The Exploration of Reflection Teaching in the Course of
Spiritual Nursing with Respect to Nursing Students’ Spiritual Status
and the Abilities of Spiritual Nursing Care
Ya-Lie Ku, Assistant Professor Man-Hua Shen, Instructor
Department of Nursing, Fooyin University Ta-Liao District, Kaohsiung City, Taiwan
Nursing is the profession of holistic care, including physical, psychological, social, and spiritual care. However, nurses often lack the ability to give spiritual care a skill that should be cultivated starting during nursing education. The effectiveness of spiritual nursing education has been identified in the literature. The purpose of this study was to use reflection teaching to help nursing students improve their grasp of how to practically apply concepts of spiritual nursing. This study was conducted with 46 nursing students who took a course on spiritual nursing from September, 2010 to January, 2011. This reflection teaching was accomplished by having nursing students write their reflections in a journal each week responding to probing questions for each teaching unit in the course. It was projected that through using reflection journals, nursing students would enhance both their individualized learning experiences as well as group assignments. Results showed that more than 90% of the 46 nursing students improved in their reflection levels to become critical reflectors, with themes such as realization, adjustment, changing, adaptation, positivism, and application, which intertwined with the themes generated from the weekly reflection journals. Both quantitative and qualitative data from this study have empirically validated the effectiveness of reflection teaching in spiritual nursing for promoting nursing
students’ spiritual status and spiritual care abilities through improving their reflection levels.
Spiritual nursing started in the 1960s, but nursing education put little emphasis
on spirituality. Many studies also identified that nursing students were not competent
in spiritual care because they were not prepared by what they had learned about
spiritual care (Caranzaro, & McMukken, 2001; Keefe, 2005; McSherry, 2006; Ross,
2006; van Leeuwen, Tiesinga, Post, & Jochemsen, 2006). American Association for
College of Nursing (AACN) in 1998 and United Kingdom Central Council (UKCC)
in 2000 both have proposed that nursing education should instruct nursing students on
how to assess and care for the spiritual problems of patients; nevertheless, Meyer
(2003) identified that less than 6% of nursing curricula included spiritual topics.
Lemmer (2002) investigated nursing teaching plans in 132 universities and found that
few nursing faculties could define their spirituality and have enough knowledge to
teach nursing students about spiritual knowledge and interventions. Taylor, Mamier,
Bahjri, Anton, and Petersen (2008) again reported the lack of an evidence-based
nursing educator to teach nursing students about spiritual care. They found that it was
not clear as to the correct and appropriate ways and skills to instruct nursing students
about spiritual care; therefore, nursing students expressed difficulty in describing their
own spirituality accurately and felt a lack of preparation in being able to care for the
Literature has indicated the need for spiritual nursing education; however,
Granham (2008) found spirituality has seldom been listed in the development and
graduation criteria in nursing, or as part of the evaluation standard in nursing
practicum. Nevertheless, the effectiveness of spiritual nursing education has been
identified in the literature. van Leeuwen, et al. (2006) reviewed nine research articles
about spiritual education in nursing and identified the influence of spiritual education
on the spiritual care competence for health care professionals. Additionally, the
spiritual care competence of 97 nursing students was shown to have improved after
six weeks of spiritual care training (van Leeuwen, et al., 2006); the spiritual attitudes
and knowledge of nursing students were significantly different when compared before
and after taking a spiritual education course (Lovanio & Wallace, 2007). Furthermore,
Taylor, Mamier, Bahjri, Anton, Petersen (2008) used a quasi-experimental study
which identified significant improvement in the spiritual care attitudes, abilities,
experiences, and knowledge of 84 nursing students and 91 nurses after using
self-learning spiritual education materials.
Wallace, et al. (2008) developed a curriculum for spiritual nursing and integrated
it into 13 different nursing curricula, and they identified that the spiritual knowledge
and attitudes of 34 senior nursing students improved significantly after taking the
empirically validated a teaching course on spiritual care for a Masters nursing
program in Taiwan over 18 weeks, including classroom lectures, field trips, clinical
implications, and presentation-appraisal. Results identified four ways the Masters
nursing students were helped by the course: in identifying the symbolic meaning and
impact of religious rituals, clarifying the concepts of spiritual care, enabling the
students’ self-discovery of their personal values and spiritual needs, and providing the culture-bonded spiritual care plan. Despite the evidence in the literature indicating the
usefulness of spiritual nursing education, Ku (2010) investigated 39 nursing
universities in Taiwan and found that the majority of spiritual courses were merged
into hospice nursing as a teaching unit, with only 12 schools having spiritual nursing
(30.8%) as an independent course. However, spiritual nursing is different from
hospice nursing, and while spiritual characteristics and abilities must be a prerequisite
for a hospice nurse, these qualities are important for other areas of nursing, as well.
The author has taught a course on spiritual nursing since 2006 in 10 different systems
of classes. The majority of the nursing students were interested in the spiritual nursing
course, and evaluations of the course were satisfactory overall. However, nursing
students in the spiritual course often complained about not understanding how to
Purpose of the Study
The purpose of this study was to use reflection teaching to help nursing students
improve their grasp of how to practically apply concepts of spiritual nursing.
Chien (2008) emphasized that the importance of reflection teaching is for the
educators and learners to reflect their own teaching and learning process through
continuous reflection with the spiral circulation of improvement process. Literature on
reflection teaching included the impact on learning for both clinical nurses and
nursing school students. Liu, Lu, and Jeng (2004) invited 56 clinical nurses to view
the video depicting characteristics of a good nurse and had them reflect and discuss
the meaning of being a good or bad nurse. They identified six characteristics of being
a good nurse, such as being able to communicate, autonomic, being respectful, able to
have empathy for the patient, helpfulness, and honesty. Additionally, Shiau, Chang,
Rong, and Kang (2010) led eight psychiatric nurses in participating in a 3C (concern,
care, compassionate) growing group to explore therapeutic relationships, and results
indicated two themes - listening to the inner voices of the patients and helping patients
cope with difficulties. Finally, Chiang, Chen, and Sue (2006) applied reflection skills
in leading clinical nurses to think about ethical difficulties for SARS patients, and
Chiang (2006) also applied reflection skills in leading clinical nurses to think about
ethical issues concerning sexually violent predators.
Concerning classroom learning for nursing students, Kuo, Lee-Hsieh, and Wang
(2007) applied reflection teaching strategies in developing a caring curriculum and
had nursing students review their caring experiences to learn by reflection and
dementia, nutrition, activities for elders, and groups of nurses learning how to work
together to help the patient to increase self-learning by using reflection journals to
make them reflect on their own learning process and evaluate the extent of
approaching the education goals of this curriculum. Also in the area of elder care
courses, Barber (2008) conducted a phenomenological study with 11 senior nursing
students participating in a spiritual conference to explore their realization of
spirituality, and four interpretations from this study included listening to others’
stories, understanding the extent of spirituality, realizing the influence of the spiritual
conference on the nursing students themselves, and providing spiritual care.
Baldacchino (2008) suggested that the practice of self-reflection, consideration of case
studies, and small group discussion as non-traditional ways for nursing teachers to
improve nursing students’ understanding of spiritual care to accomplish holistic care.
Concerning practicum teaching strategies, Furtado (2005) used inspirational and
phenomenological studies to help nurses and nursing teachers develop their spiritual
practicum teaching skills through photography, drawing, and reviewing interview data
that identified areas in their personal lives and practicum behaviors that were
consistent. The study is seeing if those three types of reflection teaching helped the
teachers know and communicate about themselves better so they can teach better.
Catanzar and McMukken (2001) proposed that daily journal records in a community
nursing practicum course can improve the spiritual sensitivity of nursing students.
Rankin and DeLashmutt (2006) assigned 188 nursing students to a community crisis
center to conduct a faith-based community practicum through small group meetings,
and discussion revealed support for integrating reflection skills into the clinical
practicum. The nursing students expressed that use of reflection skills in the practicum
process helped them to find themselves and understand spiritual maturing. Mitchell,
use as the spiritual protocol for nursing students when caring for terminal patients,
and this map included three main themes for a spiritual assessment tool as self
spiritual assessment, trauma and self-healing, and power, peace, and security.
Overall, reflection teaching in nursing emphasizes value, nurse-patient
relationship, ethical issues, cultivating caring, and how to approach learning goals.
Additionally, teaching strategies in spiritual nursing education include self-reflection,
journals, a spiritual care map, small group meeting with a lecture format, photography,
drawing, interviews, life-review, oral history, conferences, case study, and small group
discussion being each group member sharing with the others. Although reflection
teaching has been applied to spiritual nursing education, no specific level of reflection
was identified in the literature for nursing studies. Boud, Keogh, and Walker (1985)
used reflection as the basis to derive six levels of reflection process, including
attending to feelings, association, integration, validation, appropriation, and outcome
of reflection. Attending to feelings means that a person could feel any experience
happened around him/her. Association means that a person could relate the new
experience with that was already known before. Integration means that a person could
view the relationship between various experiences. Validation means that a person
could determine the truth ideas and feelings that have results. Appropriation means
that a person could produce own knowledge. Outcome of reflection means that a
person could change his/her bad characters, and promote his/her spiritual status
merging into daily lives with compromising acting behaviors. Wong, Kember, Chung,
and Yang (1995) used the Boud, Keogh, and Walker (1985) reflection model as the
basis for Hong Kong registered nurses to take a 30-hour education course, which
involved writing in reflection journals. Results identified that 13.3% were
non-reflectors, 75.6% were reflectors (level 1, 2, 3), and 11.1% were critical reflectors
The reflection teaching in this study used probing questions in each teaching unit
as the core of the spiritual nursing course. Nursing students who took the teaching unit
wrote in reflection journals weekly in response to the probing questions to enhance
individual learning experiences. Reflection evaluation was conducted before and after
the spiritual nursing course by following the Boud, Keogh, and Walker (1985)
reflection model. Additionally, six groups of nursing students conducted a case
analysis to assess the spiritual problems of a patient and designed literature, music,
nature, or art spiritual nursing interventions to help solve the patient’s spiritual
problems to approach the goal of applying the spiritual nursing process.
Research Design and Sampling
This study used reflection teaching and evaluation at the same time in a course
on spiritual nursing. Students were from the two-year BSN nursing program and
elected to take the course from September, 2010, to January, 2011. The 51 students
taking the class were offered a book of 100 coupons as an incentive to participate in
this study, and 46 accepted. The following is the course description, and the seven
teaching topics with principles and the probing questions designed for use with the
weekly reflection journals.
Description of Course on Spiritual Nursing
This course mainly facilitated the students’ ability to experience their own
spiritual status through self-reflection and understanding of spiritual definitions and
theories, and the development process of human beings. Additionally, this course had
students analyze their own and others’ spiritual status in three dimensions of
relationship - with themselves, others, and with respect to faith, enhancing their
and art as spiritual nursing interventions to the nursing process of the patient to solve
his/her spiritual problems. This reflection teaching research merged into the course of
spiritual nursing required each nursing student to reflect and write in their reflection
journal weekly according to the seven teaching topics with principles and the probing
questions listed in Table 1.
Table 1: Teaching Topics with Principles and Probing Questions Topic Teaching Principles Probing Questions
Definitions of Spirituality
-Clarify values -Origins of life
-Definitions of spirituality from literature and experts
‧Write down your own definition of spirituality. Ask another person (your family member or friend) to write down his/her definition of spirituality. Compare the similarities and differences between your definition of spirituality, that of your family member or friend, and from literature and experts.
Developing Process of Spirituality
-Human beings development stages/inner healing /spiritual duties
-James Fowler - faith development stages
-Erik Erickson - human beings development stages and duties
Reflect on your own life development process. Which duties have you accomplished? Which duties do you perform best? Which duties do you perform worse? What kind of hurtful experiences have you encountered and how did you heal yourself?
Spiritual Assessment Skills -Sensitivity -Listening -Empathy -Mediation -Accompany
‧Accompany your family member or friend without saying anything and write down how you felt during this exercise.
‧Try to talk with a family member or friend and analyze the words he/she used, what was communicated without using words, and any spiritual words
Items of Assessment -Life philosophy
-Meaning and purpose of life -Submission/acceptance -Forgiveness/love -Hope/joy/peace
‧What do you think are the most important and valuable things?
‧What is the purpose of your life?
‧What are your feelings when you hear about criticism or negative rumors said about you behind your back? ‧What characteristics do you dislike about yourself? ‧What are some faults you cannot forgive yourself for? ‧What ways do you use to make yourself feel peaceful and stable?
‧What ways do you use to help you love yourself and be happy?
‧What are your wishes for yourself?
‧What things do you fear the most and how do you overcome them?
‧Which coping mechanisms should you focus on and enhance? How can you improve them?
Spirituality and Others
Items of Assessment -Relationships with family members
-Relationships with friends -Relationships with neighbors (strangers)
-Relationship with your spiritual mentor
‧Who is the closest and nicest to you among your family members?
‧Who do you have the most difficult relationship with among your family members? Do you want to repair your relationship with him/her? How could you repair it? ‧Who is the closest and nicest to you among your friends?
‧Who do you have the most difficult relationship with among your friends? Do you want to repair your relationship with him/her? How could you repair it? ‧Who is your neighbor (stranger)? How is your relationship with him/her?
‧Who is your spiritual mentor? How is your relationship with him/her?
‧Write down the things you did to hurt others or others did to hurt you on a piece of paper. Tear it up, and at the same time decide to forgive him/her.
Spirituality and Faith
Items of Assessment -The God of your faith -Your relationship with God -Rituals of faith
-Experiencing God and obtaining help from Him
Who is the God of your faith? What is your relationship with God?
What are the rituals of your faith, such as praying, reading religious verses, worship that your religious leader leads?
What is the process for experiencing God and obtaining power and help from Him?
Spirituality and Grief
-Definitions and assessment of grief
-Caring and services for the bereaved
-Individual and group grief counseling
‧What are your experiences of having a family member or friend die?
What was your grief process? ‧Make your own living will.
Research Process and Data Analysis
This reflection teaching research was conducted in three stages. First, the
investigator taught about seven spiritual topics with principles and listed the probing
questions for the nursing students to write about weekly in their reflection journals.
Then, using a case study, the researcher demonstrated the process of identifying the
spiritual problems the patient had by assessing three dimensions of relationship - with
self, others, and faith, and she designed spiritual interventions for each spiritual
problem using literature, music, nature, or art. Lastly, the 46 nursing students divided
into six groups and each group conducted a case analysis using the spiritual nursing
process the investigator had demonstrated.
Data analysis of this reflection teaching research consisted of three parts. The
status and spiritual care abilities before and after taking the course on spiritual nursing.
The nursing students evaluated themselves using both a 1-10 visual scale and the
Boud, Keogh, and Walker (1985) reflection model with six levels, including levels
1-3 (attending to feelings, association, and integration) as the reflectors and levels 4-6
(validation, appropriation, and outcome of reflection) as the critical reflectors. In
addition to the quantitative data, the qualitative data in the Boud, Keogh, and Walker
(1985) reflection model consisted of the reasons the nursing students reported as to
why they were or were not able to approach a particular reflective level. Finally,
content analysis was conducted in the seven different teaching units from picking out
the journals of 46 students for identifying the different types of themes.
A total of 46 nursing students (90.2%) completed evaluations of their own
spiritual status and spiritual care abilities before and after taking the course on
spiritual nursing. The first method of evaluation involved using a 1-10 visual scale.
The scores on the self-evaluation of spiritual status improved from 4.7 to 7.2, and the
level of spiritual care abilities improved from 4.4 to 7.1. A significant improvement
was identified in the scores for both spiritual status (p<.001) and spiritual care
abilities (p<.001) for the nursing students after taking the course on spiritual nursing.
Table 2: Spiritual Status and Spiritual Care Abilities of Nursing Students
Range Mean SD
Paire-t df Sig pre post pre post pre post
Spiritual Status 2-8 5-9 4.7 7.2 1.7 0.9 -9.083 45 .000** Spiritual Care Abilities 1-8 4-9 4.4 7.1 1.8 1.1 -9.765 45 .000**
Regarding the Boud, Keogh, and Walker (1985) six levels of reflection
evaluation model, the percentage of nursing students who achieved levels 1-3
increased from 52.2% to 97.8%. Similarly, the percentage of students achieving levels
4-6 improved from 21.7% to 95.7%. Conversely, the percentage of students not
achieving levels 1-3 decreased from 47.8% to 2.2% and was reduced from 78.3% to
4.3% of those not achieving levels 4-6. Table 3 shows the study results.
Table 3: Boud, Keogh, and Walker (1985) Six Levels of Reflection Evaluation
Levels/Testing Level 1-3 Level 4-6
Achieved Non-achieved Achieved Non-achieved Pre self-reflection 52.2% (N=24) 47.8% (N=22) 21.7% (N=10) 78.3% (N=36) Post self-reflection 97.8% (N=45) 2.2% (N=1) 95.7% (N=44) 4.3% (N=2) Qualitative Data
There were three types of qualitative data gathered in this study. Firstly, the
themes from the reasons written by the nursing students as to why they did or did not
achieve the different levels of reflection included realization, adjustment, changing,
adaptation, positivism, and application. Secondly, the themes generated from a sample
of seven reflection journals from among the 46 nursing students were that there was
no universal definition of spirituality, the shadows from different stages of
and listening to them, understanding oneself and others, forgiveness, repairing
relationships, understanding and developing faith, loss and sorrow. Finally, the six
groups of nursing students designed the literature, music, nature, and art interventions
for a case during the spiritual nursing process. For each unique spiritual nursing
intervention, the group first set the goal for the intervention according to the patient’s
spiritual needs and then searched for appropriate reading materials, songs, plants, and
pictures to draw for the case. The groups demonstrated the process of conducting
spiritual nursing interventions for the case in the classroom, and the investigator gave
suggestions to think about for further revision of the nursing interventions to better fit
the spiritual needs of the patient.
Discussion and Conclusion
Concerning quantitative data, this reflection teaching study with reflection
journals using probing questions showed that the nursing students improved
significantly in spiritual status and spiritual care abilities after taking the course on
spiritual nursing as indicated by self-evaluation using a 1-10 point visual scale. This
finding is similar to the results of several studies. The spiritual care competence of 97
nursing students improved after six weeks of spiritual care training (van Leeuwen, et
al., 2006); the spiritual attitudes and knowledge of nursing students were significantly
(Lovanio, & Wallace, 2007); 84 nursing students and 91 nurses showed significant
improvement in spiritual care attitudes, abilities, experiences, and knowledge after
using self-learning spiritual education materials (Taylor, Mamier, Bahjri, Anton, &
Petersen, 2008); and the spiritual knowledge and attitudes of 34 senior nursing
students improved significantly after taking an integrated curriculum of spiritual
nursing (Wallace, et al., 2008).
Additionally, regarding the Boud, Keogh, and Walker (1985) six levels of
reflection evaluation model, the percentage of reflectors (level 1-3) for nursing
students increased from 52.2% to 97.8%, and improved from 21.7% to 95.7% for
critical reflectors (level 4-6). It seems that before taking the course on spiritual
nursing more than half of nursing students evaluated themselves as reflectors, but less
than one-third considered to be critical reflectors. Nevertheless, both groups of
nursing students were processing into more than a 90% improvement in reflection
levels after taking the course on spiritual nursing. In other words, more than 90% of
nursing students who take the course on spiritual nursing could become critical
Concerning qualitative data, themes generated from nursing students’ reasons
about achieving or not achieving the various reflection levels included realization,
generated from seven reflection journals from among nursing students’ writings were
that there was no universal definition of spirituality, the shadows from different stages
of development and healing from those wounds, empathy through accompanying
people and listening to them, understanding oneself and others, forgiveness, repairing
relationships, understanding and developing faith, loss and sorrow. Similarly, in the
literature, Shih, Gau, Mao, Chen, and Kao Lo (2001) identified four ways Taiwanese
Masters nursing students were helped by a teaching course on spiritual care, which
were in identifying the symbolic meaning and impact of religious rituals, clarifying
the concepts of spiritual care; enabling the students’ self-discovery of their personal
values and spiritual needs; and providing the culture-bonded spiritual care plan.
Barber (2008) reported four interpretations from 11 senior nursing students
participating in a spiritual conference - listening to others’ stories, understanding the
extent of spirituality, realizing the influence of the conference on the nursing students
themselves and providing spiritual care. Shiau, Chang, Rong, and Kang (2010)
indicated two themes expressed by eight psychiatric nurses participating in a 3C
(concern, care, compassionate) growing group as being to listen to the inner voices of
the patients and to help patients cope with difficulties.
In conclusion, reflection teaching in the course on spiritual nursing helped 46
more than 90% becoming critical reflectors by the end of the class. Themes such as
realization, adjustment, changing, adaptation, positivism, and application intertwined
with the themes generated from the weekly reflection journals from the 46 nursing
students. Both quantitative and qualitative data from this study have empirically
validated the effectiveness of reflection teaching on spiritual nursing for promoting
nursing students’ spiritual status and spiritual care abilities through improving their
The author wishes to thank the 46 two-year BS nursing students for their
participation and cooperation. Most sincere thanks are extended to the six group
leaders for the 46 nursing students who assisted in the spiritual nursing process during
the case analysis.
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