Nursing students' opinions about health, spirituality and religiosity

Abstracts

O presente estudo objetivou identificar as opiniões dos estudantes de Enfermagem em relação à interface entre saúde, espiritualidade e religiosidade e as informações fornecidas durante o período da formação acadêmica. Estudo transversal em que foram entrevistados 120 alunos do curso de enfermagem (82,1%) de uma faculdade do estado de São Paulo durante maio e outubro de 2011. Destes, 76% acreditam que a espiritualidade influencia na saúde. Apenas 10% consideram-se muito preparados para abordar aspectos espirituais dos pacientes e 54% apontaram que a formação universitária não oferece informações suficientes para desenvolver essa competência. O medo de impor pontos de vista religiosos aos pacientes é a principal barreira relacionada ao assunto. A maioria dos estudantes, 83%, apontou que temas referentes a saúde e espiritualidade deveriam fazer parte dos currículos de Enfermagem. É necessária a implementação de cenários de aprendizagem durante a formação acadêmica que auxiliem o estudante a realizar o cuidado espiritual.

Espiritualidade; Religião; Enfermagem; Ensino

ORIGINAL ARTICLE

Daniele Corcioli Mendes Espinha^I; Stéphanie Marques de CamargoII; Sabrina Piccinelli Zanchettin Silva^III; Shirlene Pavelqueires^IV; Giancarlo Lucchetti^V

^INurse. Graduated from the Marília Medical School (Faculdade de Medicina de Marília - FAMEMA). Member of the Scientific Society of Health and Spirituality at the Marília Medical School (SOCISE-FAMEMA). Marília, SP, Brazil

^IINursing Academic at the FAMEMA. Member of the SOCISE-FAMEMA. Marília, SP, Brazil

^IIINursing Academic at the FAMEMA. Marília, SP, Brazil

^IVNurse. Doctor of Nursing from the Ribeirão Preto Nursing School at the da University of São Paulo. Full professor at the FAMEMA. Member of the SOCISE-FAMEMA. Marília, SP, Brazil

^VPhysician. Associate professor at the internal medicine department at the Federal University of Juíz de Fora (Universidade Federal de Juiz de Fora) Medical School, MG, Brasil. Doctor of science from the neurology/neuroscience department at the Federal University of São Paulo. Research collaborator at the Brazilian Medical Spiritist Association. Supervisor of the SOCISE-FAMEMA. São Paulo, SP, Brazil

Correspondence

ABSTRACT

The present study aimed to identify the opinions of nursing students in relation to the interface between health, spirituality and religiosity and the information provided during their undergraduate formation. A cross-sectional study was conducted in 2011 (May to October) through interviews on 120 students from a nursing school (82.1%) located at São Paulo State, Brazil. From these, 76% believe that spirituality have an influence on health. However, only 10% consider themselves very prepared to address patients' spiritual aspects and 54% stated that university education does not provide enough information to develop this competence. The fear of imposing religious beliefs is the main barrier related to this issue. Most students (83%) indicated that issues related to health and spirituality should be part of the nursing curricula. Therefore, it's necessary to implement learning scenarios during their academic training to help students in spiritual care.

Descriptors: Spirituality. Religion. Nursing. Teaching.

RESUMEN

Este estudio tuvo como objetivo identificar los puntos de vista de los estudiantes de enfermería relación con la interfaz entre la salud, la espiritualidad y la religiosidad y la información proporcionada durante el período de formación académica. Estudio transversal entrevistó a 120 estudiantes de enfermería (82,1%) de una universidad en el estado de São Paulo entre mayo y octubre de 2011. De estos, el 76% cree que la espiritualidad influye en la salud. Sin embargo, solo el 10% se consideran muy preparados para hacer frente a los aspectos espirituales de los pacientes y el 54% indicó que la educación universitaria no proporciona información suficiente para esta competencia. El temor a la imposición de puntos de vista religiosos es la principal barrera sobre el tema. La mayoría de los estudiantes (el 83%) indicó que las cuestiones relativas a salud y espiritualidad deben formar parte del currículo de enfermería. Es necesario implementar escenarios de aprendizaje durante su formación académica para ayudar a los estudiantes en el cuidado espiritual.

Descriptores: Espiritualidad. Religión. Enfermería. Enseñanza.

INTRODUCTION

Modern nursing has increasingly focused its attention on the humanization of healthcare and a broader vision of the health-disease interface. Talking about aspects that transcend the biological dimension of the patient, such as spirituality and religiosity, means caring about the experiences of the human being⁽¹⁾.

A growing number of studies point to the influence of spirituality in clinical practice in various situations⁽²⁾, including decreased prevalence of depression, lower blood pressure, decreased postsurgical complications⁽³⁾ and greater psychological wellbeing, including satisfaction with life, happiness, positive mood and increased morale⁽⁴⁾.

In the same manner, various studies have shown that patients wish to receive this type of support, varying from 33 to 94% in international studies ^(3,6), depending on the type of service, setting and clinical context.

Despite the large amount of evidence, the concept of spirituality is still not consensual. Spirituality can be defined as a personal search to understand issues related to the end of life, its meaning, and relationships to the sacred or the transcendent which may or may not lead to the development of religious practices or formations of religious communities ⁽⁵⁾. Religiosity relates to when the individual believes, follows and practices a religion. In intrinsic religiosity⁽⁷⁾ the religion has a central role in the life of the individual, it is their greatest good. In extrinsic religiosity the religion is a means used to obtain other ends, such as consolation, sociability, recreation and status.

Understanding these meanings, there is an evident increase in the recognition that spirituality is a fundamental aspect of nursing care. However, many professionals still feel hesitant and with little confidence to approach these aspects, boosted by the lack of adequate inclusion of this theme during the academic training process ⁽⁸⁾. Without well-structured evaluation and training models for the trainee professionals, it becomes difficult to introduce this support in daily clinical practice, which is already overloaded with administrative tasks and low availability of time.

Following this tendency, NANDA International (NANDA I), focusing on spiritual care in nursing diagnostics, provides stimulus to the importance of a formal study in relation to the issue of Health and Spirituality in graduation⁽⁹⁾. According to a recent study⁽¹⁰⁾, many students on nursing courses believe that spirituality influences patient health and the actual care provided by the nurse and, despite the majority wishing to cover this aspect, few judge themselves prepared for such. Notably, more than 90% of the students evaluated by this study believe that universities for not provide all the information required for this preparation.

Even if the nursing activities in respect to spiritual care are legitimate, even when offered during the work process⁽¹¹⁾, education on the issue during graduation would have an important role for the student's life in the development of the values of holistic care ⁽¹²⁾. The students tend to model themselves on their professors and, without a clearer approach to the matter, end up judging it unnecessary or outside of the scope of their work.

Therefore, understanding what the nursing students think and how they act with regard to the relationship between spirituality, religiosity and health would enable reflections in relation to the preparation supplied during undergraduate study for forming professionals that provide broader care, identification of gaps and proposing ways of implementing the subject into the curriculum.

As such, this study aimed to identify the nursing students' opinions in relation to the interface between health, spirituality and religiosity and the information supplied during the academic training period.

METHODS

An exploratory, descriptive, cross-sectional and quantitative study was conducted on the Nursing Undergraduate Course at the Marília Medical School (Faculdade de Medicina de Marília - FAMEMA), located in a city in the interior of the state of São Paulo. The population eligible for the study was composed by all the students regularly registered on the Nursing Undergraduate Course at the FAMEMA during the 2011 academic year, totaling 146 students. Those on leaves of absence or that were not located were excluded from the study, as well as academic researchers that participated in this study.

The collection of data was completed by researchers between the months May and October 2011. A standard, self-administered questionnaire was delivered to all participants in the study, through institutional authorization for the application of the instrument in opportune moments that would not interfere in the academic activities of the participants. Despite the students having been directed to complete the instrument onsite, some of those interested in participating in the research and were not able to do so at the specific time were authorized to complete it at another time.

The instrument used was adapted from a multicenter study involving medicine academics from various universities in Brazil, coordinated by the Federal University of São Paulo (Universidade Federal de São Paulo - UNIFESP)⁽¹³⁾. The questions were divided into:

- Sociodemographic data: gender, age, year of graduation, ethnicity and household income;

- Clinical practice, the patient and spirituality: evaluation of the concept of spirituality indicated by the students, knowledge about the relationship between spirituality and health, and how this context may be included in nurses' clinical practice;

- Academic training and the spirituality issue: knowledge and opinion about the way in which the university approaches the issue during undergraduate study and how preparation for working on the matter could be offered;

- Religiosity dimension: different aspects of the spirituality and religiosity of the participant were evaluated through their religious affiliation and the use of the Duke Religious Index - DUREL. This scale was validated for Brazil⁽¹⁴⁾ and includes five questions (Likert scale) that evaluate three of the religiosity dimensions that relate the most to health: organizational, non-organizational and intrinsic.

The data obtained were tabulated in Excel and analyzed using the software SPSS 17.0. Contingency tables were performed and summary averages of the profile, opinions and influence in the academic training of the participants.

The project was submitted to the Ethics Committee for Research Involving Human Subjects at the Marília Medical School, and approved under nº 557/10. All participants signed a Free and Clarified Consent term.

RESULTS

From 146 students on the Nursing Undergraduate Course, 120 participated in the study, totaling a questionnaire response rate of 82.19%. In general, all of the academic years were covered with more than 75% of the responses: 36 (78.26%) students belonging to the 1^st year, 22 (88%) to the 2^nd year, 30 (90.90%) to the 3^rd year and 32 (76.19%) students in the 4^th year.

Sociodemographic characteristics of the participants

The majority of the participants were constituted by women (90%), white ethnicities (76.3%) and family income below seven Brazilian minimum wages (67.9%). With relation to the age of the students, this varied between 17 and 34 years, 20 to 25 years (65.2%) bring predominant, and an average of 20.70 ± 3.29 years.

Beliefs and religiosity

The majority of the participants (87.9%) have some religious affiliation 67.8% considered themselves "moderately religious" (through the self-assessment of religiosity, varying from "nonreligious", "slightly religious", "moderately religious" and "very religious"). Around 32.8% of the participants affirmed they attend a religious service at least once per week, and 43.7% of the students dedicated themselves daily to individual religious practices such as prayers, meditation and religious reading.

In the evaluation of intrinsic religiosity, obtained through the Religiosity Scale, the participants obtained an average of 5.57 ± 2.10 points, indicating high intrinsic religiosity. The response options of this dimension were offered in decreasing order, where the highest score (15) is relation to lower intrinsic religiosity and the lowest score (3) is related to higher intrinsic religiosity.

The unanimity of the participants indicated belief in God; 92.4% believed that human beings are composed of a body and a soul/spirit and 80.8% believed that this soul still remains alive after physical death.

Concept of spirituality

In relation to the concept of spirituality attributed by the students, we used a closed multiple choice question in which it was possible to choose more than one option. As a result, the majority of the participants (61.7%) indicated the conception of the term as "belief and relationship with God/religiosity" and followed by a "search for the sense and meaning for human life" (40,8%), "belief in something transcendent to the material" (26,7%), "belief in the existence of the soul and life after death" (24,2%) and an "ethical and humanistic attitude" (13,3%).

Clinical practice, the patient and spirituality

The majority of the students considered religion/spirituality as exercising a lot of influence on patient health (84.9% a lot/extremely; 13.4% more or less; 1.7% little and 0.0% very little or nothing). For 66.7% of the participants this influence was generally positive, for 30.0% it was equally positive and negative, and for 3.3% the influence was negative or did not exist.

The participants also considered the patient approach to religious/spiritual aspects in clinical practice as relevant to clinical practice, and frequently had a desire to address this issue (41.5%), with the majority of students (71.4%) having already asked about the religion/spirituality of patients (Table 1).

However, when questioned about feeling prepared to approach religious/spiritual aspects with the patients, a little over half of students (50.8%) affirmed they were "moderately prepared" and 32.5% said they were "slightly prepared". The main reasons indicated included: "lack of knowledge" (34.8%), "lack of training" (39.1%), "lack of time" (26.1%), "discomfort with the subject" (11.3%), "fear of imposing religious points of view on patients " (0.9%), "not part of my work" (1.7%), "fear of offending patients" (36.5%), "fear that my colleagues don't approve" (8.7%) and "other reasons" (5.2%) (Table 1).

Academic training and the topic of "health and spirituality"

In current higher education, a large part of students negatively evaluated the approach to topics about religious or spiritual beliefs in curricular activities. Despite this fact, the students indicated that teachers in the 1^st year of the undergraduate course were those that covered such aspects most (Table 2).

In relation to the "Spirituality and health" content offered by the university, 91.6% of students believed the information supplied was insufficient for them to be able to approach religious and spiritual beliefs with the patients.

In relation to the education of students in relation to the issue, 78.0% of the participants reported not having participated in activities that helped in this process, but affirmed that they would like to participate.

When questioned in relation to the way in which they sought out information about health and spirituality issues, the students reported that this was through teachings within their own religion (54.6%), reading books (17.6%), reading scientific articles (16%), talks (9.2%), professors from the university (4.2%), while 27.7% did not seek information.

When questioned if they believed that issues related to health and spirituality should be a part of the nursing curriculum, the majority of participants responded affirmatively (83.8%) and a large part (73.1%) mentioned that they had not changed their beliefs or conduct in relation to religiosity/spirituality after entering university.

DISCUSSION

The sample in this study had a predominance of women (90%), which corroborate the national data that the female sex is predominant in undergraduate nursing courses⁽¹⁰⁾.

The majority of the participants considered the influence of religion and spirituality as positive on patient health. Indeed, studies show that religious practice is related with psychoneuroimmunology⁽⁵⁾, as well as being a prevention factor for the development of diseases in previously health populations, related with an eventual reduction in death and the impact of various diseases^{(3, 15)}. However, few students remember the negative effects of religiosity, for example, religious suffering that could lead to greater mortality and worse clinical outcomes ⁽¹⁶⁾. This finding leads us to the distorted view that religiosity only produces positive effects on patient health, undervaluing various studies on the negative aspects of religious beliefs ⁽¹⁷⁾. The approach of the patient should be consistent and based on previous training in order to not impose beliefs or make judgments.

Despite students not having expressed the desire to realize the approach of the religious and spiritual aspects of the patients in clinical practice, they believed that they still did not have the security for this practice and that the knowledge learned in their degree was not sufficient for the development of this competency. In general, the approach to spirituality during university education is not sufficiently profound, mainly in relation to theoretical discussions ⁽¹⁸⁾ and the actual practical part required for preparing the student⁽¹⁰⁾. Often the attention given to the issue takes place through conversations and prayers via the participation of chaplain, however with little clinical applicability and based on little evidence.

Our data is correlated with previous studies. In a study conducted with 30 nurses at a large hospital, the results showed that despite the majority of subjects having responded affirmatively about the importance of offering spiritual assistance to the patient, 67% of the interviewees stated they had not received professional education to render spiritual assistance to the patient in the course of their degree⁽⁹⁾. In the same manner, a recent study⁽¹⁰⁾ demonstrated that 98% of the participants reported that university education did not include sufficient information about "health and spirituality".

The inclusion of subjects or even modules based on active methodology or problems could, in a certain manner, aid the academic development of this area. However, the training of professors, mainly those working in the last semesters of the course, becomes essential in the nursing context, given that the student is more exposed to this type of situation when in the practical internship activities.

The lack of preparation for the student found in our study seems to negatively interfere in the possibility of a broader approach to the matter in the field of nursing. The main barrier identified relates to the fear of imposing religious points of views on patients. This result is similar to that found in studies conducted 118 students from the nursing course, which indicated the fear of imposing religious beliefs as the main motive⁽¹⁰⁾.

This fear can be justified by some factors: lacks of training and adequate scientific basis for a more ecumenical approach centered on the patient and the lack of knowledge of the differences inherent in the terms of religiosity and spirituality. As stated above, spirituality is related to the personal search for understating the answers to questions about life, its meaning, and the relationship to the sacred and transcendent, which may or may not be related to proposals from a determined religion ⁽⁵⁾. This concept diverges from that attributed by the students in this study, where the majority defined spirituality as a relationship connected to religiosity.

Another motive indicated by the students for not approaching the religious and spiritual dimensions of patients relates to the fear of offending patients. It is important to highlight that article 6 of the Nursing Professional Code of Ethics states that the nurse should "base their relationships on the law, prudence, respect, solidarity and diversity of opinion and ideological position"⁽¹⁹⁾. However, balancing the fundamental right to life on the one hand and the fundamental rights to intimacy, privacy and liberty owing to the religious convictions of others becomes a difficult task when considering professional training based on the biomedical rationality of many nurses. As such, the integration between spirituality, faith, religiosity and ethics becomes a new aspect of healthcare ⁽¹⁸⁾.

Various students state they believe that the religion/spirituality of nurses interferes with great intensity (42.4%) in understanding the health-diseases and the professional-patient relationship. It is worth reiterating that according to some authors ⁽¹⁸⁾, the root of religion is so entrenched in the collective memory that even at institutions that do not declare themselves to be religious, Christian presuppositions remain present, and with vitality, which can also be corroborated by the fact that all participants in the study believe in God.

When questioned in relation to the way in which they seek knowledge about health and spirituality topics, the majority of the students reported that this was through teachings within their own religion. This could mean that students in the health area are unaware of evidence in the scientific literature about the connection between spirituality, physical health⁽³⁾ and mental health⁽⁴⁾, even though when including the uniterms "religiosity", "religion", "spiritual" and "spirituality" in the MEDLINE electronic database, around 40 thousand articles can be found⁽²⁾.

This finding reinforces the lack of student knowledge in relation to this issue and investigation not based on evidence. Knowledge and religious inclusion may be important for the spiritual/religious development of nurses but cannot cover all of the information required for a correct approach to spirituality in healthcare. This fact makes it clear that there is a need for student guidance with respect to the information available for improving the education of nursing professionals so that they understand that this type of approach will be part of their profession as a nurse.

CONCLUSION

In this study, students on the nursing course considered that the approach to patient spirituality exerts an influence on clinical practice. Despite the majority having asked about patient religion or spirituality, few felt adequately prepared or had training in the subject. The main barriers for this approach were the fear of imposing a religious point of view on patients and the fear of offending patients.

In relation to the approach to religion/spirituality in academic training, students reported that the information provided by the university was insufficient and that they sought knowledge about the issue from their own religion to the detriment of reading books and scientific articles.

Some limitations should be identified in the analysis of our results. Firstly, the data comes from a single nursing school. Additional research at different educational institutions is necessary so that a broader profile of the nursing students can be characterized. Secondly, as this is a cross-sectional study, it is not possible to understand how academic training would change the student's opinion in relation to the matter throughout their degree.

This data leads to gaps in the inclusion of the subject and the training provided during academic training. Another important aspect to be reflected by these findings relates to the large human transformations involved in globalization, which has caused a profound crisis for "humanism", in which we constantly find ourselves in environments with high technological and scientific standards, but a lack of a more humanized approach ⁽²⁰⁾.

It can be concluded that there is a need to implement learning situation during academic training which provides the student with the competency to provide spiritual care.

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Nursing students' opinions about health, spirituality and religiosity

Opiniones de los estudiantes de enfermería sobre la salud, la espiritualidad y la religiosidad

Publication Dates

• Publication in this collection
  17 Mar 2014
• Date of issue
  Dec 2013

History

• Received
  04 Sept 2013
• Accepted
  27 Nov 2013