Developing and testing the EPICC Spiritual Care Competency Self-Assessment Tool for student nurses and midwives.

AIMS AND OBJECTIVES: To develop and psychometrically test a self-assessment tool that measures undergraduate nursing and midwifery students' perceptions of spiritual care competence in health care practice. BACKGROUND: Spiritual care is part of nurses/midwives' responsibility. There is a need to better benchmark students' competency development in spiritual care through their education. The EPICC Spiritual Care Education Standard served as groundwork for the development of the EPICC Spiritual Care Competency Self-Assessment Tool. DESIGN: Cross sectional, mixed methods design. A STROBE checklist was used. METHODS: The Tool (available in English, Dutch and Norwegian) was developed by an international group. It was tested between July-October 2020 with a convenience sample of 323 nursing/midwifery students at eight universities in five countries. The Tool was tested for validity using Kaiser-Meyer-Olkin (KMO) test, exploratory and confirmatory factor analysis, one-way ANOVA and independent samples t test. The reliability was tested by Cronbach's alpha coefficient. Qualitative data were analysed using thematic analysis. RESULTS: The KMO test for sampling adequacy was 0.90. All, but two, items were related to the same factor. Cronbach's alpha coefficient for the Tool was 0.91. Students found the Tool easy to use, and they gained new insights by completing it. However, students felt that some questions were repetitive and took time to complete. CONCLUSIONS: The Tool has construct and discriminant validity, and high internal consistency (is reliable). In addition, students found the Tool useful, especially in early stages of education. RELEVANCE TO CLINICAL PRACTICE: The Tool affords student nurses and midwives the opportunity to self-evaluate their knowledge, skills and attitudes about spirituality and spiritual care. The Tool offers students, educators and preceptors in clinical practice a tangible way of discussing and evaluating spiritual care competency.

The level of spiritual care competence of Polish nurses and the psychometric properties of the spiritual care competence scale (SCCS).

BACKGROUND: Providing effective spiritual nursing care requires development of professional competence which, when regularly evaluated, allows one to direct undergraduate and postgraduate nursing education in order to develop knowledge, skills and attitudes of nurses in the scope of spiritual care. AIM: The aim of this study was to analyse the level of spiritual competence of professionally active nurses in Poland and, additionally, to analyse the psychometric properties of the Spiritual Care Competence Scale (SCCS). METHODS: A cross-sectional study among Polish nurses (n = 343) was performed in accordance with the STrengthening the Reporting of OBservational studies in Epidemiology guidelines. RESULTS: An exploratory factor analysis identified five factors with 27 items explaining a total variance of 64.75%. Cronbach's alpha coefficient for the subscales ranged from 0.70 for 'Attitude toward the patient's spirituality' to 0.92 for 'Professionalisation and improving the quality of spiritual care'. Nurses reported a high level of spiritual competence (104.39 points) with better results in 'Attitude toward the patient's spirituality' and 'Communication, personal support and patient counselling' than in the 'Assessment and implementation of spiritual care', 'Professionalisation and improving the quality of spiritual care', and 'Referral, consultation and spiritual care'. Significant correlation was found between nurses' age, job seniority and spiritual competence, and between religiosity and spiritual competence. CONCLUSIONS: The study showed satisfactory psychometric properties of the Polish version of the Spiritual Care Competence Scale, confirming its potential to measure the level of spiritual competence of nurses, both in education and research processes. SCCS-PL revealed five-factor structure with good internal consistency. The findings highlight the importance of providing professional education in respect of spiritual nursing care, especially in its practical dimension regarding skills development in which nurses obtained lower scores.

Development of a spiritual care education matrix: Factors facilitating/hindering improvement of spiritual care competency in student nurses and midwives.

Spiritual care is a fundamental aspect of caring and compassionate nursing/midwifery practice. However, nurses/midwives consistently report feeling unprepared to provide spiritual care for various reasons. A key reason appears to be the lack of structured spiritual care education in undergraduate nursing/midwifery curricula. Between 2016 and 2019, the three-year, European EPICC project ('Enhancing nurses' and midwives' competence in Providing spiritual care through Innovative education and 'Compassionate Care') sought to address gaps in nursing/midwifery competence in spiritual care. A key project output, and the focus of this paper, is the EPICC Gold Standard Matrix for Spiritual Care Education ('EPICC Matrix'), which depicts the complex array of factors hindering/facilitating the development of nursing/midwifery spiritual care competency. The EPICC project followed two major studies that identified factors contributing to nursing/midwifery spiritual care competency development. This evidence, along with the mixed methods focus of the EPICC project to enable co-projection of its outputs informed the development of the EPICC Matrix. The EPICC Matrix was considered to represent 'the cultural, social and political environment in which spiritual care competency develops' in student nurses/midwives. The EPICC Matrix illustrates spiritual care educational considerations during the process of selecting suitable nursing/midwifery students; through the specific aspects of the teaching and learning environment, the student as a person, and the clinical environment in which spiritual care competency develops; and finally, how the student is assessed as competent in providing spiritual care. Recent research supports the use of the EPICC Matrix in undergraduate nursing/midwifery curricula and strengthens the case for support of the other EPICC project outputs, including: the EPICC Spiritual Care Education Standard, EPICC Adoption Toolkit, and the continuation of the EPICC Network. Further testing of the EPICC Matrix to determine its relevance in different cultural/professional contexts within and outside of Europe would be welcomed.

An Online Competency-Based Spiritual Care Education Tool for Oncology Nurses.

OBJECTIVE: The importance of spiritual care for the nursing profession has been long established. In many health care settings, including oncology, patients facing illness, suffering, and imminent death can struggle with existential questions of purpose and meaning-making. Recent research provided a competency-based educational framework to prepare nurses and nursing students to address these spiritual needs. DATA SOURCES: This qualitative study evaluated the impact of the implementation of online educational tools across four nursing bachelor's programs to acquire competencies focused on addressing spiritual care needs. CONCLUSION: Results showed that the tool added to the awareness of students and impacted among between students, teachers, and patient. IMPLICATIONS FOR NURSING PRACTICE: The results underscored the need for structural and methodical implementation of technically challenging online tools because this impacts the feasibility and applicability of blended learning.

Ethical considerations regarding the inclusion of children in nursing research.

Evidence-based nursing practice is based on three pillars: the available research, known preferences of the patient or patient group and the professional experience of the nurse. For all pillars, research is the tool to expand the evidence we have, but when implementing evidence-based practice in paediatric nursing two of the pillars demand that children are included as respondents: practice research on the nursing interventions in paediatrics and the preferences of patients, something recognized by scholars and practitioners. But including a vulnerable group as children in nursing research raises specific ethical issues that need to be considered by researchers. What are ethical considerations that are currently raised about doing research with children and what do we learn by synthesizing the narrative of these studies of why the issues are raised and which solutions can be offered for these issues? In this article, considerations on three ethical principles according to the Belmont report are described by examining recent research. Twenty-one studies were found addressing relevant ethical aspects including vulnerability, gaining consent, designing quantitative or qualitative research methods and considerations regarding the execution of the study. Ethical considerations should be much more a case of continuous awareness and attitude, then box-ticking exercise, although there are sufficient international guidelines available specifically for research that includes children to aid researchers.

The development of a consensus-based spiritual care education standard for undergraduate nursing and midwifery students: An educational mixed methods study.

AIMS: The aim of this study was to develop a consensus-based Spiritual Care Education Standard for undergraduate N/M students to use in undergraduate programmes. DESIGN: Mixed methods were used consisting of qualitative and quantitative methods based on the principles of Delphi research. METHODS: The sample consisted of a total of 58 (N = 58) participants from 21 European countries. Data collection was conducted from June 2017 - February 2019 and took place in facilitated iterative action learning cycles and online surveys. Data were analysed by descriptive statistics and qualitative analysis. Consensus was stated by >90% agreement. RESULTS: The process resulted in an EPICC Spiritual Care Education Standard consisting of the following four spiritual care competences: Intrapersonal spirituality, Interpersonal spirituality, Spiritual care: assessment and planning, Spiritual care: intervention and evaluation. For every competence, learning outcomes were described in knowledge, skills and attitudes. CONCLUSION: This Standard guides N/M spiritual care education, student assessment and research. It can be the starting point for discussing spiritual care competences in other healthcare professions. Follow-up research should focus on implementation of the standard and on assessment of students' spiritual competence. IMPACT: The Standard guides curriculum and programme development. The Standard guides students in performing their learning process. The Standard provides a frame of reference for policy making and follow-up research.

Spiritual care by nurses in curative oncology: a mixed-method study on patients' perspectives and experiences.

AIMS: Spirituality can be important in adjusting to the experience of cancer and its medical treatment. Since nurses have frequent contact with patients, they seem to have a unique role in providing spiritual care. Nurses consider spiritual care important; however, little is known about how patients in a curative setting experience and value spiritual care. Therefore, this study aimed to give insight into patients' experiences with and opinions about spiritual care as provided by nurses in curative cancer care. METHODS: This is a national, multicentre mixed-methods study, combining a quantitative approach using questionnaires (n = 62) and a qualitative analysis of semi-structured interviews (n = 61). Nonparametric tests were used for quantitative data, and qualitative data were analysed inductively. FINDINGS: Most patients rarely received spiritual care by nurses. If spiritual care was provided, it mainly consisted of noticing problems and referring to other professionals. This appeared to be dependent on certain 'triggers', such as age. Structural discussions on spirituality with a nurse were experienced rarely. This was explained by, among other factors, the hospital setting. Yet, the majority (79%) of patients found the attention to spirituality sufficient or very good. Furthermore, a majority (58%) viewed spiritual care as a nursing task: nurses should notice spiritual problems and refer to other professionals, though extensively discussing patients' spirituality was neither considered nurses' task nor capability. CONCLUSIONS: Attention to spiritual care in a curative setting, though not so much desired by most patients, should be pursued, because of its importance in performing person-centred nursing care and its positive impact on patients' health. By training nurses in offering spiritual care in proactive and 'nonactive' (accepting) ways, spiritual care could be structurally offered in clinical practice in personalised forms. Since younger and less spiritual patients are not much satisfied with spiritual care by nurses, they need special attention.

Cross-cultural validation of the Brazilian version of the spiritual care competence scale.

OBJECTIVE: This study describes the cross-cultural validation and psychometric evaluation of the Spiritual Care Competence Scale - Brazilian Portuguese version. This reliable and valid instrument is recommended in the literature to measure the outcomes of the education process in the development of spiritual care competences. METHOD: This is a cross-sectional validation study following the stages proposed by Beaton et al.: translation into Portuguese, back translation into English, expert committee review for semantic equivalence, assessment of the clarity of the pre-final version, and evaluation of the psychometric properties of the final version in Portuguese. Health professionals working at a public hospital in South Brazil participated in the different stages of this study.ResultRegarding internal consistency, total Cronbach's alpha was 0.92 and the mean inter-item correlation was 0.29. The test-retest procedure showed no statistically significant differences in the six subscales. The intraclass correlation coefficient ranged from 0.67 to 0.84, demonstrating the stability of the scale.Significance of resultsThe results support the psychometric quality of the scale and indicate that the adapted instrument is a valid and reliable scale with good internal consistency for measuring spiritual care competencies of health professionals in Brazilian healthcare settings.

Nursing and midwifery students' perceptions of spirituality, spiritual care, and spiritual care competency: A prospective, longitudinal, correlational European study.

BACKGROUND: Nurses and midwives care for people at some of the most vulnerable moments of their lives, so it is essential that they have the skills to give care which is compassionate, dignified, holistic and person-centred. Holistic care includes spiritual care which is concerned with helping people whose beliefs, values and sense of meaning, purpose and connection is challenged by birth, illness or death. Spiritual care is expected of nurses/midwives but they feel least prepared for this part of their role. How nursing and midwifery students can be prepared for spiritual care is the focus of this study. OBJECTIVES: 1. To describe undergraduate nursing and midwifery student's perceptions of spirituality/spiritual care, their perceived competence in giving spiritual care and how these perceptions change over time. 2. To explore factors contributing to development of spiritual care competency. METHODS: Prospective, longitudinal, multinational, correlational survey design. A convenience sample of 2193 undergraduate nursing and midwifery students (69% response rate, dropping to 33%) enrolled at 21 universities in eight countries completed questionnaires capturing demographic data (purpose designed questionnaire) and measuring perception of spirituality/spiritual care (SSCRS), spiritual care competency (SCCS), spiritual wellbeing (JAREL) and spiritual attitude and involvement (SAIL) on 4 occasions (start of course n = 2193, year 2 n = 1182, year 3 n = 736, end of course n = 595) between 2011 and 2015. Data were analysed using descriptive, bivariate and multivariate analyses as appropriate. RESULTS: Perceived competency increased significantly over the course of students' study which they attributed to caring for patients, events in their own lives and teaching/discussion in university. Two factors were significantly correlated with perceived spiritual care competency: perception of spirituality/spiritual care, where a broad view was preferable, and personal spirituality, where high spiritual wellbeing (JAREL) and spiritual attitude and involvement (SAIL) scores were preferable. CONCLUSIONS: We have provided the first international evidence that perceived spiritual care competence is developed in undergraduate nursing and midwifery students and that students' perceptions of spirituality and personal spirituality contribute to that development. Implications for teaching and learning and student selection are discussed. The study is limited by attrition which is common in longitudinal research.

Spiritual care by nurses in curative cancer care: Protocol for a national, multicentre, mixed method study.

AIM: To gain insight into the quantity and quality of spiritual care provided by nurses in curative cancer care, from the perspectives of both patients and nurses. BACKGROUND: Cancer causes patients to suffer from diverse symptoms related to their illness. Nurses play an important role in the care for people with cancer. Next to paying attention to physical and psychosocial needs, caring for spiritual needs of patients also belongs to good nursing. Most of the research concerning spirituality and spiritual care in relation to cancer has focused on palliative care. DESIGN: A mixed methods design will be used in two sub-phases. First, we will conduct semi-structured interviews with 72-90 patients coming from nine hospitals. Subsequently, approximately the same number of nurses working on oncology wards of these hospitals will be interviewed. METHODS: We meticulously composed both interview guides so that only near the end of the interview explicit terms like spirituality and spiritual care are explicitly mentioned. Until that point, we will use other words to define the concepts. Next to the interviews, demographics, answers to some statements and several questionnaires will be gathered. Content analysis supported by DEDOOSE will be used to answer the research questions. DISCUSSION: The insight we will gain in this study enables us to compare experiences from the perspective of both patients and nurses. This can also provide us with suggestions for the improvement of nursing care for people with cancer who are treated with curative intent, a topic until now hardly addressed.

Factors contributing to student nurses'/midwives' perceived competency in spiritual care.

BACKGROUND: The spiritual part of life is important to health, well-being and quality of life. Spiritual care is expected of nurses/midwives, but it is not clear how students can achieve competency in spiritual care at point of registration as required by regulatory bodies. AIM: To explore factors contributing to undergraduate nurses'/midwives' perceived competency in giving spiritual care. DESIGN: A pilot cross-sectional, multinational, correlational survey design. METHOD: Questionnaires were completed by 86% (n=531) of a convenience sample of 618 undergraduate nurses/midwives from six universities in four countries in 2010. Bivariate and multivariate analyses were performed. RESULTS: Differences between groups were small. Two factors were significantly related to perceived spiritual care competency: perception of spirituality/spiritual care and student's personal spirituality. Students reporting higher perceived competency viewed spirituality/spiritual care broadly, not just in religious terms. This association between perceived competency and perception of spirituality is a new finding not previously reported. Further results reinforce findings in the literature that own spirituality was a strong predictor of perceived ability to provide spiritual care, as students reporting higher perceived competency engaged in spiritual activities, were from secular universities and had previous healthcare experience. They were also religious, practised their faith/belief and scored highly on spiritual well-being and spiritual attitude/involvement. CONCLUSIONS: The challenge for nurse/midwifery educators is how they might enhance spiritual care competency in students who are not religious and how they might encourage students who hold a narrow view of spirituality/spiritual care to broaden their perspective to include the full range of spiritual concerns that patients/clients may encounter. Statistical models created predicted factors contributing to spiritual care competency to some extent but the picture is complex requiring further investigation involving a bigger and more diverse longitudinal sample.

Being the minority: Christian healthcare professionals in The Netherlands.

In many societies, spirituality is no longer specifically religious or affiliated in a traditional sense. This is especially true in The Netherlands. This study examined the qualities of Dutch Christian healthcare professionals, opportunities and threats to being Christian, and their perceived need for support to be Christian. Respondents (N = 672) had a highly homogeneous picture of the qualities, opportunities, and challenges of living out faith at work. However, they do not think they have the qualities or opportunities to be overtly Christian and would like support to be more explicit in their faith.

Student nurses perceptions of spirituality and competence in delivering spiritual care: a European pilot study.

BACKGROUND: Spiritual care is expected of nurses, but it is not clear how undergraduates can achieve competency in spiritual care at point of registration as required by nursing/midwifery regulatory bodies. AIMS: To describe undergraduate nurses'/midwives' perceptions of spirituality/spiritual care, their perceived competence in delivering spiritual care, and to test out the proposed method and suitability of measures for a larger multinational follow-on study. DESIGN: Cross-sectional, multinational, descriptive survey design. METHODS: Author administered questionnaires were completed by 86% of the intended convenience sample of 618 undergraduate nurses/midwives from 6 universities in 4 European countries in 2010. RESULTS: Students held a broad view of spirituality/spiritual care and considered themselves to be marginally more competent than not in spiritual care. They were predominantly Christian and reported high levels of spiritual wellbeing and spiritual attitude and involvement. The proposed method and measures were appropriate and are being used in a follow-on study. CONCLUSIONS: The following are worthy of further investigation: whether the pilot study findings hold in student samples from more diverse cultural backgrounds; whether students' perceptions of spirituality can be broadened to include the full range of spiritual needs patients may encounter and whether their competence can be enhanced by education to better equip them to deliver spiritual care; identification of factors contributing to acquisition of spiritual caring skills and spiritual care competency.

Screening patient spirituality and spiritual needs in oncology nursing.

AIM: To select 2 appropriate spiritual assessment tools and evaluate these by involving oncology nurses. BACKGROUND: Spirituality is recognized as an important domain of cancer care. At admission, integration of spiritual assessment seems necessary. It is unclear what kind of spiritual assessment method would be most preferable. DESIGN: This study has an explorative and qualitative design. METHODS: Spiritual assessment tools were identified by means of a systematic literature search. Two tools were selected by a 4-step selection procedure. Evaluation of these tools took place by interviewing Dutch oncology nurses (n = 8). The interviews were qualitatively analyzed. RESULTS: Of the 120 assessment tools collected, the Spiritual Health Inventory tool and the Spiritual History tool remained for further evaluation. The 8 oncology nurses did not have a unifying opinion on spiritual assessment in general, but they all agreed that in nursing practice a structural integration of spiritual assessment is lacking. The nurses preferred the use of the Spiritual Health tool for its "checklist like" approach. It seems that this tool gives them a concrete procedure to follow. CONCLUSIONS: The diversity of operationalizing spirituality is reflected in the amount of collected tools. By choosing an assessment tool, cultural related aspects should be taken in consideration.

Moral issues in mentoring sessions.

This article describes the results of research that investigated whether student nurses identified the moral aspects of everyday nursing care situations and, if so, how they dealt with them. We intended to elucidate the role of mentoring situations in moral development. Student written documents reflecting discussions during mentoring situations were analysed quantitatively and qualitatively. The students studied in one of the three nursing schools involved in the research. In only a small proportion of cases (<13%) did the students identify the ethical questions in those situations. The results indicate that the nursing students rarely identified moral issues, implying that there was little conscious moral reflection and deliberation in their mentoring situations dealing with their problematic experiences during their internship. Additional competences will be required for session leaders in order to allow mentoring situations to play a more prominent role in moral development.

The validity and reliability of an instrument to assess nursing competencies in spiritual care.

AIM: This study contributes to the development of a valid and reliable instrument, the spiritual care competence scale, as an instrument to assess nurses' competencies in providing spiritual care. BACKGROUND: Measuring these competencies and their development is important and the construction of a reliable and valid instrument is recommended in the literature. DESIGN: Survey. METHOD: The participants were students from Bachelor-level nursing schools in the Netherlands (n = 197) participating in a cross-sectional study. The items in the instrument were hypothesised from a competency profile regarding spiritual care. Construct validity was evaluated by factor analysis and internal consistency was estimated with Cronbach's alpha and the average inter-item correlation. In addition, the test-retest reliability of the instrument was determined at a two-week interval between baseline and follow-up (n = 109). RESULTS: The spiritual care competence scale comprises six spiritual-care-related nursing competencies. These domains were labelled: 1 assessment and implementation of spiritual care (Cronbach's alpha 0.82) 2 professionalisation and improving the quality of spiritual care (Cronbach's alpha 0.82) 3 personal support and patient counseling (Cronbach's alpha 0.81) 4 referral to professionals (Cronbach's alpha 0.79) 5 attitude towards the patient's spirituality (Cronbach's alpha 0.56) 6 communication (Cronbach's alpha 0.71). These subscales showed good homogeneity with average inter-item correlations >0.25 and a good test-retest reliability. CONCLUSION: This study conducted in a nursing-student population demonstrated valid and reliable scales for measuring spiritual care competencies. The psychometric quality of the instrument proved satisfactory. This study does have some methodological limitations that should be taken into account in any further development of the spiritual care competence scale. RELEVANCE TO CLINICAL PRACTICE: The spiritual care competence scale can be used to assess the areas in which nurses need to receive training in spiritual care and can be used to assess whether nurses have developed competencies in providing spiritual care.

Learning effects of thematic peer-review: a qualitative analysis of reflective journals on spiritual care.

This study describes the learning effects of thematic peer-review discussion groups (Hendriksen, 2000. Begeleid intervisie model, Collegiale advisering en probleemoplossing, Nelissen, Baarn.) on developing nursing students' competence in providing spiritual care. It also discusses the factors that might influence the learning process. The method of peer-review is a form of reflective learning based on the theory of experiential learning (Kolb, 1984. Experiential learning, Experience as the source of learning development. Englewoods Cliffs, New Jersey, Prentice Hill). It was part of an educational programme on spiritual care in nursing for third-year undergraduate nursing students from two nursing schools in the Netherlands. Reflective journals (n=203) kept by students throughout the peer-review process were analysed qualitatively The analysis shows that students reflect on spirituality in the context of personal experiences in nursing practice. In addition, they discuss the nursing process and organizational aspects of spiritual care. The results show that the first two phases in the experiential learning cycle appear prominently; these are 'inclusion of actual experience' and 'reflecting on this experience'. The phases of 'abstraction of experience' and 'experimenting with new behaviour' are less evident. We will discuss possible explanations for these findings according to factors related to education, the students and the tutors and make recommendations for follow-up research.

The effectiveness of an educational programme for nursing students on developing competence in the provision of spiritual care.

AIM: To determine the effects of a course for nursing students on developing competence in spiritual care and the factors that might influence the effects. BACKGROUND: Studies suggest that role preparation in nursing for spiritual care is poor. For the assessment of competence, few or no explicit competency framework or assessment tools seemed to be used. DESIGN: Quasi-experimental crossover design (pre-post-test). METHOD: The subjects were students from Christian nursing schools in the Netherlands (n = 97). The intervention consisted of a course in spiritual care. Competencies were measured with an assessment tool, the Spiritual Care Competence Scale. Data were analysed by t-test procedures (paired-samples t-test). At T(1) vignettes were added to assess the quality of the students' own analyses. These data were analysed by a Mann-Whitney test. Regression analyses were performed on the influence of student characteristics on the subscales of the assessment tool. RESULTS: Ninety-seven students participated in this study. Analysis showed statistically significant changes in scores on three subscales of the Spiritual Care Competence Scale between groups (T(1)) and over time for the whole cohort of students on all subscales (T(2)). Clinical placement showed as a negative predictor for three subscales of the Spiritual Care Competence Scale. Experience in spiritual care and a holistic vision of nursing both showed as positive predictors on certain competencies. A statistically significant difference was observed between groups in the student analysis of a vignette with explicit spiritual content. CONCLUSIONS: The outcomes raise questions about the content of education in spiritual care, the measurement of competencies and the factors that influence competency development. RELEVANCE TO CLINICAL PRACTICE: The results provide nurse educators with insight into the effects of education in spiritual care on students' competencies and help them consider a systematic place for spiritual care within the nursing curriculum.

Aspects of spirituality concerning illness.

The spiritual dimension of illness, health and care may be seen as a unique aspect in addition to the physical, mental and social dimension. This contribution describes experiences of patients, nurses and hospital chaplains in relation to the spiritual aspects of being ill. Qualitative research was performed with the design of a focus group study, consisting of 13 focus groups with a total of 67 participants. A purposive sample was used comprising patients, nurses and hospital chaplains working in oncology, cardiology and neurology in different institutions and regions in the Netherlands. The qualitative analysis consisted of open coding and the determining of topics, followed by the subsequent attachment of substantial dimensions and characteristic fragments. Data were analysed by using the computer program KWALITAN. Spirituality play various roles in patients lives during their illness. There is a wide range of topics that may have an individual effect on patients. Despite differences in emphasis, the topics play a role in different patient categories. Although the spiritual topics seem to manifest themselves more clearly in long-term care relationships, they may also play a role during brief admittance periods (such as treatment decisions). The spiritual topics that arise from this study offer caregivers a framework for signalling the spiritual needs of patients. The question is not whether spirituality is a relevant focus area in care, but how and to what degree it plays a role with individual patients. Follow up research should aim at further exploration of spiritual aspects in care, the relationship between spirituality and health and at effective training of caregivers.

Spiritual care: implications for nurses' professional responsibility.

AIM: This paper aimed to gain insight into the spiritual aspects of nursing care within the context of health care in the Netherlands and to provide recommendations for the development of care in this area and the promotion of the professional expertise of nurses. BACKGROUND: International nursing literature suggests that caregivers are expected to pay attention to spiritual aspects of patient care. In Dutch nursing literature, the spiritual dimension is increasingly becoming a focus of attention. Despite this, there is a lack of empirical data from professional practice in the Netherlands. METHOD: Data were collected by means of focus group interviews. The sample was made up of the specialist fields of cardiology, oncology and neurology and divided into groups of patients, nurses and hospital chaplains. The interviews took place between May and December 2004. Data were qualitatively analysed using the computer programme Kwalitan. RESULTS: Different spiritual themes emerged from the interviews. There were different expectations of the nurse's role with regard to spiritual aspects. The main themes derived from this research can be recognized as aspects of nursing competencies that are reported in the literature. However, the attention to spiritual aspects in the nursing process is not clear cut. It seems to be highly dependent on personal expression and personal commitment. CONCLUSIONS: The study raises questions about the nurse's professional role in spiritual care. The study shows that different factors (personal, cultural and educational) play a role in the fact that spiritual care is not structurally embedded in nursing care. Further research on the impact of that variable is recommended. RELEVANCE TO CLINICAL PRACTICE: Nursing care implies care for the spiritual needs of patients. To provide this care, nurses need to be knowledgeable regarding the content of spiritual care and the personal, professional, cultural and political factors influencing it. They also need to be able to participate in policy and decision-making discussions of spiritual care in clinical nursing practice.