profile (n = 745). Q29 Individuals' awareness of spirituality_SC 4.61 1.036
Q33 Experience_SC 4.52 0.950
Demographic n %
Q36 Life Experiences_SC 4.66 0.932
Age (years) Q37 Coping_SC 4.71 0.925
≥18 to 25 709 95.2 Q38 Empathy_SC 4.62 0.930
≥26 to 35 23 3.1 Q39 Trusting relationship_SC 4.71 0.963
≥36 to 55 13 1.7 Factor 2 4.70 0.969
Mean ± SD 21 ± 3.718 Q1 Universal_Sp 4.61 1.094
Type of religion Q2 Human being_Sp 4.82 0.950
No 185 24.8 Q3 Energy_Sp 4.72 0.920
Yes 560 75.2 Q4 Inner feelings_Sp 4.72 0.894
Christians 175 23.5 Q5 Innate_Sp 4.81 0.892
Muslims 159 21.3 Q6 Meaning of good and bad events in life_Sp 4.49 1.025
Buddhists 177 23.8 Q7 Emotional well-being_Sp 4.71 0.982
Hindus 22 3.0 Q8 Answers about purpose in life_Sp 4.69 0.996
Sikhs 3 0.4 Factor 3 4.66 0.930
Taoists 19 2.6 Q14 Process_SC1 4.73 0.949
Others 5 0.7 Q15 Respect religious beliefs_SC1 4.71 0.978
Gender Q16 Sensitivity and intuition_SC1 4.70 0.860
Male 101 13.6 Q17 Being/presence_SC1 4.34 1.033
Female 644 86.4 Q18 Respect cultural beliefs_SC1 4.76 0.948
Nationality Q19 Listen_SC1 4.72 0.934
Singaporeans 516 69.3 Q26 Respect dignity_SC 4.66 0.987
Malaysians 60 8.1 Factor 4 4.35 1.010
People's Republic of China 116 15.6 Q21 Believes SC gives meaning and hope_Att 4.52 0.939
Myanmar 53 7.1 Q22 SC Facilitates religious support_Att 4.49 0.917
Race Q24 Feels comfortable to provide SC_Att 4.17 1.037
Chinese 490 66.0 Q31 Reinforced in nursing education_Att 4.06 1.090
Malays 145 19.0 Q32 Reinforced in nursing practice_Att 4.25 0.853
Indians 57 8.0 Q40 SC is team effort_SC 4.39 1.067
Others 53 7.0 Q35 SC is important because it gives hope_Att 4.59 0.961
Marital status Factor 5 4.23 1.160
Married 32 4.3 Q9 Holistic care_SCV 3.95 1.357
Divorced 3 0.4 Q10 Connecting oneself with nature and others_SCV 4.25 1.146
Separated 1 0.1 Q11 Integral aspect of human being_SCV 4.61 0.986
Single 709 95.2 Q12 Spiritual care > than religious care_SCV 4.15 1.255
Sites Q13 Good nursing care = spiritual care_SCV 4.20 1.074
A (polytechnic) 426 57 Average item mean 4.54 0.989
B (polytechnic) 253 34 a
Range for each item is from 1 (strongly disagree) to 6 (strongly agree), the higher
C (polytechnic) 66 9
the scores, the higher the agreement.
 L.H. Tiew et al. / Nurse Education Today 33 (2013) 574–579
Site C vs. Site B (p = 0.001) and Site A vs. Site B (p = 0.04). The effect
size between the three sites was 0.0137.
Discussion
This work represents the only study conducted in Singapore that
investigated nursing students' perspectives about spirituality and
spiritual care. Studies conducted with nursing students in other coun-
tries, have predominantly focussed on the effects of spiritual educa-
tion on attitudes. Moreover these studies were usually conducted in
western countries with homogenous samples of students attending
religious-affiliated institutions. Findings of the present study with
an ethno-culturally diverse sample contribute to our understanding
of the universality of spirituality.
Students' Perceptions of Spirituality
Overall, participating students scored high on the SCGS. In Factor
1, Attributes for Spiritual Care, participants generally expressed
agreement with the concept that spirituality is innate and universal,
but fewer agreed that a person is not considered whole if they do
not have spirituality (item 9). It could be that this statement did not
adequately reflect the ideological perspective of participants. Spiritual
perspectives appeared to be humanistic in nature (item 2). The views
of respondents closely reflected that of Sanders (2002) who proposed
that individuals' spiritual values imbue virtues such as caring, com-
passion, love of humanity, and engagement with people.
Similarly, in Attributes for Spiritual Care (Factor 1), participants
indicated agreement about the humanistic attributes such as spiritual
awareness, empathy, and establishing trust required for spiritual care.
Students considered these attributes important precursors for spiritu-
al care. This finding was consistent with other studies of registered
nurses and affirmed the importance of spiritual awareness before
nurses can address the spiritual needs of patients (e.g. Pesut and
Reimer-Kirkham, 2010; McSherry et al., 2004).
For Factor 2 (Spirituality Perspectives), responses revealed a high
level of agreement with conceptualisations of spirituality and spiri-
tual care. For example, participants consistently agreed with the
notion of spirituality as (1) characteristic of being human; (2) devel-
opmental; (3) a unifying force to find meaning and purpose in life,
and (4) a peaceful state of well-being attained through transcending
and connecting with the external environment. These findings reveal
a heightened sense of spiritual awareness by this cohort of young (me-
dian age was 21 years) nursing students from diverse ethno-cultural
backgrounds. This result highlights the need to dispel a commonly
held belief that spirituality develops with age (MacKinlay, 2008;
Ahmadi, 2000; McFadden, 1999). Participating student nurses reported
a high level of spiritual awareness that was not constrained by age. The
results suggest that perhaps student nurses do not become “more” spir-
itual with age but rather deeper insights are gained.
Although students valued spirituality and acknowledged the sig-
nificance of spiritual care, survey results indicated difficulties in its
application in practice. Controversy about the definition of spirituality
has contributed to a lack of understanding and poor application in
practice (McSherry, 2007). Historically, the roots of spirituality can
be traced from religion. Medical and nursing services were tradition-
ally offered by members of religious orders of various denominations
(Modjarrad, 2004). Previous studies reported that nurses expressed
discomfort with the spiritual aspects of care and maintained that re-
ligious clerics and counsellors with expertise in spirituality should
take responsibility (McClung et al., 2006). Participants identified the
importance of supporting and nurturing their own spiritual well-being
as reported in item 4 (Spirituality is an expression of one's inner feelings
that affect behaviour). Students considered that certain attributes, such as
empathy and critical reflection need to be nurtured to enhance spiritual
development and care-giving. This nurtured development is important
577
because when one is content and whole, the “self” is able to better
understand and focus on the concerns of others when offering spiri-
tual care (Burkhart and Hogan, 2008; Carr, 2008; Kendrick and
Robinson, 2000).
Factor 3 (Defining Spiritual Care) revealed that students perceived
spiritual care as relational and that this relationship developed over
time with the patient. Although the assessment of spiritual needs is
an aspect of spiritual care, student nurses did not perceive this. Item
17 (being with the patient) scored the lowest mean value and may
be attributed to students' observations of nursing practice in the clin-
ical setting. In the Singaporean health care system, nurses are encour-
aged to be “busy” to a point where they may become task-oriented
and may neglect the emotional and spiritual dimensions of care. It
could be that students had an inadequate understanding of what spir-
itual care entails and did not equate meaningful conversation with
spiritual care.
In Factor 4 (Spiritual Care Attitudes) respondents valued the im-
portance of a team effort in the provision of spiritual care (item 40).
Students learnt about teamwork in their nursing programme and
may have considered this approach to be applicable in spiritual care
too. There is also a possibility that participants recognised their limi-
tations and comfort level to provide spiritual care and viewed the
multidisciplinary approach as a means of support for their practice.
This result is encouraging given that previous studies suggest that
the poor integration of spirituality in practice may be due to misinter-
pretations of a multidisciplinary approach to spiritual care from an
“ownership” instead of a “collaborative” perspective (Hubbell et al.,
2006; Koenig et al., 2004), further abrogating nurses' role in spiritual
care.
Students agreed about the importance of spiritual care in provid-
ing hope to patients, but fewer respondents agreed that spiritual
care should be addressed throughout their nursing education pro-
gramme. It is often assumed that spiritual education is essential for
the development of spiritual care giving abilities (Hoffert et al.,
2007; Meyer, 2003). Although some Nursing boards responsible for
programme accreditation do encourage the inclusion of spiritual
care as a core competency for nurses, this is not the case in all coun-
tries, and currently does not occur in Singapore. The results of the
present study suggest that rather than formal class-based activities,
individual reflection, spiritual guidance, experiential activities and
in-depth discussion in small groups in the clinical setting may be
more effective learning strategies. These pedagogical approaches
can be documented in curriculum documents and reviewed according
to feedback and learning outcomes. Importantly, other authors have
proposed that spiritual care and role-modelling need to be positively
reinforced in the educational institution in order to promote the de-
velopment of spiritual care abilities (Burkhart and Hogan, 2008;
Ross, 2006; Vance, 2001).
Responses to items related to Spiritual Care Values (Factor 5)
scored the lowest overall mean score on the SCGS. Participants did
value the importance of spiritual care (item 11) and this finding is
consistent with other studies (McSherry et al., 2008; Wallace et al.,
2008; Pesut, 2002). But there was less consistency in responses across
other items. For example, respondents' lowest score was on item 9
which stated that “without spirituality, a person is not considered
whole”. Although students readily agreed with items related to the
nature of spiritual care, their views on the values inherent within
spirituality are more individualised.
Factors Associated with Perceptions of Spirituality
There was a positive and significant relationship between SCGS
scores and the programme being undertaken by participants. Al-
though, the three educational institutions reported not offering spiri-
tuality as a “stand-alone” module, two institutions commented that
spirituality “runs through the teaching programme.” As only one
578 L.H. Tiew et al. / Nurse Education Today 33 (2013) 574–579

institution gave permission to assess the curriculum, a comparison of
programme content could not be conducted. It could be that spiritual
care and role-modelling were not positively reinforced in one partic-
ipating polytechnic institution where the students were studying. The
influence of the learning environment on the development of spiritu-
ality has been postulated in other studies (e.g., Baldacchino, 2008;
Meyer, 2003).
The degree programme offers a more broad-based curriculum that
encourages students to select electives from other disciplines to deepen
their personal and professional development. Delaney (2005) affirmed
that individual's spiritual awareness is enhanced and facilitated by
self-knowledge, self-reflection, and journaling. It is through these
activities that individuals are able to transcend and connect with their
external environment, thereby fostering and enhancing their spiritual
perspectives.
America. There was some congruence between the views of this
group of 3rd year undergraduate students and results of other studies
with students and practising nurses. A novel finding is that partici-
pants considered spirituality as an inherent part of being human; de-
velopmental in nature; and vital for well-being. Personal attributes
were viewed as important for spiritual care. Participants undertaking
the degree programme reported a different personal and professional
understanding and awareness of spirituality than students in the di-
ploma programmes. This could be related to student qualities (such
as level of academic achievement) and academic environment such
as experience of faculty, and pedagogy that encourages critical reflec-
tion and engagement. However, understanding spirituality and spiri-
tual care does not equate with translation into practice and further
attention needs to be given to minimize barriers to spiritual care in
practice.

Limitations
Appendix 1. Part 2: Spiritual Care-giving Scale (SCGS)
The findings of this study need to be considered in light of several
limitations. Firstly, participants were recruited from one cohort of For each item, please tick one answer which best reflects the ex-
final-year nursing students across three educational institutions in tent to which you agree or disagree with it.
Singapore and may not be generalised to other countries. Compara-
tive research with students from other Asian countries may reveal
SD (1): Strongly Disagree D (2): Disagree MD (3): Mildly Disagree
the extent to which the perceptions identified in the current study MA (4): Mildly Agree A (5): Agree SA (6): Strongly Agree
are shared across settings. Further, as this was a convenience sample, Items SD D MD MA A SA
participants who volunteered in this study may have a vested interest 1 Everyone has spirituality.
in this topic. Their views may differ from other students who did not 2 Spirituality is an important aspect
volunteer; however, the good response rate may minimize this effect. of human beings.
3 Spirituality is part of a unifying
There is also the possibility that participants wanted to receive the
force which enables individuals to
approval of their lecturers. Responses may therefore be biased even be at peace.
though confidentiality of participation and anonymity were ensured. 4 Spirituality is an expression of
Finally, as the nature of spirituality is complex and multidimensional, one's inner feelings that affect
exploring students' understanding and perceptions of spirituality and behaviour.
5 Spirituality is part of our inner
spiritual care via a questionnaire might limit the range of possible
being.
issues and views. Although steps have been taken to produce a valid 6 Spirituality is about finding
and reliable scale, more work is required to refine the scale and meaning in the good and bad
look at its applicability in clinical practice. events of life.
7 Spiritual well-being is important
for one's emotional well-being.
Implications for Nursing 8 Spirituality drives individuals to
search for answers about meaning
In this study, the characteristics of spirituality and spiritual care and purpose in life.
were conceptualised from a student perspective and may provide 9 Without spirituality, a person is
not considered whole.
guidance for educational content and learning strategies in preregis-
10 Spiritual needs are met by
tration programmes. connecting oneself with other
In clinical practice, nursing leaders may consider using the SCGS to people, higher power or nature.
determine the views of staff, address areas for development, and incor- 11 Spiritual care is an integral
porate spirituality concepts in their organisational policies and guide- component of holistic nursing care.
12 Spiritual care is more than
lines. However, there must also be visible leadership commitment religious care.
from senior hospital administrators to foster a culture of spiritual care 13 Nursing care, when performed
not only in the care provided to patients but also towards colleagues. well, is itself, spiritual care.
Lastly, a concerted tripartite approach, involving nursing leaders, ed- 14 Spiritual care is a process and not a
one-time event or activity.
ucators and regulators, could be taken to improve spiritual care stan-
15. Spiritual care is respecting a
dards in practice and education. Nursing boards responsible for patient's religious or personal
programme accreditation could encourage the inclusion of spiritual beliefs.
care (1) as a core competency for nurses and (2) require explicit inte- 16 Sensitivity and intuition help the
gration of spirituality in the nursing care delivery model. Educational in- nurse to provide spiritual care.
17. Being with a patient is a form of
stitutions need to introduce concepts of spirituality and spiritual care in spiritual care.
a meaningful and integrated way. Faculty need to receive professional 18. Nurses provide spiritual care by
development and support to embrace these concepts as a central part respecting the religious and
of their educational mission and demonstrate integration of these con- cultural beliefs of patients.
19. Nurses provide spiritual care by
cepts in curriculum documents and their chosen pedagogical methods.
giving patients time to discuss and
explore their fears, anxieties and
Conclusion troubles.
21. Spiritual care enables the patient
Findings from this ethno-culturally diverse Asian sample are sim- to find meaning and purpose in
their illness.
ilar to those reported by studies conducted in the UK and North
 L.H. Tiew et al. / Nurse Education Today 33 (2013) 574–579 579

Appendix A (continued) Hoffert, D., Henshaw, C., Mvududu, N., 2007. Enhancing the ability of nursing students
to perform a spiritual assessment. Nurse Educator 32 (2), 66–72.
Items SD D MD MA A SA Hubbell, S.L., Woodard, E.K., Barksdale-Brown, D.J., Parker, J.S., 2006. Spiritual care
22. Spiritual care includes support to practices of nurse practitioners in federally designated nonmetropolitan areas of
help patients observe their North Carolina. Journal of the American Academy of Nurse Practitioners 18,
379–385.
religious beliefs.
Kendrick, K.D., Robinson, S., 2000. Spirituality: its relevance and purpose for clinical
24. I am comfortable providing
nursing in a new millenium. Journal of Clinical Nursing 9, 701–705.
spiritual care to patients.
Koenig, H., George, L.K., Titus, P., 2004. Religion, spirituality and health in medically ill
26. Nurses provide spiritual care by hospitalized older patients. Journal of American Geriatrics Association 52,
respecting the dignity of patients. 554–562.
27. Spiritual care should take into Lemmer, C., 2002. Teaching the spiritual dimension of nursing care: a survey of United
account of what patients think States baccalaureate nursing programs. Journal of Nursing Education 41, 482–490.
about spirituality. MacKinlay, E.B., 2008. Practice development in aged care nursing of older people: the
28. Nurses who are spiritual aware are perspective of ageing and spiritual care. International Journal of Older People
more likely to provide spiritual Nursing 3, 151–158.
care. McClung, E., Grossoehme, D.H., Jacobson, A.F., 2006. Collaborating with chaplains to
29. Spiritual care requires awareness meet spiritual needs. Medsurg Nursing 15 (3), 147–156.
of one's spirituality McFadden, S.H., 1999. Religion, personality and aging: a life span perspective. Journal
31. Spiritual care should be instilled of Personality 67, 1081–1104.
McSherry, W., 2007. Meaning of Spirituality and Spiritual Care within Nursing and
throughout a nursing education
Health Care Practice. Quay Books Division, London.
programme.
McSherry, W., Cash, K., Ross, L., 2004. Meaning of spirituality: implications for nursing
32. Spiritual care should be positively practice. Journal of Clinical Nursing 13 (8), 934–941.
reinforced in nursing practice. McSherry, W., Gretton, M., Draper, P., Watson, R., 2008. The ethical basis of teaching
33. The ability to provide spiritual care spirituality and spiritual care: a survey of student nurses perceptions. Nurse
develops through experience. Education Today 28 (8), 1002–1008.
35. Spiritual care is important because Meyer, C.L., 2003. How effectively are nurse educators preparing students to provide
it gives patient hope. spiritual care? Nurse Educator 28 (4), 185–190.
36. Spirituality is influenced by Milligan, S., 2004. Perceptions of spiritual care among nurses undertaking post-
individual's life experiences. registration education. International Journal of Palliative Nursing 10 (4), 162–171.
37. Spirituality helps when facing life's Modjarrad, K., 2004. Medicine and spirituality. Journal of the American Medical Associ-
difficulties and problems. ation 291 (23), 2880.
38. Spiritual care requires the nurse to Mok, E., Wong, F., Wong, D., 2009. The meaning of spirituality and spiritual care among
the Hong Kong Chinese terminally ill. Journal of Advanced Nursing 66 (2),
be empathetic towards the patient.
360–370.
39 A trusting nurse–patient
Pesut, B., 2002. The development of nursing students' spirituality and spiritual care-
relationship is needed to provide
giving. Nurse Education Today 22 (2), 128–135.
spiritual care. Pesut, B., Reimer-Kirkham, S., 2010. Situated clinical encounters in the negotiation of
40 A team approach is important for religious and spiritual plurality: a critical ethnography. International Journal of
spiritual care Nursing Studies 47, 815–825.
Ross, L., 2006. Spiritual care in nursing: an overview of the research to date. Journal of
Clinical Nursing 15 (7), 852–862.
Sanders, C., 2002. Challenge for spiritual care-giving in the millenium. Contemporary
Nurse 12, 107–111.
References Shih, F.J., Gau, M.-L., Mao, H.-C., Chen, C.-H., Lo, C.-H.K., 2001. Empirical validation of a
teaching course on spiritual care in Taiwan. Journal of Advanced Nursing 36 (3),
Ahmadi, F., 2000. Reflections on spiritual maturity and gerotranscendence: dialogues 333–346.
with two sufis. Journal of Religious Gerontology 11, 43–74. Stranahan, S., 2001. Spiritual perception, attitudes about spiritual care, and spiritual
Baldacchino, D.R., 2008. Teaching on the spiritual dimension in care: the perceived care practices among nurse practitioners. Western Journal of Nursing Research
impact on undergraduate nursing students. Nurse Education Today 28 (4), 501–512. 23 (1), 90–104.
Burkhart, L., Hogan, N., 2008. An experiential theory of spiritual care in nursing prac- Swinton, J., Pattison, S., 2010. Moving beyond clarity: towards a thin, vague, and useful
tice. Qualitative Health Research 18 (7), 928–938. understanding of spirituality in nursing care. Nursing Philosophy 11, 226–237.
Cantanzaro, A., McMullen, K., 2001. Increasing nursing students' spiritual sensitivity. Taylor, E.J., 2008. What is spiritual care in nursing? Findings from an exercise in con-
Nurse Educator 26, 221–226. tent validity. Holistic Nursing Practice 22 (3), 154–159.
Carr, T., 2008. Mapping the processes and qualities of spiritual nursing care. Qualitative Tiew, L.H., Creedy, D.K., 2011. Student nurses' spiritual education perspectives: a liter-
Health Research 18 (5), 686–700. ature review. Singapore Nursing Journal 38 (3), 39–54 (Jul–Sep).
Chan, M.F., 2009. Factors affecting nursing staff in practising spiritual care. Journal of Tiew, L.H., Creedy, D.K., 2012. Development and preliminary validation of a composite
Clinical Nursing 1–9. Spiritual Care-Giving Scale. International Journal of Nursing Studies 49, 682–690.
Chism, L.A., Magnan, M.A., 2009. The relationship of nursing students' spiritual care per- Tiew, L.H., Drury, V., 2012. Singapore nursing students' perceptions and attitudes about
spectives to their expressions of spiritual empathy. Journal of Nursing Education 1–9. spirituality and spiritual care in practice: a qualitative study. Journal of Holistic
Conner, N.E., Eller, S.L., 2004. Spiritual perspectives, needs and nursing interventions of Nursing, http://dx.doi.org/10.1177/0898010111435948 (first published on March
Christian African-Americans. Journal of Advanced Nursing 46 (6), 624–632. 21, 2012).
Creel, E., 2007. The meaning of spiritual nursing care for the ill individual with no Vance, D.L., 2001. Nurses' attitudes towards spirituality and patient care. Medsurg
religious affiliation. International Journal for Human Caring 11 (3), 14–21. Nursing 10 (5), 264–268.
Delaney, C., 2005. The spirituality scale: development and psychometric testing of a Wallace, M., Campbell, S., Grossman, S.C., Shea, J.M., Lange, J.W., Quell, T., 2008. Inte-
holistic instrument to assess the human spiritual dimension. Journal of Holistic grating spirituality into undergraduate nursing curricula. International Journal of
Nursing 23 (2), 145–167. Nursing Education Scholarships 5, 1–10.
Greenstreet, W., 1999. Teaching spirituality in nursing: a literature review. Nurse Edu-
cation Today 19, 649–658.
Hart, T., Ailoae, C., 2007. Spiritual touchstones: childhood spiritual experience in the
development of influential historic and contemporary figures. Imagination, Cogni-
tion and Personality 26 (4), 345–359.