Integration of Spirituality Into the Nursing Curriculum

Nancie Crespi, PhD, RN - Director of Nursing Program Tijuana Griffin, PhD, RN - Associate Professor

Bonnie Franckowiak, DNP, FNP, CARN-AP – Professor

Washington Adventist University, Takoma Park, MD

Objectives 1. Describe methods of integrating spiritual concepts

into the education of nursing students to enhance their ability to provide holistic patient care.

2. Perform a spiritual assessment of a patient in their own nursing practice, with understanding of and respect for different cultural, religious, experiential, and personal beliefs.

What is spiritual care?

Interventions, individual or communal, that facilitate the ability to express the integration of the body, mind, and spirit to achieve wholeness, health, and a sense of connection to self, others, and a higher power. (ANA/HMA, 2005)

“We are not human beings having a spiritual experience. We are spiritual beings having a human experience.” ― Pierre Teilhard de Chardin

Literature Review • Attention to patients’ spirituality, as a moral

obligation of care, is now widely accepted in nursing practice. However, until recently, many nursing programs have paid little attention to spirituality (Yilmaz and Gurler, 2014).

Spiritual care is recognized as a domain of nursing.

How to teach spiritual assessment and how to assess student learning outcomes remain a concern to nurse educators…With the increased focus on spirituality, nurse educators must teach the art as well as science of spiritual care…Nursing students need role models who demonstrate spiritual care (Cone & Giske, 2012).

A survey of 132 baccalaureate nursing programs found that:

1) Few faculty could define spirituality, 2) Few could explain how to teach students,

and 3) Few had adequate knowledge to teach about

spirituality (Wallace, 2008)

Recommended strategies for integrating spirituality into the curriculum: • A supportive environment where faculty

act as role models (Gallia, 1996) • Assignments in the classroom and clinical

area that promote spiritual awareness and sensitivity (Callester, 2004; Brush & Daly, 2000).

Regarding integration of spirituality: “… May be easier in a faith-based institution where the vision and mission have a focus that encompasses a spiritual dimension. However, spirituality is a key component in nursing and should be incorporated into every program” (Wallace, 2008)

WAU Expected Student Outcomes: BSN

• Provide holistic care based on the human needs theory by addressing the influences of physical, developmental, mental, behavioral, spiritual, cultural, socioeconomic, and environmental factors on health and wellness.

• Utilize a Christ-centered spiritual process within a multi-cultural, multi-faith environment to help self and others identify and meet spiritual needs and bring peace and comfort.

WAU Nursing Program’s Spiritual Integration Plan

Convocation attendance weekly on Wednesdays at 11:15 AM Sligo Church Chapel

Community service through the Best Buddies program and Student Nurses Association

Annual Wednesday Chapel service conducted by the University

Annual student and faculty spiritual retreats

Requirement of four religion courses in curriculum (two courses for transfer students, BSN and RN-BSN)

WISE

Week in Spiritual Emphasis (WISE) each semester

Monthly Departmental meetings with prayer and motivational programs

Required Community Service day with a patient teaching project scheduled for each semester (BSN)

Prayer sessions in classrooms

Introduction of alternative methods of healing in NURS 341

Use of HOPE spiritual assessment tool in all clinical settings

Spiritual Assessment

H – Sources of HOPE, meaning, comfort, strength, peace, love, and connection O – Organized religion P – Personal spirituality practice E – Effects on medical care and end of life issues

The HOPE Model of Spiritual Assessment Assessing a patient’s spirituality is just one

aspect of a complete health assessment, but it is a very important one.

It contributes to one’s total view of the person and reinforces the notion of holistic care.

Anandarajah & Hight (2001) proposed a model for spiritual assessment that uses the acronym HOPE.

The HOPE Model of Spiritual Assessment H = Sources of

hope, meaning, comfort, strength, peace, love, and connection

What is there in your life that gives you internal support? ________________________________ What are your sources of hope, strength, comfort, and peace? _________________________________________ What do you hold on to in difficult times? __________________________________________ What sustains you? _______________________________________________________________ For some people, religious or spiritual beliefs act as a source of comfort and strength: Is this true for you? _____________________________________ If answer is “Yes”, go on to O and P questions. If answer is “No”, consider asking: Was it ever? If so, ask, What changed?

O = Organized religion

Do you consider yourself part of an organized religion? __________________________________ How important is this to you? _______________________________________________________ What aspects of your religion are helpful, and not so helpful, to you? _______________________ ________________________________________________________________________________ Are you part of a religious or spiritual community? ______________________ Does it help you? __________________ How? ____________________________________________________________________

P = Personal spirituality and practice

Do you have spiritual beliefs independent of organized religion? ___________________________ What are they? ___________________________________________________________________ Do you believe in God? _____________________________ What is your relationship with God? _________________________________________________ What aspects of your spiritual practices do you find most helpful? (e.g. prayer, meditation, reading scripture, music, communing with nature) ______________________________

The HOPE Model of Spiritual Assessment E = Effects on medical care and end of life issues

Has being sick affected your ability to do the things that usually help you spiritually? _____________ Is there anything that I can do to help you access the things that usually help you spiritually? ______ __________________________________________________________________________________ Are you worried about any conflict between your beliefs and decisions about medical care? _______ Would it help you to speak to a chaplain or community spiritual leader? ______________________ Are there any specific practices or restrictions that I should know about in providing your medical care? (e.g. dietary restrictions, use of blood products) ______________________________________ If patient is dying: How do your beliefs affect the kind of medical care you would like me to provide during the next few days / weeks / months?

Integration of textbook and journal readings related to spirituality required in all nursing courses, with journal articles listed on syllabus, uploaded to D2L, and placed in student study hall O’Brien, M. E. (2014). Spirituality in nursing. Standing on holy ground. Burlington, MA: Jones & Bartlett. ISBN: 978-1-4496-9467-8

Mauk, K. L., & Schmidt, N. K. (2004). Spiritual care in nursing practice. Philadelphia, PA: Lippincott. ISBN: 0-7817-4096-7

White, E. G. (2011). The ministry of healing. Guildford, UK: White Crow Books. ISBN: 9781907661327

BSN Course Objectives related to Spirituality Course Objective

NURS222 Professional Nursing Foundations

Develop a definition of spirituality that expresses sensitivity of human needs fulfillment that will assist clients to move toward health and well-being.

NURS446 Public Health Nursing and Population Health

Deliver holistic care based on the human needs theory by addressing the influences of physical, developmental, mental, behavioral, spiritual, cultural, socioeconomic, and environmental factors on health and wellness in the community.

Objectives (cont.) Course Objective

NURS354 Psychiatric – Mental Health Nursing

Discuss professional standards of nursing relating to caring, altruism, autonomy, human dignity, integrity, and social justice in psychiatric mental health nursing.

NURS364 Adult-Gerontology Nursing I

Utilize a Christ-centered spiritual process to help clients and their families identify and meet self-care and spiritual needs and bring peace and comfort.

Integration of Spirituality into NURS 222 Professional Nursing Foundations

Readings in E.G. White, The Ministry of Healing

Readings in Mauk and Schmidt, Spiritual Care in Nursing Practice

Other Assignments Related to Spirituality

Chapt 1 Our Example Chapt 4 The Touch of Faith Chapt 15 In the Sickroom Chapt 20 General Hygiene Chapt 23 Diet and Health Chapt 24 Flesh as food

Chapter 1 Spirituality as a Life Journey Chapter 3 Development of Spiritual Care

Spirituality Reflective Journal Paper Requirement in Clinical Readings and Lecture on Spiritual Integrity and Concept of Caring Clinical Performance Evaluation Tool that measures spirituality (spiritual well-being) in the student as demonstrated in the clinical setting Clinical care plan requirement that measures patient’s spiritual well-being Daily Clinical Log that allows for reflections of the day

Integration of Spirituality into NURS 354 Psychiatric Mental Health Nursing

Readings in E.G. White, The Ministry of Healing

Readings in Mauk and Schmidt, Spiritual Care in Nursing Practice

Other Assignments Related to Spirituality

Chapt 10 Helping the Tempted Chapt 18 Mind Cure Chapt 25 Extremes in Diet Chapt 26 Stimulants and Narcotics Chapt 27 Liquor Traffic and Prohibition

Chapt 19 The Nurse’s Spiritual Health

Spirituality Reflective Journal Paper Requirement in Clinical Powerpoint Lectures on: Story Telling as Healing Clinical Performance Evaluation Tool that measures spirituality (spiritual well-being) in the student as demonstrated in the clinical setting Clinical care plan requirement that measures patient’s spiritual well-being Daily Clinical Log that allows for reflections of the day

Integration of Spirituality into NURS 446 Public Health Nursing and Population Health

Readings in E.G. White, The Ministry of Healing

Readings in Mauk and Schmidt, Spiritual Care in Nursing Practice

Other Assignments Related to Spirituality

Chapt 12 Help for the Unemployed and the Homeless Chapt 13 The Helpless Poor Chapt 14 Ministry to the Rich Chapter 28 Ministry of the Home Chapter 30 Choice and Preparation of the Home Chapter 33 Home Influences Chapter 40 Help in Daily Living

Chapt 5 Judaism and Its Branches Chapt 7 Islam and Its Branches Chapt 9 Other Religions: Voodoo and Native/Indigenous American Traditions Chapt 10 South Asian Traditions Chapt 11 Buddhist Traditions Chapt 12 East Asian Traditions

Spirituality Reflective Journal Paper Requirement in Clinical Clinical Performance Evaluation Tool that measures spirituality (spiritual well-being) in the student as demonstrated in the clinical setting Community Assessment that evaluates the places of worship and spiritual well-being of the population.

SELF-CARE PLAN

Taking care of oneself is vital to personal and professional development. Write the self-care activities that you practice on a regular basis in the appropriate category below. If any one category seems particularly sparse, that might be an area of need, on which you need to focus, and engage in self-care activities to strengthen that aspect of your life.

Physical Health Emotional Health

Social Health Spiritual Health

For each category below, write some self-care activities that you can perform to work toward fulfilling the needs you have identified.

Physical Health Emotional Health

Social Health Spiritual Health

Biopsychosocial – Spiritual Self-Assessment

Clinical Care Plan Rest and Comfort 1. Pain 2. Stress and Coping 3. Fatigue

Coping: ineffective Anxiety Fear Fatigue Pain Chronic Pain

Spiritual Integrity 1. Grief and loss 2. Cultural

Spiritual Distress Risk for Spiritual Distress Readiness for Enhanced Spiritual Well-Being

Clinical Care Plan Affiliation 1. Love and Belonging 2. Social Support Systems 3. Self-Actualization

Verbal, disorder Social, impaired interaction Social isolation Coping: ineffective Recreation, deficit Role, impaired performance Parenteral, alteration Parenteral, high risk of disruption Parenteral, role conflict Adaptation disorder Family, alteration processes Role of caregiver, overexertion in The role of caregiver, high risk to overuse in the Defensive coping Denial ineffective Ineffective family coping: disabling Ineffective family coping: engaged

Spirituality Reflective Journal Paper required in all BSN clinicals

Department of Nursing Grading Criteria for Spirituality Reflective Journal Paper

Course Number: NURS

Name of the Professor: Student Name: Date:

You have been assigned required readings on spirituality in your course. You may choose one or more chapters from each assigned book to read. You will then write a reflection paper regarding your thoughts, meaningful ideas, feelings, and/or reactions, and the application of these to nursing practice or your own spiritual growth and self-care.

1. Paper is typed in at least 3 pages, double spaced and turned in on time via D2L or email to your professor, with coversheet title page in APA format; thoughtful, suitable title

10 Points

2. Introductory paragraph is attention-getting 10 Points

3. Spelling, grammar, mechanics, and usage are correct throughout paper

10 Points

4. Thoughts are expressed in a coherent and logical manner. 20 Points

5. Viewpoints and interpretations are insightful, demonstrating an in-depth reflection.

20 Points

6. Concluding paragraph sums up information, reiterates ideas and opinions, and leaves reader with a call to action or something meaningful to remember

10 Points

7. Pertinent reference sources are skillfully woven throughout paper without over use of quotations but, rather, attempt to paraphrase

10 Points

8. References are properly cited in APA format with no plagiarism. 5 Points

9. At least 3 references are cited in paper, including a reference from current class assigned chapter readings in Mauk, a reading in an assigned chapter in White, and one journal article of your own choice.

5 Points

Total 100 Possible Points Actual Points =

Evaluation of Integration of Spirituality in WAU Curriculum

• Nursing students scored 4.14 on a 5-point scale on their graduating senior survey in Fall 2014 on satisfaction with ethical and spiritual values learned in general education courses.

• On the annual satisfaction survey completed by the current students in the Fall 2015 semester, growth in spirituality scored 4.2 on a 5-point scale.

Evaluation on spirituality on BSN Clinical Performance Assessment Tools

• Clinical Performance Evaluation Tool adapted from Flores, L., Shakhshir, P., & Lopez, M. (2014). Clinical

evaluation tools embodying AACN BSN essentials and six QSEN KSAs. QSEN Institute.

Retrieved from http://qsen.org/clinical-evaluation-tools-integrating-qsen-core-competencies-and-aacn-bsn-essentials/

• Assessment of spirituality and a 5-point rating scale were added to the original tools

Core Competencies NURS 222 Level I

Mid-Way Through Clinical

Final Evaluation

U NI S 1 U

2 NI

3 S

4 AA

5 E

Focusing on wellness, health promotion, and illness and disease management across the lifespan in a variety of settings while recognizing the diverse uniqueness of individuals, providing directed care to individuals with well-defined health alterations, the student at the end of NURS 222, should be able to:

U = Unsatisfactory NI = Needs Improvement S = Satisfactory AA = Above Average E = Exceptional

Patient-Centered Care Develop an individualized plan of care with a focus on assessment and planning utilizing the nursing process Demonstrate caring behaviors Conduct a comprehensive assessment while eliciting patient values, preferences and needs Respect diversity of individuals Assess the presence and extent of pain and suffering Demonstrate beginning competency in skills

Teamwork and Collaboration Develop effective communication skills (verbally and through charting) with patients, team members, and family Identify relevant data for communication in pre and post conferences Identify intra and inter-professional team member roles and scopes of practice Establish appropriate relationships with team members Identify need for help when appropriate to situation

Evidence-Based Practice Locate evidence-based literature related to clinical practice and guideline activities Reference clinical related activities with evidence-based literature Value the concept of evidence-based practice in determining best clinical practice Quality Improvement Deliver care in timely and cost effective manner Seek information about processes/projects to improve care (QI) Value the significance of variance reporting

Safety Demonstrate effective use of technology and standardized practices that support safety and quality Implement strategies to reduce risk of harm to self or others Demonstrate appropriate clinical decision making Identify national patient safety goals and quality measures Use appropriate strategies to reduce reliance on memory Communicate observations or concerns related to hazards and errors to patient, families, and the health care team Organize multiple responsibilities and provide care in a timely manner

Informatics Navigate the electronic health record for patient information where appropriate for clinical setting Document clear and concise responses to care in the electronic health record, where appropriate for clinical setting Identify information and clinical technology using critical thinking to collect, process, and communicate data Manage data, information, and knowledge of technology in an ethical manner Protect confidentiality of electronic health records

Professionalism Demonstrate core professional values (caring, altruism, autonomy, integrity, human dignity, and social justice) Maintain professional behavior and appearance Comply with the Code of Ethics, Standards of Practice, and policies and procedures of WAU, Department of Nursing, and clinical agencies Accept constructive criticism and develop plan of action for improvement Maintain a positive attitude and interact with inter-professional team members, faculty, and fellow students in a positive, professional manner Provide evidence of preparation for clinical learning experiences Arrive to clinical experiences at assigned times Demonstrate expected behaviors and complete tasks in a timely manner Accept individual responsibility and accountability for nursing interventions, outcomes, and other actions Engage in self evaluation Assume responsibility for learning

Spirituality Evidence peace, contentment, and joy in life rather than worry and anxiety Demonstrate self-control in stressful situations Admit errors in relationships, seeking forgiveness Demonstrate humility in relating to others Seek unity in relationships rather than creating division Encourage others instead of criticizing Show gentleness and kindness in interactions with others Treat needs of others as important as one’s own Demonstrate an attitude of servanthood Serve others expecting nothing in return

Level I Assessment of Spirituality

Level II Assessment of Spirituality Spirituality

Evidence peace, contentment, and joy in life rather than worry and anxiety Demonstrate self-control in stressful situations

Admit errors in relationships, seeking forgiveness Demonstrate humility in relating to others

Seek unity in relationships rather than creating division Encourage others instead of criticizing

Show gentleness and kindness in interactions with others Treat needs of others as important as one’s own Demonstrate an attitude of servanthood

Serve others expecting nothing in return

Level III Assessment of Spirituality Spirituality

Evidence peace, contentment, and joy in life rather than worry and anxiety Demonstrate self-control in stressful situations Admit errors in relationships, seeking forgiveness Demonstrate humility in relating to others

Seek unity in relationships rather than creating division Encourage others instead of criticizing

Show gentleness and kindness in interactions with others Treat needs of others as important as one’s own Demonstrate an attitude of servanthood

Serve others expecting nothing in return

Discuss your self-care and spiritual needs

Demonstrate the ability to help clients meet their spiritual needs within a multicultural multi-faith environment

Level III Assessment of Spirituality – Senior Synthesis Course Spirituality

Evidence peace, contentment, and joy in life rather than worry and anxiety

Demonstrate self-control in stressful situations Admit errors in relationships, seeking forgiveness Demonstrate humility in relating to others Seek unity in relationships rather than creating division Encourage others instead of criticizing

Show gentleness and kindness in interactions with others Treat needs of others as important as one’s own Demonstrate an attitude of servanthood

Level III Senior Synthesis (cont.)

Serve others expecting nothing in return

Lead a small group study relating to self-knowledge and personal growth

Discuss ways you can improve your relationships

Identify your self-care and spiritual needs Show knowledge of self-care behaviors leading to growth

Demonstrate the ability to help clients meet their spiritual needs within a multicultural multi-faith environment

Discuss the pursuit of continued spiritual growth, lifelong learning, and a personal contribution to the profession of nursing

Expected Student Outcome Related to Spirituality: MS in Nursing

• Demonstrate attributes supportive of spirituality within a multicultural, multi-faith

environment to facilitate self-awareness and meet spiritual needs of client and self.

Master’s Level Courses (cont.)

Course Objective

NURS516 Health Policy, Social Justice, and Ethics

Develop strategies nurses can implement as advocates for social justice and health policy regulations.

Assignments & Evaluation Field trips; Reflective reading and writing; Advocacy activities; Social justice paper

Relevance of Spirituality

• Advanced practice role • Nurse educator • Nurse administrator • Social justice • Direct patient care

WAU Evaluation Plan: MS in Nursing

• Practicum logs • Reflective writing • Self-assessment • Survey of students

How can we – as nurses and educators – grow spiritually?

• Challenge to Students during this year of “Be”.

• Seven Key points of advice:

CHALLENGE TO BE Be Free, Be Transformed, Be Immovable, Be Together

“Be”

This years theme: “Be” • Be loving God • Be Loving Others • Be Saturated in the Bible • Be Done with Self-Reliance • Be-Long to a Church • Be Guarded From the World • Be Testing All Things

1. Be Loving God Love God with all your heart and soul and mind and strength. It is the first and the great commandment (Matthew 22:37–38). Use your mind, your college-educated mind, to feed the fires of the heart with the fuel of truth.

2. Be Loving Others

The second commandment is like it. You shall love your neighbor as yourself (Matthew 22:39). Be a servant in college, not a self-preoccupied, self-exalting egoist. Loving your neighbor as you love yourself doesn’t start after college.

3. Be Saturated in the Bible

Ten minutes a day in the Bible will not cut it in this world. This is the very Word of God. Read it. Meditate on it. Memorize large portions of it.

4. Be Done with Self-Reliance Be done with all vainglory, self-sufficiency, and self-reliance, and cast yourself daily on the Lord to help you with everything — everything. Jesus said, “Without me you can do nothing” — nothing (John 15:5). Turn to him afresh and pray, pray, pray for his supply of strength and wisdom and grace to do everything you do.

5. Be-Long to a Church

Belong to a Bible-saturated, Christ-exalting, God-centered church that preaches the whole counsel of God, and be connected there with God’s people. Don’t wait till after college to be a mature, responsible church member.

6. Be Guarded from the World Guard yourself from craving what the world craves. If you find that hanging out with loosers is making you love what they love rather than helping them love what you love — the one you love — back off and fill yourself with love to truth and to God some other way. Same with media. If the computer, the phone, iPod, sms, Facebook, Snapchat, Instagram, Tweeter, the tablet is making you crave what is destructive to your soul, lay it down. Do what you have to do to be radically devoted to Jesus and his holiness.

7. Be Testing All Things Finally, you have one life to live. And it is not a good thing to experiment with it. What will make life work? God did not give you life to experiment with. He gave you life and he gave you a Book. It is not a matter of experimentation. It is a matter of application of God’s Word to everything. So trust him.

References

ANA & HMA, (2005). Faith Community Nursing: Scope and Standards of Practice. Silver Spring, MD: Nursesbooks.org.

Anandarajah, G. & Hight, E. (2001). Spirituality and medical practice:

Using the HOPE questions as a practical tool for spiritual assessment. American Family Physician, 63, 81-89.

Brush, B. & Daly, P. (2000). Assessing spirituality on primary care

practice. Clinical Excellence for Nurse Practitioners, 4(2), 67-71 Callister, L.C. , Bond, A. E., Matsumura, G., and Mangum, S. (2004,

May/June). Threading spirituality throughout nursing education. Holistic Nursing Practice, 160-166.

References Clark, J. (2009). A critical view of how nursing has defined

spirituality. Journal of Clinical Nursing, 18, 1666-1673. Cone, P.H. , & Giske, T. (2012). Teaching spiritual care – a

grounded theory study among undergraduate nursing educators. Journal of Clinical Nursing, 22, 1951-1960.

Flores, L., Shakhshir, P., & Lopez, M. (2014). Clinical evaluation

tools embodying AACN BSN essentials and six QSEN KSAs. QSEN Institute.

Retrieved from http://qsen.org/clinical-evaluation-tools-integrating-qsen-core-competencies-and-aacn-bsn-essentials

References

Gallia, K. (1996). Teaching Spiritual Care: Beyond Content. Nursing Connections, 9(3), 29-35

Lantz, C. M. (2007). Teaching spiritual care in a public institution:

Legal implications, standards of practice, and ethical obligations. Journal of Nursing Education, 46(1), 33-38.

Mauk, K. L., & Schmidt, N. K. (2004). Spiritual care in

nursing practice. Philadelphia, PA: Lippincott. ISBN: 0-7817-4096-7

References O’Brien, M. E. (2014). Spirituality in nursing. Standing on holy

ground. Burlington, MA: Jones & Bartlett. ISBN: 978-1-4496-9467-8

Wallace, M., Campbell, S., Grossman, S., Shea, J., Lange, J., &

Quell, T. (2008). Integrating spirituality into undergraduate nursing curricula. International Journal of Nursing Education Scholarship, 5(1), 1-13.

Walsh, T., Jairath, N., Paterson, M., & Grandjean, C. (2010).

Quality and safety education for nurses clinical evaluation tool. Nursing Education, 49(9), 517-522.

References

White, E. G. (2011). The ministry of healing. Guildford, UK: White Crow Books. ISBN: 9781907661327

OR White, E. (1942). The ministry of healing.

http://www.whiteestate.org/books/mh/mh.asp (may be downloaded free of cost)

Yilmaz, M., & Gurler, H. (2014). The efficacy of integrating

spirituality into undergraduate nursing curricula. Nursing Ethics, 21(8), 929-945.

Contact Information • Dr. Nancie Crespi, Director ncrespi@wau.edu • Dr. Tijuana Griffin, Associate Professor tgriffin@wau.edu • Dr. Bonnie Franckowiak bfrancko@wau.edu Washington Adventist University ▪ Takoma Park, MD