Nursing Student Perceptions of Spirituality and Spiritual Care

The Journal of Nursing Research h VOL. 20, NO. 3, SEPTEMBER 2012 Nursing Student Perceptions of Spirituality and Spiritual Care Li-Fen Wu 1 * & Yu-Chen Liao 2 & Dah-Cherng Yeh 3 1 RN, PhD, Associate Professor, Department of Nursing, National Taichung University of Science of Technology & 2 RN, Department of Nursing, Taichung Veterans General Hospital & 3 MD, Attending Doctor, Department of Surgery, Taichung Veterans General Hospital. ABSTRACT Background: Spirituality is a necessary component of life. Spiritual care includes the activities necessary to meet the spiritual needs of clients. Nursing students must receive appropriate training to develop their abilities to provide spiritual care. Purpose: This study explored student nurse perceptions of spirituality and spiritual care and related factors. Methods: We used a cross-sectional descriptive design and purposive sampling. Participants were senior nursing students of both genders from 22 schools. The Chinese version of a spirituality and spiritual scale was the research tool. A total of 239 participants returned the questionnaires, giving a response rate of 91.92%. Results: Average participant age was 19.48 years; 45.61% reported no religion; 65.59% did not participate in religious activities; 94.56% reported having an interest in nursing; 52.72% were undecided about pursuing a nursing career; 3.35% did not want to be nurses; 46.44% had taken spirituality courses in school; 53.56% had taken spiritual care courses. Participants overall perception of spirituality and spiritual care was clear. This runs contrary to the idea that only religious people are spiritual and that nonreligious nurses may be less able to tend to the spiritual needs of their patients. Participants who had taken spirituality or spiritual care courses had an interest in nursing and were willing to become nurses had, on average, significantly better spirituality knowledge and spiritual care attitudes than other participants. Conclusions/Implications for Practice: This study found that education, experience, career interest in nursing, and career choice affects nursing student perceptions of spirituality and spiritual care. We also found that this effect was independent of gender. Nursing students should be holistic care providers. Integrating spirituality and spiritual care into the standard nursing curriculum is recommended to improve nursing care quality. KEY WORDS: nursing student, spirituality, spiritual care, perception. Introduction The term spirituality traces its origins to the Latin word spiritual, meaning breath and to bring to life. The essential components of life and living can be expressed by exploring the meaning of life and purpose beyond physical limitations (Wu & Hsiao, 2009). Spirituality is derived from traditional cultures and religion and is learned from and integrated into education and personal life experience (Tu, 2008). Spirituality is reflected in individual attitudes and behavior in daily life. When a person faces a major setback or loss, spiritual expression becomes even more apparent. Spiritual care involves activities that meet patient spiritual needs. Spirituality in most textbook addresses two different functions, namely, (a) supports the original religious and spiritual activities of the patient and (b) provides therapeutic use of self. The former includes encouraging patients to maintain their original religious/spiritual activities. The latter emphasizes the attitude of nurses, including companionship, listening, respect of and care for patients, and direct discussion of the meaning of life, purposes, hope, and values (Pesut, 2008). Numerous previous studies have suggested that spirituality is the essence of human beings and plays a vital role in people s lives. As the healthcare system becomes increasingly complex, there is a professional requirement for nurses to enhance their competence in spiritual care delivery and assess and meet the spiritual needs of their patients. Studies in both western countries (Greenstreet, 1999) and East Asia (Chung, Wong, & Chan, 2007) agree about the importance of teaching spirituality to nurses. These studies suggest that patients want nurses to discuss spiritual matters with them. Nursing students recognition of patients spiritual care needs will improve overall nursing care quality. Research exploring nursing students preparations and perceptions of education in this important area are rare. This study explores student nurse perceptions of spirituality and spiritual care and the influence of demographics on such perceptions. Accepted for publication: April 18, 2012 *Address correspondence to: Li-Fen Wu, No. 193, San-Min Rd. Sec. 1, Taichung 40343, Taiwan, ROC. Tel: +886 (4) 2219-6990; E-mail: lily0927@gmail.com doi:10.1097/jnr.0b013e318263d956 219

The Journal of Nursing Research Li-Fen Wu et al. Literature Review The Joint Commission on Accreditation of Healthcare Organization and International Council of Nurses (ICN) have stipulated that spiritual care be integrated into nursing care (International Council of Nurses, 2006; Joint Commission on Accreditation of Healthcare Organization, 2004). Reed identified spiritual care as the core of nursing in 1992 and presented a paradigm to frame investigations of spirituality in nursing. Elements in that paradigm include assumptions about the self-transcendent nature of human beings, as derived from the developmentalycontextual worldview; a description of spirituality regarding various forms of connectedness integral to human development and health; and assumptions about the empirical and multidimensional nature of spirituality. Studying spirituality from the perspective of the paradigm entails intrapersonal, interpersonal, and transpersonal examination of the multiple expressions of connectedness, as related to human health and wellbeing. Mueller, Plevak, and Rummans (2001) suggested that most patients have a spiritual life and value spiritual and physical health equally. Spiritual needs may increase during illness. Mueller et al. found spirituality associated with more favorable health outcomes, including greater longevity, coping skills, and health-related quality of life (even during terminal illness), as well as less anxiety, depression, and fewer instances of suicide. Care, protect, trust and respect is the core of spiritual care (Tu, 2008). The valued practices most frequently provided by nurses are listening (23%) and accompaniment (12%; Tuck, Wallace, & Pullen, 2001). McSherry and Jamieson (2011) in their online survey of 4,054 nurses perception of spirituality and spiritual care discovered that nurses across the full health economy in the United Kingdom consider spirituality to be a fundamental aspect of nursing. This indicates that nurses recognize the value of attending to the spiritual needs of patients to enhance overall nursing care quality. Pesut (2002) explored how students in a baccalaureate curriculum perceived their spirituality and spiritual health as well as their perceptions of spiritual nursing care. They discovered that they placed less emphasis on nursing agendas and qualities and more on supporting the patient s beliefs. Callister, Bond, Matsumura, and Mangum (2004) surveyed 132 baccalaureate nursing programs in the United States and found that few had defined spirituality or spiritual nursing care. There is a paucity of literature on spirituality in the field of nursing education. Chung et al. (2007) discovered a positive correlation between nursing students self-perception values and attitudes toward practicing spiritual care. Wallace et al. (2008) integrated spirituality into undergraduate nursing curricula and measured student outcomes related to spiritual knowledge and attitudes. Their research revealed significant differences in spirituality knowledge and attitudes among senior-level nursing students. Abundant research shows that nurses perceptions of their own spirituality influence the degree to which patients spiritual needs are identified and how interventions are planned and implemented (Chan et al., 2006; Chung et al., 2007). Chung et al. (2007) discovered a positive correlation between nursing students self-perception values and attitudes toward practicing spiritual care. Consequently, understanding nursing students perception of spirituality and spiritual care can establish baseline data for adjusting curricula. Integrating such content into nursing courses can help achieve holistic care. Methods Research Design This study used a cross-sectional descriptive design and employed a survey questionnaire to solicit responses from all associate nursing degree programs in Taiwan. Twenty-one schools were included in this research. GPower v3.1 software conducted t test (two-way) analyses to identify the point at which the alpha error probability reached.05, the power 1j" error =.95, and the sample size necessary (210) to achieve an actual power of.95. Purposive sampling selected participants from 26 nursing colleges. Participants were final year or senior nursing students with clinical internship experience. Researchers recruited an equal number of female and male nursing students from each school. A total of 260 senior nursing students were enrolled as participants. Participants had already finished most of their nursing courses. Instrument A data sheet was designed to collect information on participant demographics, including gender, age, interest in nursing, future career, religion, frequency of participation in religious activities, and levels of spirituality and spiritual care content in school curriculum. We used the Chinese version of the Spirituality and Spiritual Care Rating Scale (SSCRS-C) as our study tool. McSherry, Draper, and Kendrick (2002) developed the original SSCRS, which included the four subscales of (a) spirituality, (b) spiritual care, (c) religiosity, and (d) personalized care. Each statement in the SSCRS was rated on a 5-point Likert-type scale ranging from strongly disagree to strongly agree. Positively worded items were scored 1Y5; negatively worded items were scored in reverse order. In general, higher scores indicated a higher level of spirituality or spiritual care perception. The Cronbach s alpha coefficient for the SSCRS was.80, demonstrating a reasonable level of internal consistency reliability (McSherry & Jamieson, 2011). We received permission from the copyright owner to use the scale and used translation and back-translation to retain validity. Nine nursing scholars examined the SSCRS-C for semantic equivalence and content validity. The content validity index for the SSCRS-C was.98. A pilot study of 50 nurses substantiated research instrument efficacy and suggested the instrument be completed within 15Y20 minutes. The internal consistency (Cronbach s alpha) of study data was.793. 220

Student Perceptions of Spirituality and Spiritual Care VOL. 20, NO. 3, SEPTEMBER 2012 Operational Definitions Nursing students (participants): Nursing students enrolled in this study were all final year or senior nursing students with clinical internship experience. Perception of spiritual and spiritual care: Determined using scores on the SSCRS-C. Spiritual course: A course or part of a course that provides a personal sense of meaning and life purpose. Such is not confined to specific religious beliefs or practices and may address such issues as life education, or spiritual development. Spiritual care course: A course or part of a course that associates spiritual care with interpersonal care quality. Such may include assisting an individual to find meaning and purpose in their illness, listening attentively to a patient, enabling an individual to maintain their religious practices while in the hospital, maintaining privacy and dignity, validating client feelings and thoughts, facilitation, instilling hope, expressing love and compassion toward patients, and conveying a benevolent attitude through hospice/palliative care, spiritual care, and so on. Data Collection and Analysis The researchers communicated with the heads of nursing departments at participating schools through both official and personal channels. Questionnaires and informed consent were sent to the schools by mail. The office of the nursing departments helped distribute and collect the questionnaires. Confidentiality and anonymity in handling data were assured. A total of 260 questionnaires were distributed, with 239 completed questionnaires returned and included in analysis (response rate = 91.92%). Table 1 summarizes participant demographic information. This study used descriptive statistics to present participant demographic characteristics. An independent t test and one-way analysis of variance (ANOVA) determined differences in participant perceptions of spirituality and spiritual care provision and in participant demographic characteristics. Level of significance was set at.05. Ethical Consideration The institutional review board of National Taichung Nursing College approved this study. After confirming eligibility, participants received an explanation of the purpose of the study and an assurance of confidentiality for all test data. Results There was a roughly equal amount of male and female participants (114 men [47.70%] vs. 125 women [52.30%]). Participant ages ranged from 19 to 22 years (mean = 19.48 years, SD = 1.13 years). Nearly half (45.61%, n = 109) had no religious beliefs, 12.55% (n = 30) were Buddhist, 20.50% TABLE 1. Participant Demographic Characteristics (N = 239) Characteristic n % Male 114 47.70 Female 125 52.30 Religion None 109 45.61 Buddhist 30 12.55 Taoist 49 20.50 Christian 19 7.95 Catholic 3 1.26 Folk beliefs 13 5.44 Others 5 2.09 Two or more 11 4.60 Frequency of religious activity None 157 65.69 1Y2 times/week 17 7.11 3Y5 times/week 4 1.67 1 time/month 18 7.53 1 time/several month 25 10.46 1 time/year 8 3.35 Seldom 10 4.18 No interest 13 5.44 Moderate interest 161 67.36 Strong interest 65 27.20 Not nursing 8 3.35 Uncertain 126 52.72 Nursing 105 43.93 Took a spirituality course in nursing school Yes 111 46.44 No 128 53.56 Took a spiritual care course in nursing school Yes 82 34.31 No 157 65.69 Note. Mean age = 19.48 years, SD = 1.13. (n = 49) were Taoist, 7.95% (n = 19) were Protestant, 1.26 % (n = 3) were Catholics, 5.44% (n = 13) held folk beliefs, and 4.60%(n = 11) held two or more beliefs. Most (65.69%, n = 157) were not involved in religious activities. Most reported a career interest in nursing (67.36% expressed moderate interest; 27.20% expressed strong interest), and a small minority (5.44%, n = 13) had no interest in nursing. Slightly over two fifths (43.93%, n = 105) had already decided to pursue a nursing career after graduation, 52.72% (n = 126) were uncertain, and 3.35% (n = 8) indicated a career choice other than nursing. Approximately half (46.44%, n =111) had taken a spirituality course in nursing school, and the other half had not (53.56%, n = 128). Most (65.69%, 221

The Journal of Nursing Research Li-Fen Wu et al. n = 157) had not taken a spiritual care course in nursing school, with only 82 (34.31%) having done so (Table 1). The mean score for the SSCRS-C was 4.00 (SD =0.58), indicating that student nurses perceptions concerning spirituality and spiritual care were clearly defined. Results for the four subscales are as follows: (a) Spirituality: M = 4.19, SD = 0.54. The five variables in this subscale addressed issues concerning living with meaning and purpose and the need to find such during times of illness or hospitalization. Responses showed that participants tended to agree that spirituality incorporates existential elements. (b) Spiritual care: M = 3.44, SD = 0.86. This subscale s five variables addressed issues concerning the main principles associated with spiritual care. Participants were uncertain that nurses must listen, spend time, respect privacy and dignity, maintain religious practices, and deliver care by displaying qualities such as kindness and concern. (c) Religiosity: M = 4.01, SD = 0.65. The three variables in this subscale addressed the idea that spirituality goes beyond religion to embrace universal values, the composition of which are unique to each individual. Apparently, participants opposed the idea that spirituality applies only to religious people. (d) Personalized care: M = 3.87, SD = 0.43. Three variables measured the underlying associations with the dimension of spirituality, which is dictated by the need to accommodate personalized care (e.g., individual beliefs, values, and morals). Participants were uncertain that nurses must accommodate personalized care (Table 2). The t test and ANOVA results indicated a statistical significance in the mean score for SSCRS-C between participants in different spirituality courses (t = 2.75, p =.01) and spiritual care courses (t = 2.24, p =.03). significantly influenced the spiritual care subscale (t = j2.12, p =.04; Table 3). Considering the mean SSCRS-C score, the ANOVA identified a statistically significant relationship between interest in nursing (F = 8.13, p G.01) and future career (F = 9.69, p G.01). The Scheffe s test for the post hoc test showed that participants having either strong or moderate interest in a nursing career had a higher score than those who had no interest. Participants expressing a desire for a future career in nursing or those who were uncertain about becoming a TABLE 2. Participant Performance on the Spirituality and Spiritual Care Rating Scale Chinese Version (N = 239) Variable n Min Max M SD Total score 239 1.00 5.00 4.00 0.58 Subscale 1: Spirituality 239 1.60 5.00 4.19 0.54 Subscale 2: Spiritual care 239 1.00 5.00 3.44 0.86 Subscale 3: Religiosity 239 1.67 5.00 4.01 0.65 Subscale 4: Personalized care 239 2.00 4.82 3.87 0.43 nurse had a higher score than those who lacked interest in a nursing career (Table 4). Discussion Findings provide insight into senior nursing student perceptions of spirituality and spiritual care in Taiwan. Their perceptions concerning spirituality and spiritual care were clearly, although not very clearly, defined. Participants agreed on the issues concerning living with meaning and purpose and the need to find meaning and purpose during times of illness and hospitalization. Responses showed that they tended to agree that spirituality incorporates existential elements and agreed that spirituality went beyond religion to embrace universal concepts that affected each individual uniquely. Participants opposed the notion that spirituality applies only to religious people. Our results were consistent with Wong, Lee, and Lee (2008), who found a satisfactory understanding of spirituality and appreciation of providing spiritual care to patients among nurses, and inconsistent with Ozbasaran, Erqul, Temel, Aslan, and Coban (2011), who found nurse perceptions of spirituality and spiritual care to be uncertain and unclear. Wu and Lin (2011) found that education positively impacted participant perceptions of spirituality and spiritual care. A higher education level and more spiritual care lessons or training courses were found to increase perception level. Participants in our study expressed uncertainty about issues related to the main principles of spiritual care such as listening, spending time with patients, respecting patient privacy and dignity, maintaining religious practices, and delivering care with kindness and concern. Participants also expressed uncertainty regarding whether nurses could accommodate personalized care in accordance with, for example, individual beliefs, values, morals, and relationships. On this point, Chan (2010) found experienced nurses had higher levels of spiritual care perception. The relatively low spiritual care score earned by participants in our study may be because of their minimal clinical experience. Study findings indicate that gender has a significant impact in the spiritual care subscale. Neuman and Fawcett (2010) wrote that people are a complex system comprising five dimensions: physiological, social, cultural, spiritual, and developmental. Spirituality runs through all systems and affects a person s wellness level. Young people experience the most physical and psychological changes. Their spiritual needs at this stage involve looking for the meaning of life, purpose and hope (Benson & Roehlkpartain, 2008). Hendricks-Ferguson (2006) explored whether gender and age influence hope and spiritual wellness in young people. Although they found that women have a higher spiritual wellness than men of the same age, they noted no significant difference in religious practices between men and women. Women have been identified as more willing to share their love with others (Meleis, 2007; Stott, 2007), which may explain why female nursing students have a 222

Student Perceptions of Spirituality and Spiritual Care VOL. 20, NO. 3, SEPTEMBER 2012 TABLE 3. Mean Differences in the Spirituality and Spiritual Care Rating Scale Chinese Version With Different Demographics Data (N = 239) Total Score Variable n M SD t p Male 114 3.81 0.45 Female 125 3.91 0.39 j1.82.07 Spirituality course in nursing school Yes 111 3.95 0.36 2.75.01* No 128 3.80 0.45 Spiritual care course in nursing school Yes 82 3.95 0.33 2.24.03* No 157 3.82 0.46 Subscale 1: Spirituality Male 114 3.94 0.65 j1.59.11 Female 125 4.06 0.51 Spirituality course Yes 111 4.07 0.53 1.83.07 No 128 3.94 0.62 Spiritual care course Yes 82 4.07 0.45 1.26.21 No 157 3.97 0.64 Subscale 2: Spiritual care Male 114 4.11 0.55 j2.12.04* Female 125 4.26 0.52 Spirituality course Yes 111 4.27 0.51 2.24.03* No 128 4.11 0.55 Spiritual care course Yes 82 4.29 0.41 2.20.03* No 157 4.14 0.59 Subscale 3: Religiosity Male 114 3.36 0.96 j1.41.16 Female 125 3.51 0.76 Spirituality course Yes 111 3.45 0.90 0.14.89 No 128 3.43 0.83 Spiritual care course Yes 82 3.44 0.83 j0.04.10 No 157 3.44 0.88 Subscale 4: Personalized care Male 114 3.98 0.73 j0.62.54 Female 125 4.03 0.57 Spirituality course Yes 111 4.15 0.56 3.32 G.01** No 128 3.88 0.69 Spiritual care course Yes 82 4.13 0.50 2.37.02* No 157 3.94 0.70 *p G.05. **p G.01. 223

The Journal of Nursing Research Li-Fen Wu et al. TABLE 4. Mean Differences in the Spirituality and Spiritual Care Rating Scale Chinese Version Between Participants With Different Interests and Future Careers (N = 239) Variable Total Score n M SD F p Scheffe s Test ffinot interested 13 3.43 0.61 8.13 G.01** ffl9ffi fflmoderately interested 161 3.87 0.35 ƒ9ffi ƒstrongly interested 65 3.93 0.48 ffinot nursing 8 3.26.66 9.69 G.01** ffl9ffi ffluncertain 126 3.86.40 ƒ9ffi ƒnursing 105 3.91.40 Subscale 1: Spirituality ffinot Interested 13 3.43 0.96 7.20 G.01** ffl9ffi fflmoderately interested 161 4.01 0.48 ƒ9ffi ƒstrongly interested 65 4.08 0.66 ffinot nursing 8 3.10 1.06 11.38 G.01** ffl9ffi ffluncertain 126 3.99 0.51 ƒ9ffi ƒnursing 105 4.08 0.57 Subscale 2: Spiritual care ffinot Interested 13 3.72 0.66 5.60 G.01** ffl9ffi fflmoderately interested 161 4.20 0.47 ƒ9ffi ƒstrongly interested 65 4.25 0.62 ffinot nursing 8 3.50 0.58 7.87 G.01** ffl9ffi ffluncertain 126 4.18 0.50 ƒ9ffi ƒnursing 105 5.28 0.54 Subscale 3: Religiosity Not Interested 13 3.54 0.79 1.23.30 Moderately interested 161 3.38 0.86 Strongly interested 65 3.57 0.86 Not nursing 8 3.29 0.93 0.82.44 Uncertain 126 3.38 0.85 Nursing 105 3.52 0.86 Subscale 4: Personalized care ffinot Interested 13 3.23 0.77 10.73 G.01** ffl9ffi fflmoderately interested 161 4.05 0.60 ƒ9ffi ƒstrongly interested 65 4.07 0.64 ffinot nursing 8 3.42 0.97 3.95.02* ffl9ffi ffluncertain 126 3.99 0.66 ƒ9ffi ƒnursing 105 4.07 0.58 *p G.05. **p G.01. 224

Student Perceptions of Spirituality and Spiritual Care VOL. 20, NO. 3, SEPTEMBER 2012 higher perception of spirituality and spiritual care than their male counterparts. This study found that spirituality and spiritual care dimensions are not formally established in Taiwan s nursing curricula. Half of the participants had attended no spiritual classes (53.56%, n = 128) or spiritual care classes (65.69%, n = 157) in nursing school. Some complained that Nursing education did not adequately prepare us to provide spiritual care during our hospital internship and Nursing education should play an important role in preparing us for the challenge of caring for patient spiritual needs. Similarly, Wong et al. (2008) explored Hong Kong nurse perceptions of spirituality and spiritual care and suggested increasing the emphasis on spirituality in undergraduate education. Lovanio and Wallace (2007) concluded the spiritual dimension of holistic nursing to be an area neglected in nursing education. Keefe (2005) also found that spirituality has received far less attention in nursing curricula and that nursing students often lack a strong foundation in this area. Even before these studies, some professors claimed that not including such in nursing programs was a barrier to the delivery of spiritual care (Smith & Mcsherry, 2004; Stranahan, 2001; Vance, 2001). Stranahan found 58% of surveyed practitioners felt their education was inadequate or somewhat inadequate to prepare them to provide spiritual care (Stranahan, 2001). Vance (2001) concurred with Stranahan s findings, determining that 65% of surveyed nurses identified insufficient spiritual education as a barrier to providing spiritual care. This is the first study from the perspective of nursing students to identify the spiritual care needs of nursing courses. Thus, the nursing education system in Taiwan should pay greater attention to spiritual care issues, as many other countries do. In this study, participants with a strong career interest in nursing had higher perceptions of spirituality and spiritual care than those with no interest, and participants who had already chosen a nursing career earned higher scores than those who had already decided not to pursue a career in nursing. Similar to our findings, Baldacchino (2008) reported on a cohort study of 65 recently graduated nursing students. The students participated in a written self-reflection exercise designed to elicit the perceived impact of a study unit on students lives. A total of 97% of the students completed this written exercise, demonstrating student interest in this study unit and supporting that interest is the basis of nursing commitment. Positive feedback from students sheds light on the importance of teaching the spiritual dimension of nursing to undergraduate students. Career interest leads to people having more stable and lasting psychological tendencies to certain professional activities. Certain personality tendencies have been shown to be more prone to explore an occupation or engage in professional activities than others. Such allows an individual to give priority to and make an emotional investment in a profession. Career interests have a certain impact on career choice and career development. Our research finding shows perception of spirituality and spiritual care differed based on career interest and career choice. We suggest that nursing schools provide more information to students before enrollment to help give them a deeper understanding of nursing as a career. Conclusions Nurses are in an ideal position to provide spiritual care and influence physical and mental health positively. If students lack adequate spiritual education, the spiritual dimension of holistic care may never be adequately addressed. Furthermore, there has been little discussion on student nurse perceptions of spirituality and spiritual care in Taiwan. On the basis of the research findings, we suggest that holistic nursing should receive greater attention in nursing education and that the spiritual perspectives of students should be addressed. We conclude that spirituality and spiritual care must be implemented in nursing curricula to enhance nursing students awareness of spirituality and attitudes toward spiritual care. Limitations The gender ratio used in this study was nearly equally divided between women and men (52.3:47.7). All participants were students currently enrolled in nursing junior college. The Cronbach s alpha of SSCRS-C in this study was.793. Nearly half (n = 109, 45.61%) of participants reported practicing no religion, and some religious affiliations had only a small number of adherents among participants. It is improper to compare the inherent differences between religions when addressing nursing student perception of spirituality and spiritual care. Future studies should increase the number of samples to facilitate analysis. Acknowledgments This study was partially supported by a grant from Taichung Veterans General Hospital/National Taichung Nursing College Joint Research Program (TCVGH- NTCNC 1008501). The authors sincerely thank all the participating schools and the students involved, and Yu- Jing Tsai for helping with data processing. References Baldacchino, D. R. (2008). Teaching on the spiritual dimension in care: The perceived impact on undergraduate nursing students. Nurse Education Today, 28(5), 501Y512. doi:10.1016/ j.nedt.2007.09.002 Benson, P. L., & Roehlkpartain, E. C. (2008). Spiritual development: A missing priority in youth development. New Directions for Youth Development, 118, 13Y28. doi:10.1002/ yd.253 Callister, L. C., Bond, A. E., Matsumura, G., & Mangum, S. (2004). Threading spirituality throughout nursing education. Holistic Nursing Practice, 18(3), 160Y166. 225

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The Journal of Nursing Research VOL. 20, NO. 3, SEPTEMBER 2012 1 * 2 3 1 2 3 22 260 239 91.92% 19.48 45.61% 65.69% 94.56% 52.72% 3.35% 46.44% 53.56% 101 4 18 * 40343 193 04 22196990 E-mail: lily0927@gmail.com 227