The World Health Organization (WHO 2020) designated 2020 as the International Year of the Nurse and the Midwife. This celebration also recognises the 200th anniversary of Florence Nightingale’s birth. Nightingale is one of the pioneers and founders of the modern nursing profession. In considering her legacy, there is no doubt that she recognised the importance of caring for the whole person, body, mind, and spirit.
Nursing Standard. 35, 10, 65-68. doi: 10.7748/ns.35.10.65.s35
Published: 30 September 2020
The past three decades have seen a proliferation in international research detailing and debating the role that spirituality and spiritual care plays in nursing. Early studies investigating spirituality in nursing originated in North America and the UK.
Early findings, therefore, reflected a Western understanding of spirituality and spiritual care, rooted in the Judaeo-Christian tradition. However, anyone conducting a literature review of these concepts today will see that this body of research has extended across many continents and cultures.
In recent years, preparing nurses and midwives to be competent and feel confident in providing spiritual care has become the subject of international research. There is an emerging body of evidence affirming the importance of spirituality in promoting the health and wellbeing of individuals. Despite this growing recognition, there are still inconsistencies in the way that undergraduate nursing and midwifery students are taught and prepared to assess and address this dimension of person-centred care, and fundamentally how these concepts are integrated in programmes of education.
This article charts the evolution of a European programme of research, spanning a decade, exploring undergraduate nurses’ and midwives’ perception of spirituality and perceived competence in providing spiritual care. The research culminated in an educational research study that led to the co-production and development of best practice standards for spiritual care education for Europe, and the launch of a network to sustain and advance this neglected area of nursing and midwifery practice.
McSherry W, Ross L, Attard J et al (2020) Preparing undergraduate nurses and midwives for spiritual care: Some developments in European education over the last decade. Journal for the Study of Spirituality. 10, 1. doi: 10.1080/20440243.2020.1726053
Within healthcare, the term ‘spirituality’ is generally considered to be broader than religion, additionally encompassing peoples’ personal and existential beliefs, values and practices. However, there remains a tendency to associate spirituality with religion. The prevalence of this view means that spirituality and spiritual care may be considered only relevant to people who are religious, rather than to all, meaning that non-religious spiritual needs may not be addressed. Therefore, nurses are confused about what spirituality and spiritual care mean for their practice. In addition, media coverage of instances where nurses have been investigated for overstepping the mark by allowing their personal beliefs to encroach on patient care, means that nurses are reticent to engage with this aspect of their practice and have asked for more guidance. For example, an on-line survey by the Royal College of Nursing (RCN) (2011) of its members (n=3,181) found that 79.3% considered they did not receive sufficient education and training concerning spirituality and spiritual care and (n=3,207) 79.8% wanted to see the topic formally integrated in programmes of education. Other international studies have since replicated the RCN survey, reporting similar findings, suggesting that there is a gap in spiritual care education internationally (Austin et al 2017, Egan et al 2017).
The EPICC Project was a landmark initiative: Enhancing Nurses’ and Midwives’ Competence in Providing Spiritual Care through Innovative Education and Compassionate Care. This project was funded under the Erasmus+ K2 Strategic Partnerships funding stream. The grant awarded was €242,093. The project involved six partners from four countries in Europe. Collectively, the group was known as the EPICC Strategic Partners. The partnership involved Professor Wilfred McSherry of Staffordshire University; Prof Linda Ross of the University of South Wales; Dr Josephine Attard, University of Malta, Msida, Malta; Professor, René van Leeuwen, Viaa Christian University of Applied Sciences, Zwolle, Netherlands; Professor Tove Giske, VID University, Bergen, Norway; Professor Tormod Kleiven, VID University, Oslo, Norway; and EPICC project manager Dr Adam Boughey of Staffordshire University.
The EPICC Project sought to clarify what spirituality and spiritual care mean for nursing and midwifery practice, and to provide the evidence-based guidance that nurses have been seeking for over three decades. This article reports on that landmark initiative, which brought together 31 nursing and midwifery educators from 21 European countries and international stakeholders (including the RCN and governments) to achieve those aims using action learning cycles and on-line questionnaires between November 2016 and July 2019.
To clarify these definitions, we started with a consensus definition of spirituality adopted by the European Association of Palliative Care (EAPC) (2011), and the National Health Service Education Scotland (NES) (2009) definition of spiritual care widely used in healthcare practice. The EAPC (2011) defined spirituality as: ‘The 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.’
The spiritual field is multidimensional:
» Existential challenges (for example, questions concerning identity, meaning, suffering and death, guilt and shame, reconciliation and forgiveness, freedom and responsibility, hope and despair, love and joy).
» Value-based considerations and attitudes (for example, what is most important for each person, such as relations to oneself, family, friends, work, aspects of nature, art and culture, ethics and morals, and life itself).
» Religious considerations and foundations (for example, faith, beliefs and practices, the relationship with God or the ultimate).
The NES (2009) defines spiritual care as: ‘Care which recognises and responds to the human spirit when faced with life-changing events (such as birth, trauma, ill health, loss) or sadness, and can include the need for meaning, for self-worth, to express oneself, for faith support, perhaps for rites or prayer or sacrament, or simply for a sensitive listener. Spiritual care begins with encouraging human contact in compassionate relationship and moves in whatever direction need requires’ (NES 2009).
These definitions were accepted as being relevant for nursing/midwifery, with the addition of the italicised words, which were added to reflect wellbeing as well as illness. It is evident that spirituality and spiritual care acknowledge and respond to peoples’ personal, religious, and spiritual beliefs but also go beyond that to encompass what gives their lives meaning, purpose and fulfilment and what facilitates connection with self, others, nature and the transcendent (Puchalski et al 2014, Weathers et al 2016, Murgia et al 2020).
EPICC’s co-produced novel outputs offer an evidence-based suite of interventions to enable nursing and midwifery educators and practitioners to integrate spiritual care in new and existing programmes of undergraduate education. The EPICC (2019a) Spiritual Care Education Standard describes the spiritual care competencies expected of undergraduate nursing and midwifery students. It sets out the knowledge, skills, and attitudes expected for each of the four competencies:
1. Intrapersonal spirituality is aware of the importance of spirituality on health and wellbeing.
2. Interpersonal spirituality. Engages with persons’ spirituality, acknowledging their unique spiritual and cultural worldviews, beliefs and practices.
3. Spiritual care: assessment and planning. Assesses spiritual needs and resources using appropriate formal or informal approaches, and plans spiritual care, maintaining confidentiality and obtaining informed consent.
4. Spiritual care: intervention and evaluation. Responds to spiritual needs and resources within a caring, compassionate relationship.
The preamble provides the definitions of spirituality and spiritual care.
» EPICC (2019b) Gold Standard Matrix for Spiritual Care Education is an evidence-based diagram that represents the cultural, social and political environment in which spiritual care competency develops. It should be read in conjunction with the accompanying EPICC (2019c) Gold Standard Matrix Narrative.
» EPICC (2019) Adoption Toolkit contains teaching and learning activities designed to help students achieve the four competencies, grouped accordingly.
» The EPICC Website and 5. Network exist to sustain, develop, and advance the EPICC project that ended in August 2019.
The impact of EPICC has been rapid and substantial with key improvements taking place across Europe and beyond in just 12 months. EPICC has raised awareness of the importance of spirituality and spiritual care in the nursing/midwifery professions and offers a standardised approach to curriculum development. EPICC responds to the United Nations (UN) (2015) sustainable development goal 3 (good health and wellbeing) through the development of quality education (goal 4).
Testimonials provided by EPICC participants/organisational leaders demonstrate the reach and impact of the EPICC project since the launch of its outputs at the University of South Wales, Cardiff, on 1-2 July 2019 by the Minister for Health and Social Services Wales. The following are examples from the Netherlands, England, Austria, and Poland. These accounts are in addition to the change in pre-registration nursing and midwifery programmes in Wales in September 2020 and Norway already published (Health Education and Improvement Wales 2020, McSherry et al 2020).
A head of school in the Netherlands described how: ‘The EPICC outputs are used within curriculum design in our bachelors of nursing programme. The competencies described in the EPICC Spiritual Care Education Standard are also used to train nurses in practice and on a specialist programme we deliver for practitioners to become special caregivers in spiritual care. We also offer training to people from other healthcare institutes throughout the Netherlands. This e-learning programme is based on the outputs from the EPICC projects, as they are very practical e-learning tools.
We are leading the way in spiritual care in the Netherlands, students specifically attending our university to develop competencies within this field’.
One participant from England stated: ‘I believe strongly that the work of EPICC has raised the awareness of spirituality in nursing and midwifery and created a cohesive language which can be used across Europe. … In order to continue to ensure spirituality is embedded in the undergraduate nursing and midwifery curriculum in the UK there have been high level discussions with policy makers, the Nursing and Midwifery Council, higher education institutions and clinicians regarding the work of EPICC, findings and resources. This work is not without its challenges when there is still confusion about the concept of spirituality. The work carried out by EPICC has reduced the confusion about the meaning of spirituality and how this can be integrated into nursing.’
A participant from Austria concluded their testimonial by offering a future vision and expansion of the EPICC project: ‘I believe that the EPICC Network – under the excellent leadership of Prof Ross and Prof McSherry – has wider relevance for all kinds of nursing, through improving training, communication issues and reflective practice. It could be used in public health, illness prevention, and by nurses based in schools, so that people understand how important these questions of meaning, or spiritual moments in nature are, when taking care of ourselves daily, not just in crisis.’
A participant from Poland recounted: ‘I translated the first draft of the standard into Polish and informed the Polish Association for Medicine Care of its salience and utility. This translation of the EPICC standard plus a presentation about the EPICC project and spiritual care has been on the Polish Association for Medicine Care website since late 2016. Its inclusion on the website sparked a lot of interest and led to the beginning of discussion with nurses and other healthcare professionals about the importance of embedding spiritual care into research, education, and practice. The translation of the standard and the competencies made this more concrete – it increased awareness with healthcare professionals of their role in the provision of spiritual care’.
These examples selected from four countries across Europe illustrate the current and potential impact of the EPICC project.
In the short-term the EPICC project is shaping pre- and post-registration curriculum development in multiple institutions and countries across Europe and beyond. In the mid-term, these innovations will lead to advancement and improvements in nurses’/midwives’ educational preparedness to support their patients’ spiritual needs better.
EPICC’s longer term legacy will be to offer a more cohesive language for spirituality and spiritual care, dispelling some of the myths and misconceptions that still exist in the nursing and midwifery professions and wider society.
The EPICC outputs are starting to influence the education of other healthcare professions beyond nursing/midwifery and in continents beyond Europe through the project’s website and expanding network.
The EPICC Network has 69 members from 25 countries across six continents. The project responds to the call from nurses and patients for better preparation of nurses for spiritual care, acknowledging Florence Nightingale’s vision for true holistic care.
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