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Correspondence: Frans Cilliers, Department of Industrial and Organisational Psychology, PO Box 392, UNISA 0003, South Africa. Tel: � 27.83.709.8776. Fax: � 27.12.429.8368. E-mail: [email protected]
The role of spirituality in coping with the demands of the hospital culture amongst fourth-year nursing students
FRANS CILLIERS 1 & LANDA TERBLANCHE 2
1 Department of Industrial and Organisational Psychology, University of South Africa, Pretoria, South Africa, and 2 School of Nursing, Trinity Western University, Langley, Canada
Abstract The aim of this research was to describe the role of spirituality in coping with the demands of the hospital culture amongst fourth-year nursing students. Qualitative, descriptive, hermeneutic interpretive research was done. A case study of 14 female Canadian nursing students was asked to write an essay on their experiences of the demands of the hospital culture. Con- tent analysis was used and positive psychology served as the interpretive lens. Trustworthiness and ethicality were ensured. The fi ndings indicated that although the nursing students expressed themselves in religious and spiritual words, they did not signifi cantly illustrate the theoretically associated intra-, interpersonal and sacred behaviours to be referred to as being spiritual in their experience as a care giver in the hospital culture. They also did not illustrate behaviours linked to other positive psychology constructs such as sense of coherence, resilience, engagement or emotional intelligence. Rather, the nursing students experienced identity crises. Recommendations for the inclusion of mentoring in the curriculum of nursing students were formulated.
Introduction
Organizational culture can be defi ned as the customs, ways, rituals, rules and regulations implemented by a system to preserve its identity (Robbins et al., 2009). As institutions, hospitals are seen as different from most other types of orga- nizations because of their unique primary task of attending to illness, pain, dying and death (Katz & Kahn, 1978). This has resulted in a worldwide hos- pital culture of strict hierarchy and control in order to preserve order in reporting lines, obedience to methodology and technique, and cleanliness and sterility for the survival of patients, their families, communities and hospital staff. Menzies ’ (1993) research on hospital organizational dynamics found that hospitals as systems compensate for manifest- ing institutionalized survival anxieties (amongst patients) and performance anxieties (amongst staff) by enforcing strict personnel and procedural con- trol mechanisms.
It is generally accepted in the nursing fraternity that student nurses experience emotional diffi culty upon entering the hospital culture (Lanzette, 2010). As little information is available on their spiritual experiences, this study investigated how they cope from a spiritual perspective.
Literature review
Nursing science views and studies nurses as whole people, and it is believed that their professional and work performance depends on the level of inte- gration of their physical, psychological (including cognitive, emotional, motivational), social, cultural, environmental and spiritual functioning (Duke, 2013; Lanzette, 2010; Meier et al., 2005; Reimer- Kirkham et al., 2012; Young & Koopsen, 2005). Of these domains, research on spirituality is limited and controversial (Wissing & Fourie, 2000) due to the multidimensionality of spirituality, its confusion with religiosity or religious activities, as well as the diverse research methodologies being applied.
Spirituality input has been studied amongst vari- ous patient groups (Bauer & Barron, 1995; Brillhart, 2005; Hampton & Weinert, 2006; Lovanio & Wallace, 2007; Meraviglia, 2004; Reynolds, 2006; Tuck et al., 2001). Although the results are inconsistent, it has been shown to facilitate patients in coping with pain, hopelessness and despair. Research on the spiritual- ity of nursing students showed that the women especially regard themselves as having high levels of spirituality characterized by religious activities (discussions, church attendance) and experiencing meaning in life (Shores, 2010). Spiritual sensitivity
International Review of Psychiatry, June 2014; 26(3): 279–288
ISSN 0954–0261 print/ISSN 1369–1627 online © 2014 Institute of Psychiatry DOI: 10.3109/09540261.2014.890922
280 F. Cilliers & L. Terblanche
increases with age and experience (Callister et al., 2004), especially after inputs containing self- refl ection (Catamzaro & McMullen, 2001), and increases the nurse ’ s competence in patient care- giving (Mitchell et al., 2006; Pesut, 2002). Nursing students ’ spirituality at Christian universities does not differ signifi cantly from students at public universities (Garner et al., 2002).
Conceptualizing spirituality
The existing literature on spirituality does not pro- vide a clear and comprehensive conceptualization or clear behavioural characteristics on the construct (Pargament, 2013a; 2013b). It was therefore decided to create a profi le from the existing positive psychol- ogy literature.
Psychology in general and organizational psy- chology specifi cally, has for a long time ignored, pathologized and reduced spirituality as a part of many underlying psychological functions (Snyder & Lopez, 2009). Organizational psychology is increas- ingly exploring the role of spirituality in leadership, ethical behaviour, communication, motivation and sustainability (Pargament, 2013b). Since the popu- larization of positive psychology (Seligman & Csik- szentmihalyi, 2000), spirituality was recognized as a psychological construct (Pargament, 2013a; 2013b). Positive psychology is defi ned as the scien- tifi c study of strengths, virtues, positive emotions, traits and values towards enabling individuals, orga- nizations and communities to thrive, and positive organizational psychology as the study of the nature of and enhancement of coping behaviour (Azar, 2011; Linley & Joseph, 2004; Lopez & Lyubomir- sky, 2008; Seligman & Csikszentmihalyi, 2000; Seligman et al., 2005; Sheldon & King, 2001; Shel- don et al., 2011; Snyder & Lopez, 2009; Str ü mpfer, 2005). Coping behaviour is operationalized in con- structs such as respect, mindfulness, emotional intelligence, happiness, hardiness, resilience, engage- ment, self-effi cacy, sense of coherence and learned resourcefulness as well as some less well-known constructs such as positive character strengths, pos- itive emotions, fl ourishing, curiosity, hope, and joy (Snyder & Lopez, 2009).
Spirituality is derived from the Latin spiritus , mean- ing breath, and refers to the essence of who and how people are in life. As a multidimensional phenome- non, spirituality has no universally accepted defi ni- tion (Duke, 2013; Meier et al., 2005; Young & Koopsen, 2005). The World Psychiatric Association (Verhagen et al., 2010) defi nes spirituality as a per- sonal belief in ideas of religious signifi cance such as God, the soul or heaven. The Canadian Nursing Association (CNA, 2010) endorsed Wright ’ s (2005) defi nition, namely that spirituality refers to whatever
or whoever gives ultimate meaning and purpose to one ’ s life that invites particular ways of being in the world in relation to others, oneself and the universe. Pargament (2013a; 2013b) presents an impressive, extensive and recent rendition of the history and psy- chology of spirituality with reference to relevant paradigms, social contexts, methodological and psy- chometric data.
In positive psychology, spirituality is defi ned as a pervasive, basic human, personal, individualistic, subjective, life-enhancing and growth-stimulating force indicative of psychological well-being, in search of the sacred (Linley & Joseph, 2004; Meier et al., 2005; Pargament, 1999; 2013a; 2013b; Peterson & Seligman, 2004; Snyder & Lopez, 2009; Young & Koopsen, 2005). The search refers to the ongoing life journey and process of discovery of something sacred (such as personal accomplishments or revelations), conservation (holding on to the discovery, building and sustaining the connection) and transformation (the purifi cation and reframing of the individual ’ s tie and connectedness to the sacred). Sacred refers to what is set apart from the ordinary, worthy of ven- eration and respect, the individual ’ s concept of God as well as the manifestations of the divine. Individu- als experience transcendence (the felt presence of a reality or a being that is wholly different from ordi- nary experience), immanence, boundlessness and ultimacy (the experience of something as fundamen- tal to the nature of reality, at the heart of the mystery of the universe and of all human experience).
Spirituality has always been connected to religion (a belief system towards a specifi c concept such as a god) and religiosity (an ideology based on the belief that right and wrong behaviour exist) (Duke, 2013). On the other hand religiousness is seen as a socially, culturally, and collectively shared, external, institu- tional, structural, administrative (often bureaucratic and hierarchical) structure, confi ned to predefi ned and cognitively justifi ed beliefs, dogma, creeds and rituals of a particular organized religion (e.g. Chris- tian, Judaism, Islam, African, Eastern) (Pargament, 1999; 2013a; 2013b; Robertson, 2006; Wissing & Fourie, 2000). Spirituality and religion are increas- ingly differentiated and even polarized. This is evi- dent in popular expressions such as ‘ being spiritual, not religious ’ which favours spirituality as more in vogue than religion (Pargament, 2013b). It is as if in comparison, spirituality represents a more basic and inherent human characteristic that precedes religion and is used as an escape from religious servitude towards personal development (Pargament, 2013b).
Spirituality is described in terms of intelligence, coping and well-being. Spiritual intelligence can be defi ned as a mental capacity to think, reason and dream about, and strive towards meaning, value, vision, holistic integration, joy, happiness and
Sprirituality in coping with culture 281
transcendence, while knowing that the whole is greater than the sum of the parts (Meier et al., 2005). Spiritual coping refers to dealing effectively with stressful contexts and demands through self-empow- erment based on meaning-making (positive and negative reappraisal), control (active and passive ways of gaining mastery), comfort (spiritual connec- tion and support), intimacy (religious support with the others), and self-transformation (Pargament, 2013a). Spiritual well-being follows from spiritual intelligence and coping. It refers to a harmonious interconnectedness with the self, the other, commu- nity, environment and a deity/the divine in the expe- rience of gratitude, forgiveness, existential purpose, meaning, hope, and transcendence, and is connected to psychological well-being through constructs such as happiness and quality of life (Frankl, 1969; Parga- ment, 2013a; Young & Koopsen, 2005).
Operationalizing spirituality
The operationalization of spirituality is complex. Popular and scientifi c literature is fi lled with lists and descriptions of desirable characteristics of what con- stitutes being spiritual, of which the following is an abbreviated categorization, integrated for purposes of this research (Fowler et al., 2012; Frankl, 1969; Jung, 1955; Kashdan, 2009; Linley & Joseph, 2004; Nasser & Overholser, 2005; Pargament 2013a; 2013b; Robertson, 2006; Snyder & Lopez, 2009; Young & Koopsen, 2005).
The self (intrapersonal behaviour and inner resources)
The individual illustrates a high level of subjective, fl exible and dynamic self-awareness and conscious- ness supported by a constant intelligent reappraisal of the spiritual self. The prevailing value system con- sists of respect and compassion for the self, personal boundaries, simplicity, solitude, submission, the exploration of all emotional experiences including love, suffering, forgiveness, grace, mystery, curiosity, courage, bravery, a search for the higher purpose and meaning of life, motivated by inner strength, strong beliefs and hope (desire accompanied by expecta- tions of fulfi lment), taking control towards personal mastery, individualization and self-actualization.
The other (interpersonal behaviour, relationships)
The individual is motivated by the belief in a univer- sal and growth-stimulating human inter-connected- ness and inter-dependence. The prevailing value system is based on the above inner resources to build deep relationships across difference. These relation- ships are characterized by social intelligence, respect for interpersonal boundaries, kindness, realness and
authenticity, grace (an understanding of the gifts of life that are often attributed to providence), support, comfort, love (an acknowledged mystery that is expe- rienced and expressed in caring acts, both given and received), intimacy, justice (civic strengths that underlie healthy and fair teamwork, leadership, citi- zenship and community life) and temperance (mod- esty, humility, prudence, forgiveness, self-control, regulation and protection against excess).
The sacred (connectedness with the universe)
The individual is energized by the above-mentioned intra- and interpersonal awareness to explore its con- tinuous connectedness with the larger, higher and permanent power outside of and beyond the self. This includes the incomprehensible, not rationally explainable, universal and unifi ed, existential essence of being, evolution and mystery, all as various con- cepts of God and the divine. The individual is ‘ inspir- ited ’ through specifi c experiential activities such as asking existential questions, having conversation and discourse about fundamental matters, reframing questions, reading, rituals, prayer, confession, wor- ship, celebration, solitude, meditation, guided imag- ery, visualization, fasting, spending time in nature, viewing and engaging in art, storytelling and service to others. The prevailing value system is a search for purpose, meaning, happiness, gratitude, wisdom, fulfi lment, transformation, harmony, peace, and being strengthened by religious beliefs, hope, awe, and transcendence. The individual values sacred objects such as time (for the self, the other, the sacred), space (nature, a spiritual place), events (birth, graduation, marriage, death), culture (visual art, music, literature) and roles (spouse, parent, employee, leader).
Not being spiritual can be described as being dispirited (Young & Koopsen, 2005). This state con- sists of spiritual distress, the disruption of life prin- ciples that pervades every aspect of the individual ’ s being, and spiritual disequilibrium (Jung, 1955), being in inner chaos when cherished beliefs are chal- lenged, and the lack of integration of good and bad which hinders individuation. Frankl (1969) referred to noogenic neuroses to describe the lack of meaning experienced, manifesting as existential frustration and spiritual emptiness.
Many positive psychology constructs have been explicated in terms of their conceptualization (Lin- ley & Joseph, 2004; Snyder & Lopez, 2009), their psychometric properties (Str ü mpfer, 2005; Wissing & Van Eeden, 2002), their inter-relationships with organizational constructs such as well-being, com- mitment and satisfaction (Basson & Rothmann, 2002; Breed et al., 2006; Cilliers & Coetzee, 2003; Feldt, 1997; Naud é & Rothmann, 2006; Pretorius,
282 F. Cilliers & L. Terblanche
2007; Rothmann & Van Rensburg, 2002; Ryan & Deci, 2000; Storm, 2002; Str mpfer et al., 2010; Van Zyl et al., 2010; Wright, 2005). The same can- not be said about spirituality, mostly because of the lack of differentiation between mental (ill) health and psychological well-being (Wissing & Fourie, 2000). Some behavioural aspects of spirituality such as meaning of work, hope, religiosity, religious orientation and coping showed relationships with other positive psychology constructs such as sense of coherence (Wissing & Fourie, 2000), work engagement (Beukes & Botha, 2013), psychologi- cal well-being (Wissing & Van Eeden, 2002) and organizational constructs such as organizational commitment (Beukes & Botha, 2013). Research in nursing on spirituality conceptualized from positive psychology is scarce, although a relationship between spirituality, sense of coherence and hope as inner resources was established (Gibson, 2003), as well as with work engagement (Van der Colff & Rothmann, 2009).
The research question, aim and purpose
This research question was framed as follows: Upon being less dependent on and contained by their clin- ical group led by the clinical supervisor/instructor, and becoming more independent and functioning increasingly as professionals in the hospital culture, what is the nature of fourth-year nursing students ’ spiritual coping? The aim of this research was to describe the role of spirituality in coping with the demands of the hospital culture amongst fourth-year nursing students. The purpose of the research was for this description to serve as normalizing informa- tion for future nursing students entering the hospital culture, and for university and hospital staff as a basis for student mentoring.
Methods
Research design and strategy
Qualitative and descriptive research was chosen (Brewerton & Millward, 2004) using the hermeneu- tic interpretive approach (Clarke & Hoggett, 2009). During the data interpretation the researchers used themselves as instruments (McCormick & White, 2000) based on the epistemological assumption that empathetic listening allows for deep understanding of shared experiences (Clarke & Hoggett, 2009). The strategy involved a single case study (Babbie & Mou- ton, 2001) used for its intrinsic (to gain theoretical and practical understanding of experiences) and instrumental values (to provide feedback) (Denzin & Lincoln, 2005).
Research setting
The researchers experienced that most nursing stu- dents enter their career oblivious of the demands of the hospital culture. Some students are motivated by their spiritual and selfl ess needs to help and care for the less fortunate – including those in Third World countries. Others are driven by an external locus of control (Rotter, 1966) fi lled with romantic images and stereotypes of nurses being admired as women by attractive and well-behaved doctors as portrayed in fi lms and TV series such as ER , Scrubs, Grey ’ s Anatomy and Call the Midwife . For these students the experience of the harsh reality of the hospital culture could be devastating and a space where they may need to rely on their inner spiritual strength.
The research was performed within a collaborative university and hospital setting. The university ’ s nurs- ing school is primarily responsible for the students ’ academic training in various hospitals (and care facil- ities) where the students were placed, for their clini- cal training. The student ’ s four-year tertiary education is professionally regulated and structured according to specifi c and relevant competencies, of which the development of clinical skills and critical thinking in the various areas of nursing, and quality care-giving to patients are the most important (see Fowler et al., 2012). Although spiritual development is desirable it is seldom directly addressed in the curriculum. The students received their clinical education fi rstly in a laboratory (in their fi rst year) after which they were increasingly exposed to real clinical experiences dur- ing their placements in various hospital divisions. Here, they worked in groups with a clinical supervi- sor/instructor.
Sample
The population was the fourth-year Bachelor of Nursing Science students in a Canadian university ’ s nursing school. A convenient and opportunistic sam- ple (Terre Blanche et al., 2006) was used – the 14 Caucasian female students between 21 and 27 years of age who responded to the invitation for participa- tion. The sample represented 70% of the total enrolled fourth-year students. The data was seen as rich enough without having to extend the sample.
Instrument, procedure and analysis
A self-report essay was used as the data collection instrument (Clark & Hoggett, 2009), using the fol- lowing question: Write an essay of maximum fi ve pages on your experiences of the demands of the hospital culture by referring to your personal and academic experiences. Students were asked to send their essays by e-mail to the second author. The
Sprirituality in coping with culture 283
data was content analysed, focusing on latent con- tent and using whole interviews as units of analysis (Graneheim & Lundman, 2004). Simple herme- neutics was used to understand participants ’ sub- jective and inter-subjective experiences and double hermeneutics to allow for the critical interpretation of their experiences from a positive psychology per- spective (Snyder & Lopez, 2009). The process of interpretation (Terre Blanche et al., 2006) involved familiarization, immersion, crystallization and cat- egorization of experiences into positive psychology constructs. Lastly, the data was integrated into a research hypothesis (Schafer, 2003).
Ensuring quality data
Scientifi c rigour and trustworthiness was attended to (Graneheim & Lundman, 2004; Johnson & Water- fi eld, 2004). Dependability was ensured in the pro- cess of enquiry and the scientifi c rigour applied in the planning and execution of the research project. Credibility was ensured through a relative intense research engagement and the authorized involve- ment of all parties (Hirschhorn, 1997). Internal gen- eralizability and confi rmability were attended to. The two researchers performed separate analyses, inte- grated these and submitted the fi ndings to two inde- pendent, theoretically informed academics for peer review. They declared the research dependable and agreed on its richness (Denzin & Lincoln, 2005). The thick and detailed data description of the experiences served the purpose of transferring the meaning to different and yet similar contexts. Confi rmability was also established through the authors ’ attempts to examine the product to attest that the fi ndings, inter- pretations and recommendations were supported by the theoretical data. Ethicality referred to informed consent and anonymity negotiated with all partici- pants during the data-gathering phase (De Vos et al., 2002).
Findings
The participants ’ experiences of the demands of the hospital culture contained a limited positive and an intense negative content. The following excerpt serves as a typical participant experience.
Driving home my mind was everywhere. I thought back to all the kids I had seen that day, all the charts and stories I read. I didn ’ t know how to process everything. I think that we are incredibly vulnerable to burnout and developing an attitude of bitterness, as it can be easy to get overwhelmed not only with a heavy workload, but also because of stress and demands that came with a new job. In addition, we can also
become easily infl uenced by other ’ s attitudes as we seek to gain the acceptance of our co-work- ers. I left the shift feeling very disheartened. I am a sensitive person and people ’ s words and attitudes rub off on me. As I hold the hand of a woman dying, I wonder if these precious, yet traumatizing moments will ever cease to break my heart. Will I ever become the nurse that is not impacted by a patient ’ s death? Will I come home this physically and emotionally tired after every shift for the rest of my career? [...] When managing the care of two patients I had the time to do the job I entered nursing to do. I had the time to invest into my patients and truly take the time to ask them questions about their lives, to grow to understand them, and to take the time to care for them. Yet when running after four sick patients, some of whom are dependent for all physical care, the list of things to do becomes overwhelming, we become rushed, patients become frustrated, and we are able to just get the job done. But the job done was never the job I wanted to do.
The hospital context
Before and on crossing the boundary into the hospi- tal culture, all the participants idealized (Blackman, 2004) the hospital environment and the nursing pro- fession. They referred to ‘ the ideals we have been taught ’ , how they ‘ felt honoured ’ to be involved in ‘ such a beautiful vocation ’ , and their expectations of having ‘ meaningful ’ and ‘ caring interactions ’ . Moti- vationally, they were ‘ willing ’ and ‘ eager ’ , to ‘ connect with suffering patients ’ and to ‘ make a difference ’ in the ‘ lives of others who are suffering ’ . After a while of being exposed to the hospital culture, they expe- rienced a ‘ culture shock ’ where the ideal was replaced by ‘ the actual realities of practice ’ and a ‘ hard ’ , ‘ cold ’ and ‘ clinical ’ culture surrounded by ‘ pain ... suffering ... and death ’ . They experienced disappointment, dis- illusionment, confusion and intense confl ict about being in the hospital ( ‘ I love it ... I hate it ’ , it is ‘ the best job ... it is the worst job ’ , ‘ it is a hopeless job ’ ). Nursing became ‘ an immense ’ and ‘ overwhelming challenge ’ – they were stressed by the ‘ actual realities of practice ’ , the ‘ business ’ , the ‘ heavy work load ’ , the ‘ very strict routine ’ and ‘ rules ’ which resulted in ‘ lim- ited time for myself ’ , ‘ my own activities ’ and ‘ other meaningful activities ’ .
Interpretation
Intellectually, the participants realized that the hos- pital is an institutional system managing its primary task of caring and secondary task of containing high
284 F. Cilliers & L. Terblanche
levels of anxiety for all involved, and with an prescribed systemic role for each, including the student nurse (Cilliers & Terblanche, 2010). Emo- tionally, they experienced overwhelming shock when they realized that they needed to adapt to the culture, which implied the deconstruction of the idealized picture in their minds about nursing and facing the reality of the shadow side of the profession and the institution (Nelson & Hogan, 2009). No participant mentioned the hospital as a space for spiritual togeth- erness or support, which was interpreted as indica- tive of how the shocking experience caused their spiritual disequilibrium and dispirited state (Shores, 2010; Young & Koopsen, 2005).
The self
Intrapersonally, participants described their physical experiences as being ‘ exhausted ’ , having ‘ diffi culty sleeping ’ and suffering from ‘ compassion fatigue ’ and ‘ burnout ’ ( ‘ I gave all of myself, there is nothing left of me ’ ). Their emotional experiences were described as ‘ disheartening ’ ( ‘ my heart has been taken out ’ , ‘ cut into pieces ’ , ‘ dispersed to various people ’ ), a constant ‘ struggle ’ and ‘ moral ’ ‘ confl ict ’ between ‘ acting responsibly ’ versus ‘ suffering ’ , ‘ feeling vulnerable ’ and ‘ inadequate ’ . They experienced ‘ paralysing fear ’ , frustration ( ‘ since I don ’ t have enough time to get the job done ’ ), blame ( ‘ for not doing more ’ ), guilt ( ‘ not able to give more to others ’ and ‘ not fulfi lling my responsibility ’ ), ‘ numbness ’ (and at ‘ a loss of words ’ ), ‘ weakness ’ , ‘ helplessness ’ , sadness ( ‘ I cry every time I drive home ’ ), ‘ a brokenness ’ and strong vulnerability ( ‘ I need to respect ’ myself, ‘ protect myself right now ’ , ‘ we need to be gentle on our- selves ’ ). Motivationally they struggled to ‘ get by ’ while they are actually ‘ striving for more ’ and having a ‘ desire to change the situation ’ . For some it was as if they were losing the ‘ balance in my life ’ and ‘ parts of myself ’ ( ‘ I have become one with ’ ... ‘ inseparable from my work ’ , ‘ when looking at the patients, I have problems in knowing the difference between my pro- fessional identity and personal identity ’ , ‘ I take the patients home with me ’ ).
Interpretation
All the participants illustrated their physical and emotional self-awareness (Naud é & Rothmann, 2006) about the content and intensity of their pain and suffering. Their experiences expressed their need for respect for and protection of their personal boundaries as if they were weak, caught up in the moment and even under attack to the point of losing the self (Cytrynbaum & Noumair, 2004). This inhib- ited their capacity to take control and intelligently appraise their spiritual self to experience solitude,
submission, courage and curiosity in search of a higher purpose and meaning in the suffering towards personal mastery (Meier et al., 2005).
The other
Interpersonally, most participants reported on the prevailing confl ict and stress in their relationships with family and friends. Although some found ‘ these conversations meaningful ’ and ‘ feeding the soul ’ , for others ‘ the connection gets lost ’ , ‘ because of limited time ’ and ‘ they fi nding it disagreeable ’ to hear ‘ about my work situation ’ . They described the connection with hospital authority fi gures as ‘ unfamiliar ’ and ‘ strange ’ . While two participants reported on having had positive peer conversations described as ‘ pro- moting camaraderie ’ , ‘ without gossiping ’ , most peer relationships are characterized as comparatively superfi cial ( ‘ we just joke around ’ , ‘ discuss current events ’ , ‘ TV-shows ’ ), non-trusting (not providing a ‘ safe ’ , ‘ private ’ or ‘ confi dential enough ’ space ‘ for venting work frustrations ’ ) and disturbing ( ‘ in the way they treat patients ’ , ‘ I am concerned that I will be infl uenced by their negative attitude ’ ). Partici- pants ’ relationships with patients were split between caring ( ‘ especially for the little babies ’ by ‘ knowing that God has been with them every step of the way ’ ) and negative sentiments ( ‘ I am uncertain ... ’ - ‘ patients treat nurses poorly ’ , ‘ how do I tolerate the abuse? ’ , feeling ‘ vulnerable ’ and ‘ scared ’ when faced with ‘ pain and death ’ – their confusion, frustration, anger, sadness ‘ breaks my heart ’ ). Most participants acknowledged that they were interpersonally not coping well. They expressed hopelessness ( ‘ how can I offer hope to hurting people when I do not have it? ’ ) and withdrawal from friends, family, colleagues and patients. One participant expressed the diffi culty ‘ to choose service over self-interest ’ – we need ‘ men- torship ’ to learn about ‘ the practice of servant leader- ship ’ . Some participants expressed their awareness of a complex emotional interconnectedness with patients, but they did not elaborate on what this meant and how this affected them.
Interpretation
Although some participants illustrated an awareness of their spiritual interconnectedness and some made use of interpersonal opportunities to debrief (Parga- ment, 2013a), most participants did not build sig- nifi cant, supportive and interdependent relationships. It was as if the intensity of the negative experience inhibited them from accessing their inner resources such as social intelligence, realness, authenticity, respect, kindness, comfort, grace, intimacy and love across the interpersonal boundary. It is ironic that when they had the fi rst opportunity to exercise their
Sprirituality in coping with culture 285
initial nursing quest to help and care for others in need, they seemed so entangled in their own painful experiences that they could not illustrate the higher order spiritual values of self-regulation, protection against excess, intimacy, temperance, humility and forgiveness. Perhaps they could not move beyond their own anger and hurt resulting in their helpless- ness to see the same in the other (Cytrynbaum & Noumair, 2004). This was interpreted as their lack of intrapersonal sophistication inhibiting their inter- personal values and skills to explore and foster spir- itual connections, fi rstly with the patients (those in immediate need) and colleagues (in the same situa- tion as themselves) (Duke, 2013; Meier et al., 2005; Pargament, 2013a; 2013b, Young & Koopsen, 2005).
The sacred
Participants illustrated their awareness of the exis- tence ( ‘ I am thankful to have an amazing God ’ ) and trust in ‘ the greater power of God ’ s strength ’ ( ‘ He will send others to continue to care for our/His patients ’ , ‘ it is only God that gives us strength to care for others ’ , ‘ I fi nd it comforting - being a Christian, to know that God gives us strength when we need it the most and that His hand is in all of this ’ ). They expressed a need ‘ to nurture my spiritual life ’ , to build ‘ an ultimate relationship with God ’ and ‘ to glo- rify God ’ , motivated ‘ to not be alone in our journey ’ . Participants reported on their involvement in a lim- ited number of inspirited activities – they were asking existential questions ( ‘ why does God allow these things to happen? ’ ), prayed to God ( ‘ between shifts ’ , ‘ in the park ’ , ‘ to put me where He wants me to be ’ , ‘ to help me to step outside of my fear ’ ), and men- tioned the possibility of meditation. They relied on hope to counteract despair ( ‘ we need to cling on every little bit of hope we can fi nd ’ , ‘ there is always hope ’ ).
Interpretation
Participants showed their spiritual awareness and connection with the higher power (Pargament, 2013b). They expressed their strong beliefs, hope, religiosity and an inner need towards searching for some meaning, which came across as a dependent way to call upon God to save them from their diffi - culties (Young & Koopsen, 2005). On the next level of spiritual values, they did not show evidence of a state of being inspirited, dynamically accessing the associated intra- and interpersonal resources and energy to make a divine connection towards an understanding of their situation, as a comfort for their painful experiences, or to reach out to the spir- itual experiences of the other in their environment
(Pargament, 2013a) – the un-understandable, not rationally explainable, universal, existential and mys- terious essence of being in the hospital and being exposed to these experiences. Their limited use of experiential activities may indicate their spiritual inhibition towards realizing the spiritual values of purpose, meaning, gratitude, fulfi lment, harmony and transcendence (Brillhart, 2005).
The research hypothesis
The nursing students ’ dominant experience of the hospital culture was one of being dispirited. Their initial idealization of being a helping and caring nurse, was followed by emotional shock caused by the hard cultural realities. Intrapersonally they illus- trated their capacity for physical, intellectual and emotional awareness, but they could not access their inner energy associated with spiritual self-exploration, meaning making and control. Interpersonally, they could not spiritually reach out to others in similar (colleagues) or different (patients) circumstances towards building comforting, real, respectful and intimate connections towards striving for purpose, meaning, hope and transcendence. The hospital cul- ture was not experienced as a potential space for spiritual connection with the self, the other, or the sacred.
Discussion
The aim of this research was to describe the role of spirituality in coping with the demands of the hospi- tal culture amongst fourth-year nursing students. The purpose of the research was for this description to serve as normalizing information for future nurs- ing students entering the hospital culture, and for university and hospital staff as a basis for student mentoring.
The research text contained many references to religiosity and spiritual matters which gave the impression that nursing students were spiritually inclined. The analysis showed that the students ’ words on the surface showed a respect for God and his power, but not deep and lived through spiritual experiences, a search for something sacred, transfor- mative, transcendental or out of the ordinary.
The students did not illustrate spiritual intelligence. They showed a lack of spiritual guidance in decision- making, meaning-making, maintaining their self-con- fi dence, self-worth, quality of their relationships and coping behaviour with the stress and anxiety (Meier et al., 2005). On the contrary, their behaviour indi- cated an existential confl ict (Frankl, 1969) between their idealized representation of nursing and their assumed competence to do good, versus their real
286 F. Cilliers & L. Terblanche
experiences of the hospital culture which over- whelmed them with a fragile sense of responsibility, doubt in their competence and questioning their career choice. It was as if they were confronted with an impossible task (Cytrynbaum & Noumair, 2004). They struggled to manage their task and ego bound- aries – it was almost as if they became depressed (Nasser & Overholser, 2005; Robertson, 2006).
The students did not illustrate spiritual coping or well-being in their lack of harmonious interconnect- edness with the self, the other, community, environ- ment and a deity characterized by a creative energy, the wholeness, strength, gratitude, forgiveness in life-affi rming relationships (Meier et al., 2005). In terms of other related positive psychology constructs the following was interpreted. In terms of a spiritual way of being in the world, they were not driven by an ongoing life process of discovery of something sacred (personal accomplishments, revelations), conservation (holding on, building, sustaining con- nections) and transformation (purifying, reframing the connectedness to the sacred) (Pargament, 2013b). In terms of sense of coherence (Antonovsky, 1987) they did show some ability to comprehend and intellectually understand their experiences, but they struggled to make emotional sense out of the experiences and to manage the situation towards spiritual well-being. Limited emotional intelligence (Bar-On, 2010) manifested in some self-awareness but not their empathy with the hospital culture, authorities, colleagues and patients. They did not access positive emotions (Frederickson, 2001). Their work engagement (Simpson, 2009) such as vigour and dedication did not manifest. Their lack of resil- ience and hardiness (Maddi & Khoshaba, 2005) meant that they could not access or develop attitu- dinal patterns to cope, nor could they turn distress into eustress, courage and motivation, use their har- diness skills of social support and self-care. They did not show high levels of self-effi cacy (Bandura, 1977), learned resourcefulness (Rosenbaum, 1990), psy- chological and character strengths (Peterson & Seligman, 2004), curiosity (Kashdan, 2009), self- authorization (Hirschhorn, 1997), optimism (Peterson, 2000) or happiness (Buss, 2000). In the text, some students mentioned having to be mindful (Pargament, 2013b) but the data did not reveal their internal integration, coherence, openness, receptivity, attunement and attachments. In terms of individuation, Jung (1955) mentioned that real spir- itual integration only manifests from 60 � years of age, which means that this group of students are far away from having the insights, emotional experi- ences and spiritual maturity to be individualized.
It was concluded that the only spiritual coping mechanisms with the hospital culture amongst these fourth-year nursing students were limited amounts
of self-awareness, a search for meaning and hanging on to hope. Their behaviour did not refl ect their capacity to be described as being spiritually inclined as employees in the hospital culture, nor did they illustrate any learned spiritual resourcefulness over three years of nursing education.
In revisiting the research question it was concluded that becoming more independent as professionals working in the hospital culture, these fourth-year nursing students did not make sense of their diffi cult experiences through inner spiritual resources. Maybe the strong emphasis in nursing students ’ education on cognitive and clinical development, and medical care for patients did not include time and energy for spiritual development. It would then be unfair to expect of them to ‘ be spiritual ’ , especially at such a young age.
A limitation needs to be mentioned that the spiri- tual experiences of students were measured in a gen- eral manner as part of their holistic experiences in the hospital. Maybe a more specifi c and directed way of questioning (e.g. using open ended questions or an interview) would have elicited more exact spiri- tual experiences.
It is recommended that the description of nursing students ’ behaviour (not only the spiritual) can be used as information for future nursing students entering the hospital culture. Thus, they may learn from pervious colleagues what exposure to the hos- pital culture may be like. It is recommended that nursing schools take note of the experiences in fos- tering a learning climate focusing on the spiritual development of students. More specifi c inputs may be included in the curriculum such as mentoring in the culture of the hospital (Cilliers & Terblanche, 2010) to provide students with intellectual, emo- tional and spiritual insight into their own experiences (see Catamzaro & McMullen, 2001; Rankin & DeLashmutt, 2006; Pesut, 2002; 2003).
Follow-up and even longitudinal research was rec- ommended to ascertain the spiritual growth of the students in preparation for, and during the rest of their academic education. Research on systems psy- chodynamic role analysis is recommended to study the dynamic aspects of the student nurse ’ s role, e.g. what the new nurse represents in the hospital culture, what the student introjects and what is projected onto the student on behalf of the hospital system.
Declaration of interest : The authors report no confl ict of interest. The authors alone are responsible for the content and writing of the paper.
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