2MSN, RN, Department of Nursing, Dominican University
3MPHc, Department of Nursing, Dominican University
4MSN, APN, FNP-C, Department of Nursing, Dominican University
5EdDc, MSN, RN, Department of Nursing, Dominican University
Method: Participants completed the Spiritual Intelligence Self- Report Inventory (SISRI-24) and the Resilience Scale before and after participating in the simulation.
Results: There were statistically significant changes in resilience and spirituality growth in the nursing students after participating in the simulation (p< 0.05). In addition, a statistically significant (p< 0.001) weak (r=0.482) to moderately (r=0.530) positive correlation occurred in resilience and spirituality in the nursing students occurred before and after participating in the simulation respectively.
Conclusion: Nursing students experienced greater growth in resilience and spirituality after participating in the simulation. In addition, a correlation between resilience and spirituality levels was evident. Nursing educators should consider providing challenging simulations to nursing students.
Keywords: End-of-Life Care; Spirituality; Resilience; Undergraduate Nursing Education; Simulation
Mealer, Jones, and Moss (2012) interviewed thirteen nurses determined to be highly resilient and fourteen nurses diagnosed with post-traumatic stress disorder. The findings demonstrated that the highly resilient critical care nurses had greater spirituality, optimism, and were involved in a supportive network, including having a mentor that was deemed highly resilient. For the nurses with post-traumatic stress disorder (PTSD), they lacked optimism, a social network, a resilient role model, and experienced regret. Resilience was found to be key to a fulfilling critical care nursing career. Taheri-Kharameh (2016) found similar findings to Mealer, Jones, and Moss (2012) and found a positive correlation with spirituality and general health in 55 intensive care unit nurses in Iran (r=0.348). Similar to Mealer, Jones, and Moss (2012), Gaydos (2004) utilized cocreative aesthetic inquiry and found that a fruitful nursing career in hospice required nurses to enter the field with high resilience, spirituality, endurance, and previous exposure to loss and grief [18,43].
The North Shore-LIJ Health System in New York recognized the need for resilience training and implemented a one day program for newly graduated nurses. The nurses reported feeling more reflective and self-aware after participation . However, efforts in exploring resilience and spirituality should be examined at the pre-licensure nursing level as well.
Beauvais, Stewart, DeNisco, and Beauvais (2014) assessed 124 undergraduate and graduate nursing students’ resilience, psychological empowerment, emotional intelligence (perceiving emotions), spiritual well-being, and academic success. Grade point average determined students’ academic success. In the undergraduate nursing students, one correlation was found between emotional intelligence (perceiving emotions) and academic success r(73)=-0.232, p=0.48. While this does not explore a specific intervention, this study offers baseline resilience and spiritual well-being data for the undergraduate and graduate nursing student perspective .
Shores (2010) examined spiritual perspectives of 205 undergraduate nursing students at random. Many scored highly on the Spiritual Perspectives Scale (SPS), though the highest scores occurred in those associated with more frequent participation in religious activities. This research examined spirituality through a religious context, though Shore (2010) acknowledges that spirituality encompasses various meanings and dimensions. Similar to Shore (2010), Boswell, Cannon, and Miller (2013) also assessed students’ perceptions on spirituality and also found that nursing students equated religion and spirituality [22, 23].
As opposed to at random and varying participants, as the case was with Shore (2010), Cilliers and Terblanche (2014) conducted a case study on 14 senior nursing students examining spirituality when working with a full nursing assignment in the hospital. Participants were asked to write an essay based upon their hospital experiences. Trustworthiness of the data was secured, and the findings demonstrated that students did not demonstrate spiritual intelligence; rather, internal conflict was evident and spiritual coping did not transpire [22,24].
Mitchell, Bennett, and Mandfrin-Ledet (2006) recommended nursing educators utilize case studies and care maps to enhance nursing students’ development of spiritual and competent care to the end-of-life care patient. Despite this recommendation, understanding nursing students’ personal growth of spirituality and resilience continues to be a shortfall in the literature. The literature is deficient of research examining resilience and spirituality development in nursing students in challenging patient situations such as end-of-life care. Rather, the literature mostly focuses on teaching undergraduate nursing students about spiritual care and resilience [25,26]. Furthermore, the current state of the literature typically involves exploration of undergraduate nursing students’ development of resilience or spirituality, rarely both. The research at hand will explore development of resilience and spirituality in senior nursing students participating in an end-of-life care simulation.
1. Is there a statistically significant difference in undergraduate nursing students’ resilience scores before and after participating in a holistic, critical care end-of-life care simulation?
2. Is there a statistically significant difference in undergraduate nursing students’ spirituality scores before and after participating in a holistic, critical care end-of-life care simulation?
3. Is there a correlation between resilience and spirituality scores in undergraduate nursing students participating in a holistic, critical care end-of-life care simulated patient?
King (2008) created the SISRI-24 and found it to be a highly reliable measure of spiritual intelligence (α=0.92) and with construct validity in 305 undergraduate students. Further testing of the instrument included test-retest reliability was r=0.89 (p< 0.001) and a full factor analysis when studying 25 undergraduate students . Multiple recent studies have assessed, confirmed reliability and validity of the SISRI-24 [35,37,38]. Considering this and the original intention was to measure undergraduate students’ spirituality, this tool was deemed most appropriate
Students were given prep work, which required them to answer questions about providing holistic care to end-of-life care patients prior to coming to the simulation. In addition, since the simulation was offered during the final week of the class, all nursing students were given class instruction of how to provide holistic care to a critically ill adult patient across the eight week course. In addition, all of the nursing students completed a total of 91 clinical hours in a high acuity telemetry or intensive care unit prior to participating in the simulation.
The students were asked to arrive ten to fifteen minutes early for the simulation, which included 30 minutes of exposure to the simulated patient and a 30 minute debriefing. At that time, students were provided information about the study from the primary investigator, signed consent form, and filled out the initial Resilience Scale and SISRI-24 questionnaires if volunteering to participate. From there, the nursing students were given report on a simulated critically ill, geriatric oncology patient.
The simulated patient was a high-fidelity mannequin dressed to resemble an elderly female. The patient was on multiple vasopressors, Amiodarone, intravenous fluids, receiving a blood transfusion, and had a Morphine Sulfate pain-control analgesia pump; all medications were administered through a triple lumen catheter in the left subclavian vein. Also, the patient had continuous blood pressure monitoring per a right arterial line. An electronic health record, including e-MAR and physician’s orders, was made available to the students on a laptop in the room. The nursing students were able to obtain the Morphine Sulfate intravenous push medication from the Pyxis.
The patient moaned in pain and did not have family at the bedside. The nursing students were required to provide comfort care, including administering pain medication and turning off the vasopressors and blood transfusion. In addition, the students had to recognize various cardiac arrhythmias, including identifying atrial fibrillation on initial assessment. After one of the students pushed Morphine Sulfate, the patient went into ventricular fibrillation and then a systole. The students notified the physician and students provided post-mortem care to the patient.
Once post-mortem care was completed, the simulation was completed. The students filled out the Resilience Scale and SIRSI-24 again, which required approximately five minutes of time. From there, the scales were submitted to the primary investigator; students were able to select a candy bar as remuneration for the time, energy, and honest sharing of thoughts. After that, a 30 minute debriefing followed. The debriefing using structured questions that reflected on the simulation, providing end-oflife care that included holistic care, coping with loss, feelings surrounding a patient dying without family at the bedside, and their state of mind when turning off the intravenous pumps and intravenously pushing the Morphine Sulfate.
Statistical analysis was conducted using paired samples t-test and Pearson’s r correlation in SPSS. When applicable, a Cohen’s d was utilized to assess effect size. All data was assessed for missing data and outliers prior to statistical analysis, including for linearity.
A paired-samples t-test was conducted to evaluate the impact of participating in an end-of-life care simulation on nursing students’ resilience on the Resilience Scale and SISRI-24. There was a statistically significant increase in resilience scores on the Resilience Scale from pre-simulation (M=139.02, SD=14.07) to post-simulation (M=142.27, SD=15.22), t(47)=2..99, p=0.004 (two-tailed). The mean increase in resilience scores was 3.25 with a 95% confidence interval ranging from 1.07 to 5.43. The Cohen’s d statistic (0.22) indicated a small effect size. There was a statistically significant in spirituality scores on the SISRI-24 from pre-simulation (M=62.44, SD=13.28) to post-simulation (M=67.00, SD=13.54),t(47)=5.54,p=0.000 (two-tailed). The mean increase in spirituality was 4.56 with a 95% confidence interval ranging from 2.91 to 6.22. The Cohen’s d statistic (0.33) indicated a small effect size. (Table 1)
95% Confidence Interval
Change in Mean Score Percentage
1.07 to 5.43
t(47)=2..99, p=0.004 (two-tailed)
2.91 to 6.22
t(47)=5.54, p=0.000 (two-tailed)
An interesting observation was to see the nursing students provide holistic care to the patient during post-mortem care. Some of the groups held a moment of silence, while one group verbally prayed over the patient after closing the body bag. Incorporating such care was not discussed or described in the course, which is what made these moments remarkable to observe.
Shores (2010) recommended nursing educators having greater awareness of nursing students’ spiritual perspectives to enhance opportunities to link theory and practice. Despite those recommendations and requests for further research, the literature has been short of research examining various pedagogies that can support the development of resilience and spirituality in undergraduate nursing students. This study began to address this by studying resilience and spirituality development in undergraduate nursing students in a holistic, end-of-life care simulation. Simulation can serve as a safe environment to explore resilience and spirituality in difficult patient scenarios, including providing holistic to an end-of-life care patient.
- Kopp W, Hanson MA. High-fidelity and gaming simulations enhance nursing education in end-of-life care. Clinical Simulation in Nursing. 2012; 8(3): e97-e102. DOI: 10.1016/j.ecns.2010.07.005
- American Association of Colleges of Nursing. ELNEC fact sheet. 2016.
- Allen ML. Examining nursing students’ stress in an end-of-life care simulation. Clinical Simulation in Nursing. 2018. 14(1): 21-28. DOI: 10.1016/j.ecns.2017.10.006
- Caton AP, Klemm P. Introduction of novice oncology nurses to end-of-life care. Clinical Journal of Oncology Nursing. 2006; 10(5):605-608.DOI: 10.1188/06.CJON.604-608
- Gillan PC, Parameter G, Van der Riet PJ, Jeong S. The experience of end of life care simulation at a rural Australian university. Nurse Education Today. 2013; 33(11):1435-1439. DOI: 10.1016/j.nedt.2012.11.015
- Holms N, Milligan S, Kydd A. A study of the lived experiences of registered nurses who have provided end-of-life care within an intensive care unit. Int J Palliat Nurs. 2014; 20(11):549-556. DOI: 10.12968/ijpn.2014.20.11.549.
- Kwekkeboom KL, Vahl C, Eland J. Companionship and education: A nursing student experience in palliative care. J Nurs Educ. 2005; 44(4):169-176.
- Leighton K, Dubas J. Simulated death: An innovative approach to teaching end-of-life care. Clinical Simulation in Nursing. 2009; 5(6): e223-e230.
- Sampaio AV, Comassetto I, Faro A, Santos RM, Monteiro FS. The experience of nursing students facing death and dying. Investigacion & Educacion en Enfermeria.2015; 33(3):305-314. DOI: 10.17533/udea.iee.v33n2a13
- Mealer M, Jones J, Newman J, McFann KK, Rothbaum B, Moss M. The presence of resilience is associated with a healthier psychological profile in intensive care unit (ICU) nurses: results of a national survey. Int J Nurs Stud. 2012; 49(3):292-299. DOI: 10.1016/j.ijnurstu.2011.09.015.
- McGarry S, Girdler S, McDonald A, Valentine J, Lee SL, Blair E, et al. Pediatrics health-care professionals: relationships between psychological distress, resilience and coping skills. Journal of Pediatrics and Child Health. 2013; 49(9):725-732. DOI: 10.1111/jpc.12260
- Berragan L. Simulation: An effective pedagogical approach for nursing? Nurse Educ Today. 2011; 31(7):660-663. DOI: 10.1016/j.nedt.2011.01.019
- Lavoie P, Clarke SP. Simulation in nursing education. Nursing. 2017; 47(7):18-20. DOI: 10.1097/01.NURSE.0000520520.99696.9a
- Gropelli TM. Using active simulation to enhance learning of nursing ethics. J Contin Educ Nurs. 2010; 41(3):104-105. doi: 10.3928/00220124-20100224-09
- Ouyang JR, Stanley N. Theories and research in educational technology and distance learning instruction through Blackboard. Universal Journal of Educational Research. 2014; 2(2):161-172.
- Hodges HF, Keeley AC, Grier EC. Professional resilience, practice longevity, and Parse’s Theory for Baccalaureate Education. J Nurs Educ. 2005; 44(12):548-554.
- Reinert KG, Koenig HG. Re-examining definitions of spirituality in nursing research. J Adv Nurs. 2013; 69(12):2622-2634. DOI: 10.1111/jan.12152
- Mealer M, Jones J, Moss M. A qualitative study of resilience and posttraumatic stress disorder in United States ICU nurses. Intensive Care Med. 2012; 38(9):1445-1451. DOI: 10.1007/s00134-012-2600-6
- Richez M. Resilience-building strategies for nurses in transition. J Contin Educ Nurs. 2014; 45(2):54-55. DOI: 10.3928/00220124-20140124-12.
- Stephens TM, Gunther ME. Twitter, millennials, and nursing education research. Nurs Educ Perspect. 2016; 37(1):23-27
- Beauvais AM, Stewart JG, DeNisco S, Beauvais JE. Factors related to academic success among nursing students: A descriptive correlational research study. Nurse Educ Today. 2014; 34(6):918-923. DOI: 10.1016/j.nedt.2013.12.005
- Shores CI. Spiritual perspectives of nursing students. Nurs Educ Perspect. 2010; 31(1):8-11.
- Boswell C, Cannon SB, Miller J. Students’ perceptions on holistic care. Nurs Educ Perspect. 2013; 34(5):329-333
- Cilliers F, Terblanche L. The role of spirituality in coping with the demands of the hospital culture amongst fourth-year nursing students. Int Rev Psychiatry. 2014; 26(3):279-288. DOI: 10.3109/09540261.2014.890922
- Mitchell DL, Bennett MJ, Manfrin-Ledet L. Spiritual development of nursing students: Developing competence to provide spiritual care to patients at the end of life. J Nurs Educ. 2006; 45(9):365-370
- Timmins F, Neill F. Teaching nursing students about spiritual care: A review of the literature. Nurse Educ Pract. 2013; 13(6):499-505. DOI: 10.1016/j.nepr.2013.01.011
- Corry DS, Lewis CA, Mallett J. Harnessing the mental health benefits of the creativity–spirituality construct: Introducing the Theory of Transformative Coping. Journal of Spirituality in Mental Health. 2014; 16(2):89-110. DOI: 10.1080/19349637.2014.896854
- Corry DA, Mallett J, Lewis CA, Abdel-Khalek AM. The creativity-spirituality construct and its role in transformative coping. Mental Health, Religion & Culture.2013; 16(10):979-990. DOI: 10.1080/13674676.2013.834492
- Faul F, Erdfelder E, Lang A, Buchner A. G*Power (Version 188.8.131.52) [Computer software]. 2007.
- Wagnild G. The Resilience Scale user’s guide for the U.S. English version of the Resilience Scale and the 14-Item Resilience Scale (RS-14) [User’s guide]. Worden, MT: Resilience Center. 2016
- Burnett HJ Jr, Helm HW Jr. Relationship between posttraumatic stress disorder, resilience, and religious orientation and practices among university student earthquake survivors in Haiti. Int J Emerg Ment Health. 2013; 15(2):97-104.
- Oladipo SE, Idemudia ES. Reliability and validity testing of Wagnild and Young’s Resilience Scale in a sample of Nigerian youth. Journal of Psychology.2015; 6(1): 57-65.DOI: 10.1080/09764224.2015.11885524
- King DB. Rethinking claims of spiritual intelligence: A definition, model, & measure (Unpublished doctoral dissertation). Trent University, Peterborough, Ontario, Canada. 2009.
- Emmons RA. Spirituality and intelligence: Problems and prospects. The International Journal for the Psychology of Religion. 2000; 10(1):57-64. DOI: 10.1207/S15327582IJPR1001_6
- Wan Zulkifi WN, Ishak NA, Mat Saad ZB. The Spiritual Intelligence Self Report Inventory (Sisri 24) instrument reliability among delinquent teenagers. IOSR Journal of Humanities and Social Science. 2017; 22(7):44-447.
- King DB, DeCicco TL. A viable model and self-report measure of spiritual intelligence. International Journal of Transpersonal Studies. 2009; 28(1):68-85.
- Ahoei K, Faramarzi M, Hassanzedeh R. The relationship between spiritual intelligence and psychological well-being in women with breast cancer. Shiraz E-Medical Journal. 2017; 18(10): e15103. DOI: 10.5812/semj.15103
- Anbugeetha D. An analysis of the Spiritual Intelligence Self Report Inventory (SISRI). International Journal of Management. 2015; 6(7):25-36. DOI: 10120150607004
- Botma Y. Nursing student’s perceptions on how immersive simulation promotes theory–practice integration. International Journal of Africa Nursing Sciences. 2014; 1(1):1-5. DOI: 10.1016/j.ijans.2014.04.001
- Scammell J. Resilience as part of nursing education: Supporting nurses in times of austerity. Br J Nurs. 2017; 26(13):772. DOI: 10.12968/bjon.2017.26.13.772
- Robert Wood Johnson Foundation. Nearly one in five new nurses leave first job within a year, according to survey of newly-licensed registered nurses. 2014.
- American Association of Colleges of Nursing. CARES: Competencies and recommendations for educating undergraduate nursing students preparing nurses to care for the seriously ill and their families. 2016.
- Barbato Gaydos HL. The living end: Life journeys of hospice nurses. Journal of Hospice &Palliative Nursing. 2018; 6(1):17-26.
- Nelson R. Replicating real life: Simulation in nursing education and practice. American Journal of Nursing. 2016; 116(5):20-21.
- Ormsby A, Harrington A, Borbasi S. ‘You never come back the same’: The challenge of spiritual care in a deployed military nursing context. J Clin Nurs. 2017; 26(9-10):1351-1362. DOI: 10.1111/jocn.13685