Spiritual Care in the Undergraduate Nursing Degree in Portugal
1
Institute of Health Sciences, Center for Interdisciplinary Research in Health Palma de Cima, Universidade Católica Portuguesa, 1649-023 Lisbon, Portugal
2
NURSE’IN Nursing Research Unit for South and Islands, Polytechnic Institute of Setúbal, School of Health, 2914-503 Setúbal, Portugal
*
Author to whom correspondence should be addressed.
Educ. Sci. 2023, 13(3), 273; https://doi.org/10.3390/educsci13030273
Submission received: 20 December 2022
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Revised: 7 February 2023
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Accepted: 1 March 2023
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Published: 4 March 2023
(This article belongs to the Special Issue Faith, Religion, and Global Higher Education)
Abstract
:Spiritual care is an essential dimension of holistic care. The purpose of this study was to identify the explicit presence of spiritual care in undergraduate nursing curricula in Portugal. Data were collected through a search in the syllabuses of undergraduate nursing degrees as displayed on the websites of higher education institutions (HEI). Of the 36 HEI, none had a course unit entitled (with title or subtitle) spirituality or spiritual care, even though all the HEI describe a common mission related to preparing nursing students for holistic care.
1. Introduction
A person is not only a body nor a bio-psycho-social being; today, the spiritual dimension is considered in a holistic or integral perspective. Therefore, making spiritual care accessible to all who use healthcare services should not be considered an option but an ethical and legal imperative for holistic care.
Relevant international organizations highlight the importance of spirituality for health and the urgency of nurses providing spiritual care [1]. Spirituality can be defined as a “dynamic dimension of human life that relates to the way persons (individual and community) experience, express and/or seek meaning, purpose and transcendence, and the way they connect to the moment, to self, to others, to nature, to the significant and/or the sacred” [2].
Studies concerning spirituality demonstrate the positive effects on patients’ health outcomes, such as the coping strategies that facilitate overcoming crises or struggling experiences [3], gratitude, the meaning of life, and forgiveness [4]. Furthermore, nurses consider attending to spiritual needs a part of their role [5], even though the effective provision of spiritual care may require a collaborative relationship with other professionals, such as chaplains, for example [6]. Despite this evidence, spiritual care provision is often described as neglected. Some barriers have been related in the literature to justify this situation. Still, the lack of undergraduate nursing degree training has been considered one main etiologic factor [7]. Additionally, attention should be given to the fact that many students probably have no previous education in spirituality [8].
Due to the subjectivity of the theme and the fact that it is a personal and exclusive experience, although lived in a relationship, the question of whether spirituality and spiritual care can be taught may arise. According to Ross et al. (2018), the delivery of spiritual care requires professional skills and attitudes that may be related to personal characteristics [9]. Nonetheless, the competencies to provide spiritual care may be learned and trained, starting in nursing undergraduate degree programs. Nursing education requires students to complete their degrees with skills and competencies in providing holistic care to the fullest, and to do so safely, respectfully, compassionately, and while preserving patient dignity [9].
In order to be able to provide holistic care, nursing students must develop their holistic competencies, which include professional, intellectual, spiritual, physical, and psychological dimensions [10]. Only by acknowledging religious, spiritual, and belief diversity is holistic care possible, and there must be teaching about these diversities [11].
According to Chiang et al. (2020), there is a positive relationship between spiritual education and spiritual competencies, thus emphasizing the need for spiritual education as an integral and regular part of nursing course curriculum. Nursing teachers also recognize the importance of spirituality and spiritual care in the nursing curriculum [7].
A recent study evaluated the frequency of spiritual care provided by nurses, verifying that for effective implementation of spiritual care in nursing practice, more excellent knowledge and investment are essential. Thus, schools have an important role in this endeavor [12]. So, teaching spirituality in undergraduate nursing degrees seems a key element in improving spiritual competencies [3,9]. Interestingly, this subject has been discussed in the literature many times, and Shores (2010) has considered that nursing curricula should be improved regarding students’ awareness and knowledge of spirituality [13].
Many educational strategies have been implemented and published, but the lack of consensus and a systematic approach remains, and this compromises the inclusion in curricula. Recently, the EPICC project (Nurses’ and Midwives’ Competence in Providing Spiritual Care through Innovative Education and Compassionate Care) has been implemented as a turning point in nursing education for spiritual care and spirituality by involving multiple partners and experts from different European countries, thus providing a systematic, consensual, and effective response to a need identified more than 30 years ago [14].
There are many studies on the importance of spirituality and spiritual care in health and well-being, the frequency of its provision, the competence perceived by students and nurses, its importance in teaching, and the best strategies to adopt. However, it has yet to be determined whether, currently, syllabuses reflect the learning of this essential dimension for holistic care. This work is part of the Ph.D. study about educational aspects of spiritual care in nursing aiming to understand the teaching process regarding the spiritual care of undergraduate nursing students in Portuguese schools.
School curricula and respective syllabuses are not random. They are influenced by the competencies designated by the Dublin descriptors (qualifications frameworks, under Bologna process, for evaluating students for bachelor’s, master´s, and doctoral degrees) as suitable for the academic degree, the international and national guidelines, and the professional identity that the educational institution wants to promote in its students. The choice of different curricula results from reflexive and intentional processes in each institution. Regardless of the autonomy of the HEI, but believing in the importance of spiritual care for holistic care, this brief research aimed at mapping the formal reference of spiritual care in undergraduate nursing degrees in Portugal. To do this, we ask the following research question: Is there proper evidence of teaching spiritual care through independent curricular units in undergraduate nursing degrees in Portugal?
2. Materials and Methods
This is an exploratory study for the purpose of obtaining a deeper and complete knowledge on the state-of-the-art on spiritual care in undergraduate nursing degree curricula in Portugal, aiming at developing a case study as the main research in the next phase. Data were collected in September 2022 and the sample consisted of all undergraduate degrees in all HEI that teach undergraduate nursing degrees in Portugal.
Initially, a search was carried out on the website of the Portuguese General Directory of Higher Education (dges.gov.pt) of all national institutions that teach undergraduate nursing degrees. A double-entry table was created as an excel database with each column containing a nursing school and with rows containing the various curricular units as presented on the websites of each school.
Our objective was to identify the terms spirituality or spiritual care in the title of the curricular unit. For this purpose, research was carried out with the spiritual* research term in the designation of the curricular unit. We excluded the optional curricular units and focused on the mandatory curricular units, since not all schools had the optional curricular units available on their website.
We recognize the limitation of looking only at the title of the curricular unit. We also recognize that there are curricular units that students can choose from; however, if spirituality is an important topic recognized by so many renowned organizations as an integral part of the nursing undergraduate degree, and if the course has holistic care as its purpose, then it is important that curricula make formal reference to it.
In Portugal, there is a binary system comprising universities and polytechnics. In this study, we made categorizations in Public and Private Higher Education.
3. Results
In September 2022, 36 institutions were identified as teaching undergraduate nursing degrees in Portugal. Of these, 56% belong to public higher education and 44% to private higher education (Table 1).
Although there are 36 HEI, 39 degrees are being taught in Portugal because there are three institutions in two different geographical locations. Within the 39 degrees, 880 curricular units were identified, and in none of these were the terms spiritual care or spirituality identified in the title (Table 2).
However, there were curricular units such as “personal development”, “ethics”, and “Christianity and culture”.
4. Discussion
There needs to be formal visibility of spiritual care teaching in the designation of curricular units.
In a study about spirituality in nursing curricula in Portugal and Brazil, 38.8% of nursing teachers said that “spirituality was included in the curriculum”, 34.9% said “No”, and 26.4% said “I am not sure” [7]. A total of 36.1% of nursing teachers said that they do not include spirituality in their curricular units or courses, and 54.6% said that sometimes they do. Researchers found that spirituality teaching was done in curricular units that do not designate the terms spirituality or spiritual care [7]. Furthermore, in Canada’s study that sought to determine whether religion, spirituality, practices, and beliefs were visibly referenced in syllabuses, the authors concluded that although it could not be inferred that these were not taught, there was a lack of evidence in the description of the syllabuses, thus reflecting the lack of importance that these themes assumed in the syllabuses [10]. A similar situation can happen in this study; we consider that some curricular units, depending on how they are organized, will be able to address spirituality.
The importance of addressing spirituality in undergraduate nursing degrees is not new. Studies show a positive relationship between spiritual education and spiritual competencies [3]; so, the fact that spirituality teaching is hidden in the curriculum seems to be conducive to doubts about its teaching.
Curricular units with terms referring to biological and psychological dimensions were identified in all the syllabuses, which were expected to attend to the Portuguese regulations concerning the core areas of the undergraduate degree. Furthermore, this study considered the titles of the curricular units, which are often chosen according to the epistemological and ontological foundations of the HEI. Still, questions could be raised regarding the invisibility of the spiritual dimension or related terms in times of holistic health and nursing care perspectives.
Nursing teachers recognize the importance of spirituality and the need for it to be a topic included in curricula. They also suggested the need to clearly define when, how, and by whom spirituality should be taught [7].
In this study, and due to our sample size, we were able to perform a document analysis of all undergraduate nursing degrees in a country, thus having a global and realistic view of the curricula, which is something not yet found in similar studies. From 2016 until today, no such study has been carried out in Portugal, and our data show that after six years since the Caldeira et al. study [7], there is no greater visibility of this dimension in the syllabuses of undergraduate nursing degrees in Portugal, which demonstrates a gap in the translation of evidence–practice.
People want their spiritual beliefs addressed in healthcare settings [15]. As nursing must provide for the needs of the person, the individual, the family, and society, it is essential that nursing curricula are modified to provide these needs, and this is a situation which should have been observed in the study conducted. On the other hand, there are also studies that show that, for most people, going to a doctor’s surgery may not be the ideal context to talk about their spirituality [16]. However, also in this context, the teaching of spiritual care is essential for the recognition of the needs of each individual, respecting their rights, differences, autonomy, and decisions.
This research, part of a broader project, brings to light the invisibility of spirituality in undergraduate nursing degree curricula, despite all the evidence about its importance. Rather than being conclusive, this work aims to be reflective on practice to obtain deeper understanding and question themes so essential to nursing, such as what professional identity schools intend to promote when their curricula do not reflect all the dimensions of holistic care.
There are ethical, legal, and clinical requirements for spiritual care provision, so it seems urgent to determine how the teaching of spiritual care is carried out in an undergraduate nursing degree and search for greater congruence between research and teaching practice to consolidate the place of spiritual care in nurses’ competencies in Portugal.
This study has some limitations. First, the fact that the study was carried out in Portugal, a very particular context, and second, that this study did not analyze the syllabuses of the curricular units investigated to find out if and how spiritual care is addressed.
5. Conclusions
In September 2022, none of the 39 degrees in HEI had the terms spirituality or spiritual care in their curricular syllabuses.
The spiritual dimension is essential for holistic care, and a curriculum is a form of social visibility of a discipline and a profession. These findings lead us to reflect on the (in)visibility given to the spiritual dimension. Although it cannot be inferred that it is not addressed, is it enough for the visibility of professional identity that the spiritual dimension is part of a shy curriculum?
Evidence shows the importance of spirituality teaching in undergraduate nursing degrees, demonstrating its benefits. Future work could aim towards understanding why this dimension is not visible in curricula to the same degree as physical or psychological dimensions are, and also raise the awareness of teaching staff about the need to formally introduce this theme into the training of nursing students.
Author Contributions
Conceptualization, A.A., S.S., and S.C.; methodology, A.A., S.S. and S.C.; software, A.A.; validation, A.A., S.S. and S.C.; formal analysis, A.A., S.S. and S.C.; investigation, A.A.; resources, A.A. and S.C.; data curation, A.A.; writing—original draft preparation, A.A. and S.S.; writing—review and editing, I.R., L.N. and S.C.; visualization, A.A., S.S. and S.C.; supervision, I.R., L.N. and S.C.; project administration, A.A. and S.C.; funding acquisition, S.C. All authors have read and agreed to the published version of the manuscript.
Funding
This study was supported by FCT—Fundação para a Ciência e a Tecnologia, I. P., Project UIDB/04279/2020.
Institutional Review Board Statement
Not applicable.
Informed Consent Statement
Not applicable.
Data Availability Statement
Not applicable.
Conflicts of Interest
The authors declare no conflict of interest. The funders had no role in the design of the study.
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Table 1.
Public and Private Higher Education Institutions.
| Public Higher Education Institutions | N | % |
|---|---|---|
| Escola Superior de Enfermagem do Porto | ||
| Escola Superior de Enfermagem de Coimbra | ||
| Escola Superior de Enfermagem de Lisboa | ||
| Instituto Politécnico de Beja—Escola Superior de Saúde | ||
| Instituto Politécnico de Bragança—Escola Superior de Saúde de Bragança | ||
| Instituto Politécnico de Castelo Branco—Escola Superior de Saúde Dr. Lopes Dias | ||
| Instituto Politécnico da Guarda—Escola Superior de Saúde da Guarda | ||
| Instituto Politécnico de Leiria—Escola Superior de Saúde | ||
| Instituto Politécnico de Portalegre—Escola Superior de Saúde | ||
| Instituto Politécnico de Santarém—Escola Superior de Saúde de Santarém | ||
| Instituto Politécnico de Setúbal—Escola Superior de Saúde | ||
| Instituto Politécnico Viana do Castelo—Escola Superior de Saúde | ||
| Instituto Politécnico de Viseu—Escola Superior de Saúde de Viseu | ||
| Universidade dos Açores—Escola Superior de Saúde Angra do Heroísmo e Ponta Delgada | ||
| Universidade do Algarve—Escola Superior de Saúde | ||
| Universidade de Aveiro—Escola Superior de Saúde de Aveiro | ||
| Universidade de Évora—Escola Superior de Enfermagem de São João de Deus | ||
| Universidade da Madeira—Escola Superior de Saúde | ||
| Universidade do Minho—Escola Superior de Enfermagem | ||
| Universidade de Trás-os-Montes e Alto-Douro—Escola Superior de Saúde | ||
| 20 | 56 | |
| Private Higher Education Institutions | ||
| Escola Superior de Enfermagem São Francisco das Misericórdias | ||
| Escola Superior de Enfermagem de São José de Cluny | ||
| Escola Superior de Saúde Atlântica | ||
| Escola Superior de Saúde Cruz Vermelha Portuguesa—Alto Tâmega | ||
| Escola Superior de Saúde da Cruz Vermelha Portuguesa—Lisboa | ||
| Escola Superior de Saúde Norte da Cruz Vermelha Portuguesa (Oliveira de Azeméis) | ||
| Escola Superior de Saúde Egas Moniz | ||
| Escola Superior de Saúde da Fundação Fernando Pessoa | ||
| Escola Superior de Saúde Jean Piaget de Viseu | ||
| Escola Superior de Saúde de Santa Maria | ||
| Instituto Politécnico Jean Piaget do Norte—Escola Superior de Saúde Jean Piaget de Vila Nova de Gaia | ||
| Instituto Politécnico Jean Piaget do Sul—Escola Superior de Saúde Jean Piaget do Algarve | ||
| Instituto Politécnico da Lusofonia—Escola Superior de Saúde Ribeiro Sanches | ||
| Instituto Politécnico de Saúde do Norte—CESPU—Escola Superior de Enfermagem do Tâmega e Sousa e CESPU—Escola Superior de Saúde do Vale do Ave | ||
| ISAVE—Instituto Superior de Saúde | ||
| Universidade Católica Portuguesa—Escola de Enfermagem de Lisboa e Escola de Enfermagem do Porto | ||
| 16 | 44 | |
Table 2.
Curricular units with research terms.
| Dimension | Research Terms | N | % |
|---|---|---|---|
| Biological | Bio* OR Physio* OR Anat* | 39 | 100 |
| Psychological | Psyc* OR Mental | 39 | 100 |
| Social | Soci* | 34 | 87.2 |
| Cultural | Cultur* | 8 | 20.5 |
| Spiritual | spiritual* | 0 | 0 |
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MDPI and ACS Style
Afonso, A.; Sitefane, S.; Rabiais, I.; Nunes, L.; Caldeira, S. Spiritual Care in the Undergraduate Nursing Degree in Portugal. Educ. Sci. 2023, 13, 273. https://doi.org/10.3390/educsci13030273
AMA Style
Afonso A, Sitefane S, Rabiais I, Nunes L, Caldeira S. Spiritual Care in the Undergraduate Nursing Degree in Portugal. Education Sciences. 2023; 13(3):273. https://doi.org/10.3390/educsci13030273
Chicago/Turabian StyleAfonso, Ana, Sara Sitefane, Isabel Rabiais, Lucília Nunes, and Sílvia Caldeira. 2023. "Spiritual Care in the Undergraduate Nursing Degree in Portugal" Education Sciences 13, no. 3: 273. https://doi.org/10.3390/educsci13030273
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