Introduction
As nurses can play a significant role in providing spiritual care to patients at end-of-life (Selman et al. Reference Selman, Brighton and Sinclair2018), their competence in providing this care impacts patient well-being. Consequently, much research has focused on nurse characteristics that can be used as predictors of spiritual care competence. Five particular characteristics have attracted considerable attention: comfort, confidence and frequency of spiritual care provision, adequacy of training in spiritual care, and personal spirituality, as summarized below. (Competence herein refers to the ability of the nurse to assess and care for a patient’s spiritual needs (Green et al. Reference Green, Kim-Godwin and Jones2019); the terms “competence” and “ability” will hereon be used interchangeably.)
Comfort and confidence in providing spiritual care are often used as proxies of ability in spiritual care, mirroring the practice in other healthcare disciplines (e.g., physicians (Lafrance Robinson et al. Reference Lafrance Robinson, Boachie and Lafrance2013); surgeons (Antonacci et al., Reference Antonacci, Patel and Dechario2021)). These 2 constructs are very closely associated with spiritual care ability such that they are sometimes used interchangeably with ability (though this paper will not treat comfort and confidence as interchangeable between themselves). For example, one study measures the ability to perform a spiritual assessment using items such as “I feel uncomfortable [emphasis added] asking questions related to spirituality” and “I am more confident [emphasis added] assessing clients’ nutritional status than their spiritual status” (Hoffert et al. Reference Hoffert, Henshaw and Mvududu2007). This close association is not unwarranted, though, as many quantitative studies found that spiritual care ability is highly correlated with comfort (e.g., Lundmark Reference Lundmark2006; Taylor et al. Reference Taylor, Highfield and Amenta1999) and confidence (Jones et al. Reference Jones, Paal and Symons2021).
Frequency of provision of spiritual care is another factor thought to be related to ability to provide spiritual care. Frequent provision of spiritual care allows the nurse to build up experience in spiritual care, which is necessary to move from one level of expertise to another (Benner and Wrubel Reference Benner and Wrubel1982). Several quantitative studies report a positive association between ability and frequency, whether assessed by a global measure (e.g., Taylor et al. Reference Taylor, Highfield and Amenta1999) or several itemized spiritual care interventions (e.g., Chen et al. Reference Chen, Chen and Lin2020; Green et al. Reference Green, Kim-Godwin and Jones2019; Vogel and Schep‐Akkerman Reference Vogel and Schep‐Akkerman2018). Frequency of spiritual care is implicitly recognized as an indicator of ability by spiritual care competency standards that describe levels of competence (e.g., the Marie Curie Cancer Care competence standards (2014) associates higher levels of competence with deeper patient contact and greater responsibility for spiritual care, which are loosely associated with frequency of spiritual care).
Adequate training in spiritual care is another factor thought to be related to ability to provide spiritual care. These training programs aim to increase levels of competence in spiritual care delivery, by influencing intrapersonal and interpersonal spirituality, and/or improving spiritual care assessment and intervention (Jones et al. Reference Jones, Paal and Symons2021). Quantitative studies have shown that adequacy of training is highly correlated with spiritual care ability (Green et al. Reference Green, Kim-Godwin and Jones2019; Seid and Abdo Reference Seid and Abdo2022; Taylor et al. Reference Taylor, Highfield and Amenta1999).
Personal spirituality. Several reviews have noted the important role played by nurses’ spirituality in their ability to provide spiritual care (Cockell and McSherry Reference Cockell and McSherry2012; Paal et al. Reference Paal, Helo and Frick2015) and holistic nursing care more generally (Tiew and Creedy Reference Tiew and Creedy2010). An individual’s understanding and awareness of their own spirituality supports empathetic development (Chism and Magnan Reference Chism and Magnan2009), understanding of other people’s spiritual needs (Jones et al. Reference Jones, Smith, McSherry, Wattis, Curran and Rogers2017) and the planning and implementation of spiritual care interventions (Biag and Angeles Reference Biag and Angeles2021; Chung Reference Chung, Wong and Chan2007; Epstein-Peterson Reference Epstein-Peterson, Sullivan and Enzinger2015), and reduces the risk of the nurse’s own fears impinging on patient care (Arman Reference Arman2007). Qualitative (e.g., Kociszweski, Reference Kociszewski2004) and quantitative studies (e.g., Heidari et al. Reference Heidari, Afzoon and Heidari2022; Hsieh et al. Reference Hsieh, Hsu and Kao2020; Ross et al. Reference Ross, McSherry and Giske2018; Taylor et al. Reference Taylor, Highfield and Amenta1999; Wang et al. Reference Wang, Zhao and Zhang2022) report close associations between spiritual care competence and degree of nurse spirituality or spiritual health. For this reason, spiritual care competency standards include awareness of one’s own spirituality, and meaningful reflection upon one’s own values and beliefs as contributors to competence (Attard et al. Reference Attard, Ross and Weeks2019; Marie Curie Cancer Care 2014; McSherry et al. Reference McSherry, Ross and Attard2020; Rogers and Wattis Reference Rogers and Wattis2015; van Leeuwen et al. Reference van Leeuwen, Tiesinga and Middel2009).
By now it might seem self-evident that these 5 characteristics increase progressively with spiritual care ability. A progressive increase with ability would justify the use of confidence and comfort as proxies for ability, and would justify training programs focusing on enhancing personal spirituality, and frequency of provision of spiritual care. However, it is difficult to state outright that the characteristics do increase progressively with ability because the quantitative studies cited above, relating characteristics to ability, rely on self-ratings of spiritual care ability. These self-ratings are problematic as will be discussed next.
Self-ratings of spiritual care ability
Self-ratings of spiritual care ability are common in spiritual care studies, probably due to the ease of data collection and the personal nature of spiritual care provision eluding external observation. These self-ratings are either single-item global measures (e.g., “My ability to provide spiritual care is (1) weak, limited [to] (5) strong, comprehensive” (Taylor et al. Reference Taylor, Highfield and Amenta1999, p. 32); “How high do you consider your ability to provide spiritual care is? Very Low … very high” (Lundmark Reference Lundmark2006, p. 867)) or multi-item measures that assess several aspects of spiritual care competence (e.g., “I can evaluate the spiritual care that I have provided” and “I can record … a patient’s spiritual care in the nursing plan” are 2 items in van Leeuwen et al.’s (Reference van Leeuwen, Tiesinga and Middel2009, p. 2867) scale; other scales are the EPICC Spiritual Care Competency Self-Assessment Tool (Giske et al. Reference Giske, Schep‐Akkerman and Bø2023) and the Student Survey of Spiritual Care (Meyer Reference Meyer2003)). These types of self-rating measures of ability are used not just in studies of spiritual care competence but also in studies of nurse wellbeing (e.g., Manookian et al. Reference Manookian, Nadali and Ghiyasvandian2023; Wang et al. Reference Wang, Zhao and Zhang2022) and training evaluation (e.g., Kang et al. Reference Kang, Kim and Kim2023; Petersen et al. Reference Petersen, Callahan and McCarthy2017).
However, psychological research has shown that personal assessments of one’s own level of ability are generally flawed (e.g., Kruger and Dunning Reference Kruger and Dunning1999), with most studies reporting low correlations between estimated and actual ability (Mabe and West Reference Mabe and West1982). The problematic nature of self-ratings are recognized in nursing (e.g., Kajander-Unkuri et al. Reference Kajander-Unkuri, Leino-Kilpi and Katajisto2015; Liang et al. Reference Liang, Tang and Wang2021), and in other healthcare disciplines (e.g., physicians (Davis et al. Reference Davis, Mazmanian and Fordis2006), psychiatry (Sowden et al. Reference Sowden, Vestal and Stoklosa2017; pharmacy (Gabbard and Romanelli Reference Gabbard and Romanelli2021)). One type of flaw in self-assessment is that “the skills that engender competence in a particular domain are often the very same skills necessary to evaluate competence in that domain – one’s own or anyone else’s” (Kruger and Dunning Reference Kruger and Dunning1999, p. 1121), thus rendering the information individuals use to form the assessment incomplete in some way (Dunning et al. Reference Dunning, Heath and Suls2004).
Another flaw in self-assessment of spiritual care ability in particular is that the term “spiritual care” does not have a widely accepted definition (Mascio et al. Reference Mascio, Lynch and Hosie2023) – if different nurses have different understandings of the term “spiritual care,” they are not all answering the same question. These issues have prompted Ross et al. (Reference Ross, McSherry and Giske2018) to call for measures of actual rather than self-perceived spiritual care competence.
An alternative measure of spiritual care competence
Fortuitously, an approach to work competence has emerged recently that exploits differences in understandings of work among workers, which can be used as a measure of actual competence (Sandberg Reference Sandberg2000). This approach is based on the premise that work is understood in a limited number of qualitatively different ways. These different understandings are manifested in different ways of working, and can be ordered in terms of complexity or completeness, with more complete or broader understandings being associated with better job performance. An individual’s level of competence can therefore be gauged by the level of their understanding of work. Studies of competence based on this approach have been conducted in many work domains, such as engine optimization (Sandberg Reference Sandberg2000), project management (Chen and Partington Reference Chen and Partington2006), veterinary practice (Matthew et al. Reference Matthew, Ellis and Taylor2011), program management (Partington et al. Reference Partington, Pellegrinelli and Young2005), acupuncture (Ryan Reference Ryan2005), anesthesia (Larsson et al. Reference Larsson, Holmström and Lindberg2004), telenursing (Kaminsky et al. Reference Kaminsky, Rosenqvist and Holmström2009), and diabetes care (Holmström et al. Reference Holmström, Jonsson and Rosenqvist2000).
The first part of our study, reported in Mascio et al. (Reference Mascio, Lynch and Hosie2023), applied the same approach to nurses’ understanding of spiritual care. Four models, representing meanings of spiritual care work by nurses, were found:
• Model A – active management of the patient’s experience, in which the nurse decides and performs actions that nurses unilaterally believe, will bring patients comfort;
• Model B – responsive facilitation of patient’s wishes, in which the nurse elicits from patients the emotional/spiritual needs/desires that have value/meaning for them, and ensuring these needs are met to the best of their ability;
• Model C – accompaniment on the patient’s dying journey by having patients share their thoughts/feelings about the situation; and
• Model D – empowering co-action with the patient, in which the nurse collaborates/partners with the patient to move them along their unique, dying journey.
By drawing on spiritual care, work pedagogy, and expertise development evidence, Mascio et al. (Reference Mascio, Lynch and Hosie2023) demonstrated that these models could be arranged in order of increasing competence from A to D. These models can thus be used as an alternative to self-rating of spiritual care competence, by determining the spiritual care models subscribed to by nurses.
The aim of the current exploratory study is to re-examine the relationship between nurse characteristics and spiritual care competence, using spiritual care models as a proxy for competence.
Method
Overview
This work is part 2 of a 2-part study of nurses’ spiritual care behavior. Data was collected from a convenience sample of 66 American nurses who completed an anonymous, online survey. The survey provided qualitative data about what spiritual care means for them and what they generally do to provide spiritual care. The first part of our study analyzed this qualitative data, finding 4 different ways of understanding spiritual care, which are reported in Mascio et al. (Reference Mascio, Lynch and Hosie2023) and Supplementary Material. The survey also provided quantitative data: demographic data (sex, age, nursing experience, education levels); how frequently they provided spiritual care; and their levels of agreement, using Likert scales, with statements relating to confidence and comfort providing spiritual care, spirituality and adequacy of training in spiritual care. This study presents an analysis of this quantitative data.
Analysis
The sample was divided into groups based on the spiritual care model ascribed to participants, according to the 4 categories described in Mascio et al. (Reference Mascio, Lynch and Hosie2023).
The variables of age, education, and nursing experience were treated as ordinal variables and each participant’s response was assigned a numerical code, shown in Table 1. Kolmogorov–Smirnov tests and Q–Q plots showed that the Likert variables were not normally distributed.
Table 1. Characteristics of participants (N = 66)
a Codes for Likert variables ranged from 1 = strongly disagree to 5 = strongly agree.
The median of each variable for each spiritual care model group was calculated. Kruskal–Wallis statistical tests were used to compare variables across model groups. Where significant differences were identified, post hoc comparisons assessed which groups differed from one another. Responses to the variable of sex were assigned a numerical code, shown in Table 1, and were compared across model groups using the χ 2-test.
Results
Table 1 shows the sample characteristics. Of the 149 nurses who responded to the invitation to participate, 66 completed the survey. Of these, 89% were female, and ranged in age (18–60+ years), nursing experience (up to 20+ years), education levels (from vocational/practical to Masters), and health settings (e.g., general hospital, ICU, community).
Table 2 shows the number of nurses in each spiritual care model group, ascribed to participants according to the 4 categories described in Mascio et al. (Reference Mascio, Lynch and Hosie2023). The numbers of nurses assigned to Model A, B, C, and D groups were 12, 28, 16, 10 respectively.
Table 2. Statistical comparison of medians of nurse variables for each spiritual care modela
a SPSS version 28.0 (IBM) software was used for all statistical analyses.
b Significant differences (p < .05) are denoted with an asterisk.
c p-values were not adjusted for multiple comparisons as doing so would be overly conservative for this exploratory study, masking important findings that could warrant further investigation (Armstrong Reference Armstrong2014).
d A line joining 2 groups denotes no significant difference between these groups. Groups not joined by lines are significantly different from each other, with values of the characteristics increasing from Model A to Model D.
Table 2 also shows the median of each variable for each model group. Kruskal–Wallis tests detected that the 4 groups did not differ significantly in comfort and confidence providing spiritual care, age, education level, nursing experience, or sex; that is, nurses in all 4 competence levels scored similarly on these variables.
Table 2 shows that the Kruskal–Wallis test detected significant differences (p < .05) across spiritual care models in training adequacy(/spirituality). Nurses in Model A and B groups scored lower in training adequacy(/spirituality) than nurses in Model C and D groups. However, there was no difference in scores between Model A and B groups, or between Model C and D groups.
Table 2 shows that the Kruskal–Wallis test detected a significant difference (p < .05) across spiritual care models in frequency of provision of spiritual care. Nurses in the Model A group scored lower in frequency than nurses in Model C and D groups, and nurses in the Model B group scored lower in frequency than nurses in the Model D group. However, there was no significant difference in frequency scores between nurses in Model A and B groups, between nurses in Model B and C groups, and between nurses in Model C and D groups.
Based on the premise that the 4 groups can be arranged in order of increasing competence from Model A to Model D (Mascio et al. Reference Mascio, Lynch and Hosie2023), the overall results show that while the least and most competent groups scored lowest and highest respectively on training adequacy, spirituality, and frequency, relationships between competence and these variables were not linear; i.e., higher competence did not always correspond with higher scores of training adequacy, spirituality, and frequency of provision of spiritual care.
Discussion
This study divided a sample of nurses into sub-groups based on their model of spiritual care, obtained a profile of nurse characteristics for each sub-group, and tested whether characteristics differed across groups. To the extent that the spiritual care models can be arranged in order of increasing competence from A to D, the result have implications for predictors and development of competence.
Enhanced understanding of predictors of spiritual care competence
We found that confidence and comfort in providing spiritual care did not differ significantly across spiritual care models, suggesting that confidence and comfort may not be related to actual performance in spiritual care. This result may initially seem contrary to much of the spiritual care literature in which confidence and comfort are used as measures of competence (e.g., Temby et al. Reference Temby, Rasmussen and Bronner2020). However, the result may have arisen because the questions used in those studies – and our study – referred to “spiritual care” without defining spiritual care (e.g., “I am comfortable providing spiritual care”) so respondents would likely have substituted their idiosyncratic definition. Thus, a nurse with a Model D understanding and another nurse with a Model A understanding could experience similar levels of confidence and comfort in providing what they define as spiritual care. This finding has practical relevance for spiritual care researchers, as it raises concerns about the construct validity of using comfort and confidence as estimates of spiritual care ability. Researchers should also consider the implications of using survey items that refer to “spiritual care” generically without providing a definition (i.e., with the implicit assumption that all participants understand the term “spiritual care” in the same way). In our study, a deliberate choice was made not to provide a definition of spiritual care, because our method actually relied on differences in understanding of the term “spiritual care” as a proxy for competence.
Our results partly conform to extant findings regarding the positive relationships between competence and nurse spirituality, training, and frequency: higher levels of these characteristics were associated with higher order models (i.e., Model D had higher levels than Models A and B), but higher models were not necessarily associated with higher levels of these characteristics (i.e., there was no significant difference in these characteristics between Models A and B, and between Models C and D). This partial discrepancy is most likely due to extant studies assuming linear relationships between predictor and ability across the whole sample of nurses (allowing correlations and regression to be used as statistical tools), and assuming that all sample participants understood spiritual care in the same way. These studies produce findings, such as “the higher the self-assessed competence was scored, the higher the frequency of delivering spiritual care” (Vogel and Schep‐Akkerman Reference Vogel and Schep‐Akkerman2018, 1317); “[s]piritual … [i]nvolvement score increasing by one point will likely increase [spiritual care competence] by 0.14 point” (Hsieh et al. Reference Hsieh, Hsu and Kao2020, 1611) and “Training in spiritual care increased spiritual care competence by 0.238 times compared to those who didn’t receive any training in spiritual care …” (Seid and Abdo Reference Seid and Abdo2022, 6).
Our study did not make these assumptions: we divided the sample into groups based on understanding of spiritual care (thereby relaxing the assumption that participants understood spiritual care in the same way) and used Kruskal–Wallis tests to assess equality of medians between groups (thereby relaxing the assumption of linearity between predictor and ability across the whole sample). As a result, our findings show that the relationship between the characteristics of frequency, training, and spirituality might not be as linear as portrayed in extant studies; that is, higher levels of these characteristics were not necessarily associated with higher competence. This result has implications for competence development in spiritual care. Let’s take as an example the nonlinear relationship between personal spirituality and competence. A key aim of many spiritual care training programs is to increase competence by enhancing participants’ own spirituality (Jones et al. Reference Jones, Paal and Symons2021). If the relationship between spirituality and competence is not linear, then the outcomes achieved by efforts to enhance personal spirituality are not assured, because the outcome depends on the model of spiritual care subscribed to by training participants. For instance, our findings suggest that efforts to enhance the spirituality of nurses who subscribe to Model B might increase competence, but such efforts may not be effective in enhancing the spiritual care competence of a nurse subscribing to Model C.
None of the measured characteristics distinguish between Models A and B, or between Models C and D. This suggests that other characteristics play a role, and begs the question of what those characteristics might be? Our previous study (Mascio et al. Reference Mascio, Lynch and Hosie2023) found that Models A and B are similar in that both are relate detachedly from the patient, whereas Models C and D both relate intimately with the patient. As well, Models B and C are similar in that the patient is more active and directive than the nurse, whereas in Models A and D the nurse takes a more directive role. These attributes of intimacy and directivity loosely concord with the characteristics of affiliation and control in psychological theory. Affiliation (i.e., to be friendly and caring toward) and control (the degree to which one person attempts to dominate or control another’s behavior) are independent, universal, pervasive dimensions underlying all human interpersonal behavior (Leary Reference Leary1957). These 2 dimensions have been shown to operate in a range of personal and professional interpersonal contexts (e.g., parent-child (Wilson et al. Reference Wilson, Revelle and Stroud2013), between-children (Ojanen et al. Reference Ojanen, Grönroos and Salmivalli2005), staff-prisoner (Gredecki and Ireland Reference Gredecki and Ireland2012), teacher-student (Roorda et al. Reference Roorda, Spilt and Koomen2017), staff-patient (Ma and Dubé Reference Ma and Dubé2011), physician-patient (Kiesler and Auerbach Reference Kiesler and Auerbach2003)). Therefore, we propose that affiliation and control could be 2 characteristics that distinguish the spiritual care models according to the proposed pattern in Table 2. This should be tested in further research.
An application of Ericsson’s framework for expertise development
Our results can be interpreted within the expert-performance framework of Ericsson (Reference Ericsson and Ericsson2009) to provide suggestive insights about how nurses achieve high levels of spiritual care competence. This framework describes expertise acquisition as a sequence of states associated with higher levels of performance, which is facilitated by several components, such as deliberate practice, motivation, and specialized training. We chose this framework because it accounts for variables comparable to those used in our study, and it is commonly used in interventions to develop nursing skills (e.g., triage (Campbell et al. Reference Campbell, Fetters, Getzinger, Perko and Slater2022); vaccine recommendation (Rosen et al. Reference Rosen, Real and Bishop2022); cardiovascular assessments (Jeffries et al. Reference Jeffries, Beach and Decker2011); and transition to practice (Bloomingdale et al. Reference Bloomingdale, Darmody and Ellis2022). The framework has traditionally been applied to domains where there is an element of competition (e.g., sports, chess, music) and where tasks/problems are relatively well-defined and reproducible. It requires adaptation when tasks are not so easily reproduced. We discuss here how some elements of the framework could be adapted to the “task” of spiritual care, using the patterns of results shown in Table 2 as a springboard.
Ericsson (Reference Ericsson and Ericsson2009) proposes that each state that accompanies a higher level of performance is associated with more refined mental representations of task requirements. These representations are structures of task-related knowledge. To illustrate, representations that mediate expert music performance include an image of the sound that the musician wants to produce, and a means of translating that image into action (Lehmann et al. Reference Lehmann, Gruber, Kopiez, Williams, Kozbelt, Ericsson and Hoffman2018). When applied to the “task” of spiritual care, the models of spiritual care could be a type of mental representation of the task, outlining the condition the nurse wants to achieve with the patient, and the actions to be implemented to achieve that condition.
A specific form of task-related knowledge stems from an individual’s spirituality. Emmons, an expert in the psychology of spirituality, states that spirituality is part of a person’s knowledge base (Emmons Reference Emmons2000). Spirituality (i.e., information related to the sacred, however defined) helps a person to process spiritual data, to utilize spiritual resources to resolve situations, and to engage in virtuous behaviors such as being compassionate, humble, and grateful. The role of spirituality could thus explain how and why spirituality is loosely related to competence in our study.
Within Ericsson’s framework, several components facilitate the acquisition of expertise. These components act together and are not independent of each other. One component is the amount of time spent in deliberate practice, which is an activity engaged in with the goal of improving performance; merely repeating the same practice activities mindlessly would not lead to significant improvement (Ericsson Reference Ericsson2008). We posit that the amount of deliberate practice in spiritual care could loosely be related to the frequency of spiritual care. We have already noted that several studies report positive associations between ability and frequency of spiritual care (e.g., Taylor et al. Reference Taylor, Highfield and Amenta1999). Additional support for this posit lies in studies that document improvements in performance with increasing frequency of performing medical procedures of a given type (e.g., colorectal surgery (Huo et al. Reference Huo, Phan and Morris2017); bariatric surgery (Zevin et al. Reference Zevin, Aggarwal and Grantcharov2012; radiology diagnosis (Nodine et al. Reference Nodine, Kundel and Mello-Thoms1999)).
Another component in Ericsson’s framework that facilitates expertise acquisition is motivation (Ericsson Reference Ericsson and Ericsson2009). The key attribute of deliberate practice is that individuals seek out opportunities to improve; and those who become expert persist in doing and reflecting on activities that are not absolutely necessary and that require focus and effort. Given that many workplaces and nurses prioritize physical care over spiritual care (Selman et al. Reference Selman, Brighton and Sinclair2018), one could argue that nurses who provide spiritual care are doing something not absolutely necessary. We posit that spirituality, besides being a form of knowledge, could also act as motivation to improve. This posit arises directly from Pargament (Reference Pargament2013), who offers extensive theoretical and empirical evidence to show that spirituality is a distinctive human motivation in individuals that urges them to build a relationship with something sacred in their lives. Additional support for this posit comes from studies in nursing spiritual care that report a connection between spirituality and motivation to provide good spiritual care (e.g., Gholamreza et al. Reference Mahmoodishan, Alhani and Ahmadi2010; Golberg Reference Golberg1998; Taylor et al. Reference Taylor, Park and Pfeiffer2014). As well, a quantitative study examining nurses’ desire for spiritual care training – which could reflect a desire to improve – found that lower spirituality was significantly associated with a lack of desire for training (Balboni et al. Reference Balboni, Sullivan and Enzinger2014).
Another component in Ericsson’s framework that facilitates expertise acquisition is specialized training specific to the task, aiming to enhance the ability to perform the task (Ericsson Reference Ericsson2008). Specialized training facilitates the acquisition of mental representations to monitor, control, and refine performance in a specific task, and provides immediate feedback. In a review of research of expertise in nursing and medicine, Ericsson (Reference Ericsson2004, Reference Ericsson, Whyte and Ward2007)) found that consistently superior performance in certain, specific tasks were all linked to specialized training in those tasks, and that level of general nurse education had mixed effects on performance. These findings of Ericsson’s are loosely reflected in our study in which higher spiritual care models were proximately related to more adequate spiritual care training but not to nurse education level.
One component NOT in Ericsson’s framework is length of professional experience, which Ericsson et al. (Reference Ericsson, Whyte and Ward2007) found bears no relationship to performance. His finding is echoed in our finding that length of nursing experience is unrelated to spiritual care competence. The reason for this lack of relationship is most likely explained by the following: “Experience is necessary for moving from one level of expertise to another, but experience is not the equivalent of longevity …. Experience means living through actual situations in such a way that it informs the practitioner’s perception and understanding of all subsequent situations” (Benner and Wrubel Reference Benner and Wrubel1982, 13).
Confidence does not figure as a measure of performance in Ericsson’s framework, because experts can miscalibrate their capabilities by being overly confident (Chi Reference Chi, Charness, Ericsson, Feltovich and Hoffman2006). Comfort also does not figure in Ericsson’s framework because, as most individuals adapt to a domain, their skills become automated enabling them to execute actions smoothly and without apparent effort (i.e., comfortably) (Ericsson Reference Ericsson2004), and triggering a tendency to remain at this comfortable level that maintains a sufficiently satisfactory level of performance (Ericsson et al. Reference Ericsson, Whyte and Ward2007).
We have suggested a preliminary adaptation of some of Ericsson’s framework components – deliberate practice, motivation, specialized training – which can be perceived in our results. Future research could explore the adaptation of these components more fully (e.g., there may be other motivators besides spirituality that operate in expertise acquisition of spiritual care) and of other components not discernible in our study (e.g., immediate feedback).
Limitations and future research
Use of a convenience sample of nurses means that the representativeness of respondents and external validity are unknown. The sample size and data non-normality obliged the use of the Kruskal–Wallis test to detect group differences, but this test is not as powerful as some other statistical tests in detecting differences. The cross-sectional data gathered does not permit conclusions about causality between predictors and competence. Future research should examine a larger representative sample over time, to increase the power and external validity of findings and to investigate causality.
Conclusion
This study suggests that confidence and comfort in providing spiritual care are not related to actual performance of spiritual care, which raises concerns about the construct validity of using comfort and confidence as estimates of spiritual care competence. The study also shows that the relationship between spirituality, training adequacy, and frequency of spiritual care provision might not be as linear as portrayed in extant literature, which suggests that outcomes of training may depend on the type of spiritual care model subscribed to by training participants. The results can be interpreted within an expert-performance framework to provide insights about how nurses could achieve high levels of spiritual care performance.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/S1478951524000750.
Acknowledgments
The University of Notre Dame, Australia gave ethical approval for the initial survey. Thanks to D. Isaac for assistance in the coding of responses.
Competing interests
The authors declare none.
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