Athletic Training Student Perspectives on Spirituality and Spiritual Care in Clinical Practice: A Pilot Study

Participants

All athletic training students enrolled in the clinical portion of the athletic training program at a small private religiously affiliated university were recruited for participation in this study (n = 33; Table 1). Students at this university are not required to have any particular religious affiliation or spiritual background; there are no religious or faith-based restrictions or preferences on admission or enrollment. Athletic training students were recruited in September (at the beginning of the school year) via an announcement in a commonly required clinical course and via email.

Table 1 Participant Demographics

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Procedures

Due to the small sample size this study was considered a pilot study that would lead to further research. This study was approved by the University Institutional Review Board. Participants were recruited via email and announcements made in required clinical courses. The recruitment email included study details, including the voluntary and confidential nature of the study, and a link to the study questionnaires. A reminder email was sent after 1 week and 2 weeks. Data collection was closed after the end of 3 weeks. Two $20 gift cards given to randomly selected participants were offered as an incentive to participate.

All data were collected online using Qualtrics Survey Software (Qualtrics LLC, Provo, UT). After giving informed consent, participants were asked to complete 4 items in a single session: a demographic background questionnaire, the Spiritual Perspectives Scale (SPS), the modified Spiritual Care Therapeutics Scale (mSCTS), and the modified Spiritual Care Perspectives Scale (mSCPS). The mSCTS was completed twice, once by the student concerning his or her own behaviors, and once by the student concerning observed preceptor behaviors. The SPS, mSCTS, and mSCPS instruments are described below. The demographic background questionnaire included items about the participant's year in school, sex, ethnicity, and so on. Completion of all items took approximately 15 minutes.

Individuals who completed the surveys in the fall (n = 31) were contacted again in the spring (first week of April) to complete the follow-up surveys. Reminders were sent after 1 and 2 weeks, and data collection was closed 3 weeks after the initial spring survey request. The follow-up surveys were identical to the first surveys. Only individuals who completed surveys in both fall and spring were eligible for inclusion (n = 26). At the beginning of the survey, participants were given the following definition of spirituality: “In general, spirituality refers to an awareness of one's inner self and a sense of connection to a higher being, nature, others, or to some purpose greater than oneself.”^1,13 The variable of time (fall to spring) was included to assess for changes over the course of a single academic year. We hypothesized changes in athletic training student beliefs or actions might occur as a result of the holistic education received during clinical and academic classes at our institution. Specifically, clinical classes encourage students to reflect on how personal beliefs or worldview might influence their actions as clinical health care providers, and to reflect on when it might be appropriate (or inappropriate) to perform spiritual care actions. Academic classes in the department encourage adoption of a holistic model of wellness (including components such as physical, emotional, and spiritual health). Outside of the holistic education received in clinical and academic classes, there was no active controlled intervention in the current study.

Instruments

The SPS by Reed^1,26 is a 10-item questionnaire that measures participants' perspectives of their own spiritual views and spiritually related interactions on a 6-point Likert-like scale. SPS reliability is high (Cronbach α > 0.90), and both criterion-related validity and discriminate validity have been reported.^1,26 The SPS is scored by calculating the average score across all 10 items (Table 2). Permission was obtained before the use of the SPS.

Table 2 Spiritual Perspectives Scale Results in Athletic Training Students (n = 26), Mean ± SD (Range)

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The Spiritual Care Perspectives Scale (SCPS), originally developed by Taylor et al.²⁷ and revised by Stranahan,¹⁰ is a 13-item questionnaire that asks participants to rate their level of agreement on a 5-point Likert-like scale (from strongly disagree to strongly agree) with various statements about the importance of spirituality in health (eg, Relationships with others are important to a patient's spiritual health). This scale has acceptable reliability (Cronbach α 0.79).²⁷ The SCPS was originally developed for nursing, and thus included discipline-specific language that was adapted to general health care professions in the current study. For example, the item “Spiritual care is a significant part of nursing” was adapted to read “Spiritual care is a significant part of my health care discipline.” And “The nurse should wait for a patient to raise spiritual issues” was adapted to “The clinician should wait for a patient to raise spiritual issues.” This modified SCPS was labeled the mSCPS (Table 3).

Table 3 Modified Spiritual Care Perspectives Scale Results in Athletic Training Students (n = 26)

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The Spiritual Care Therapeutics Scale (SCTS)²⁸ is a 17-item questionnaire that asks how frequently respondents utilized specific therapeutic activities in providing clinical care (eg, listened to a patient talk about spiritual concerns, prayed with a patient). Spiritual care therapeutics are specific actions intended to promote well-being, coping, relationship, and growth.²⁷ Participants select responses ranging from never to very often referring to frequency of behaviors in the last 80 hours of clinical care. Response anchors were defined and coded with the following categories: 1 (never = 0 times), 2 (rarely = 1–2 times), 3 (occasionally = 3–6 times), 4 (often = 7–11 times), and 5 (very often = more than 12 times). Scale development, validity, and good reliability (alpha coefficient = 0.93) were reported by Mamier and Taylor.²⁸ Since this scale was developed for nursing, 4 hospital nursing-specific questions (items 4, 8, 10, and 11; eg, “Arranged for a chaplain to visit a patient”) were removed for the current study. One question, “Prayed for a patient,” was added. Removing 4 questions and adding 1 question resulted in a final 14-item questionnaire, which was labeled the mSCTS (Table 4). The mSCTS was completed twice in the fall and twice in the spring. For the first mSCTS, participants were asked to complete it regarding their own clinical actions. For the second mSCTS they were asked to report how often they observed a clinical preceptor completing any of the mSCTS items (Table 5).

Table 4 Modified Spiritual Care Therapeutics Scale Results in Athletic Training Students

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Table 5 Student's Observed Preceptor Behaviors of Actions on the Modified Spiritual Care Therapeutics Scale

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Data Processing and Statistical Analysis

Data were exported from Qualtrics to Excel (Microsoft, Redmond, WA) and then imported into IBM SPSS version 20 (IBM, Armonk, NY) for analysis. A paired t test assessed for differences in the SPS at 2 time points (fall and spring). Individual item responses for the mSCPS and mSCTS were scored individually, averaged across participants, and then organized from lowest (or least frequent) to highest (or most frequent). A paired t test was used to assess for differences between fall and spring responses. Additionally, for both fall and spring, a Spearman rank correlation was used to assess for correlation between preceptor modeling and athletic training student actions. Since slight modifications were made to the previously reported survey instruments, reliability for the mSCPS and mSCTS was assessed after the initial survey administration (fall) using Cronbach α.

Participant Demographics

The final response rate was 26 out of 33 possible athletic training students (78.8%) who completed both fall and spring questionnaires. Participant characteristics are reported in Table 1. The participants' (age = 20.3 ± 2.1) self-reported prior hours of athletic training clinical experience were 435 ± 310 hours (range, 90–1000) in the fall, and 789 ± 446 hours (range, 208–2000) in the spring.

Spiritual Perspectives Scale

Item responses for the SPS are presented descriptively in Table 2. The SPS did not change significantly over time (t = 0.194, df = 25, P = .848; fall summary score = 4.74 ± 0.96, spring summary score = 4.73 ± 0.87).

Modified Spiritual Care Perspectives Scale

Descriptive data for the mSCPS as well as results of the paired t test between fall and spring are presented in Table 3. Reliability for the mSCPS was acceptable (Cronbach α = 0.77). The mSCPS items with the highest agreement on a 5-point Likert scale were “Relationships with others are important to patient's spiritual health” (4.12 ± 0.86), “My spiritual views influence my clinical practice of my health care discipline” (3.65 ± 0.89), and “The clinician should wait for a patient to raise spiritual issues” (3.58 ± 0.76). The mSCPS items with the lowest agreement were “Spiritual care is only for religious persons” (2.00 ± 0.75), “Religious beliefs can be a hindrance to health” (2.12 ± 0.95), and “A person must believe in a higher being/power to be spiritually healthy” (2.27 ± 1.04). Only 3 mSCPS items changed significantly over time (P < .05, Table 3). Specifically, agreement increased on the item “The clinician should wait for a patient to raise spiritual issues,” and disagreement increased for the items “I believe that as a clinician, I should never share my beliefs with patients” and “In general, my patients have no spiritual need.”

Modified Spiritual Care Therapeutics Scale

Participants completed the mSCTS twice, once reporting on their own actions (Table 4) and once reporting on actions they observed in their clinical preceptors (Table 5). Reliability for the mSCTS reporting students' own actions was acceptable (Cronbach α = 0.74), and reliability was high for reporting preceptor observed behaviors (Cronbach α = 0.92). Descriptive data as well as results of the paired t test between fall and spring are presented in Tables 4 and 5. The average frequency for each item ranged from 1 (never), 2 (rarely), to 3 (occasionally); there were no items that averaged 4 (often) or 5 (very often). For students' self-reported actions, the mSCTS items with the highest frequency were “After completing a task, remained present just to show caring” (3.19 ± 1.02), “Listened actively for spiritual themes in a patient's story of injury/illness” (2.31 ± 1.09), and “Prayed for a patient” (2.19 ± 1.17). The mSCTS items with the lowest frequencies were “Offered to pray with a patient” (1.15 ± 0.37), “Asked a patient about how you could support his or her spiritual or religious practices” (1.15 ± 0.37), and “Discussed a patient's spiritual care needs with colleague/s” (1.15 ± 0.37). Eight student mSCTS items changed significantly over time (all P < .05, Table 4), whereas only 2 preceptor mSCTS items changed significantly (all P < .05; Table 5). Preceptors were also most likely to “After completing a task, remain present just to show caring” (3.28 ± 1.46), followed by “Help a patient have quiet time or space” (2.31 ± 1.01) and “Pray for a patient” (2.00 ± 1.08). Preceptors' least frequent spiritual therapeutic action was “Offer[ing] to read a spiritually nurturing passage (eg, patient's holy scripture)” (1.31 ± 0.62), followed by “Asked a patient about how he/she could support his or her spiritual or religious practices” (1.38 ± 0.64), and “Discussed a patient's spiritual care needs with colleague/s” (1.38 ± 0.64). Spearman rank correlations between fall student and preceptor actions on each mSCTS item are reported in Table 6. The 2 strongest correlations were for the items “Encouraged a patient to talk about what gives his or her life meaning amidst injury/illness” (r = 0.611, P < .001) and “Helped a patient have quiet time or space” (r = 0.610, P < .001).

Table 6 Correlation Between Student Actions and Observed Preceptor Behaviors on the Modified Spiritual Care Therapeutics Scale

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Modified Spiritual Care Perspectives Scale

The mSCPS measures respondent's level of agreement (or disagreement) with multiple statements regarding the role of spirituality in health, for example, “Relationships with others are important to patient's spiritual health.” Interestingly, results indicated that students did not feel very strongly about any item—with mean scores for all items ranging from 2.0 (disagree) to 4.1 (agree), and the majority in the 3 (neutral) range. It is unknown why students tended to be fairly neutral in their responses. Considering that past research on practicing clinicians^10,11 has identified training in providing spiritual care as lacking (eg, 22% of nurse practitioners had received no training or education in spiritual care¹⁰), it may reflect a lack of professional development on the potentially beneficial role of spirituality in health.

The 3 most agreed-upon mSCPS items emphasized general spiritual well-being or that spiritual care was a personal decision (eg, “The clinician should wait for a patient to raise spiritual issues”). This trend may highlight a deference to personal autonomy, which aligns with past research in physical therapy students²⁵ and practicing athletic trainers who identified “fear of imposing personal spiritual views on the athlete” as the most frequent and significant barrier to providing spiritual care.¹¹ In contrast, the 3 items with the highest level of disagreement had terms that were explicitly religious or referred to a higher power (eg, “Spiritual care is only for religious persons”). This trend may show that students were less comfortable with statements using the narrower and less inclusive terminology of religion.

Additionally, changes over time in athletic training student responses on the mSCPS were minor (only 3 out of 13 items showed significant change; Table 3). Specifically, students were more likely to see their patients as having spiritual needs, and more likely to feel that it could be appropriate to share personal beliefs with patients, but more likely to affirm that the clinician should wait for a patient to raise spiritual issues. This is an interesting combination, potentially affirming a heightened awareness of patients' spiritual needs while simultaneously having a greater respect for a patient's privacy and wishes regarding spiritual care. Alternatively, it may be that students had a heightened awareness of spiritual needs but were more uncomfortable with addressing them. Interestingly, in contrast, time in the educational program (eg, first year versus third year) did not significantly influence perceptions of spirituality in other health care students.^22,24 The contribution of professional socialization or academic preparation toward the reported changes is unclear, but may merit consideration in future research. Since clinicians often cite a lack of preparation related to spirituality and health,^10,11 introduction of this theme into the athletic training curriculum may be a good place to start.

Modified Spiritual Care Therapeutics Scale

Unlike the mSCPS, which asks students their beliefs regarding spiritual care, the mSCTS asks students to report the frequency with which they have engaged in specific therapeutic actions in their past 80 hours of clinical experience. As expected, initially students largely reported never or rarely engaging in any of the identified actions (Table 4). In contrast, past research on practicing athletic trainers reported that high percentages of clinicians employed similar spiritual care therapeutics (mean = 38 ± 24%, range, 4%–90%).¹¹ However, these clinicians were asked simply if they had ever performed each action, as opposed to the frequency of performance, limiting direct comparison to the current work. Unfortunately, past research on students in other health care professions has also not reported the frequency of utilization of spiritual care therapeutics, only the level of agreement/disagreement on how appropriate such actions might be.^22–24 Similar to trends in nurse practitioners identified by Stranahan,¹⁰ students were more likely to practice items that did not require direct or noticeable involvement in the spiritual care action with the patient. For example, the 3 most commonly practiced items in the fall were praying for (but not with) a patient, active listening, and remaining present with a patient to show caring. It should be noted that even though these 3 items were practiced more frequently than others, they were only reported as rarely or occasionally employed.

It is interesting that while athletic training student perspectives on spiritual care were predominately stable over time, the frequency of student self-reported spiritual therapeutic actions did change over time (8 out of 14 items increased in frequency; Table 4). Thus, while beliefs were fairly static, student clinical behaviors were dynamic over time. The observed spring behavior changes may have resulted from exposure to principles of holistic health care in clinical or academic classes, increased awareness of spiritual therapeutics due to completing the fall survey, exposure to preceptor modeling, increased autonomy as students advanced through clinical experiences, or other factors—we are not able to assign causality based on the current study design. In contrast to student behaviors, there were few changes in preceptor modeling of spiritual care therapeutics over the course of the year (as reported by students). This would be expected from professionals with set clinical practice behaviors. While the reported frequency of preceptor modeling of spiritual care therapeutics was largely stable, the strong correlation between preceptor modeling and student behavior may indicate preceptor behaviors were influential. Future research should further investigate the role of the clinical preceptor in modeling appropriate integration of spiritual care therapeutics. In agreement with past research,^10–12 we recommend that professional curricula and clinical experiences incorporate the role of spirituality in health and health care practice.