Teaching on spiritual care: The perceived impact on qualified nurses

Article Outline

• Abstract
• Introduction
• Aim
• Definitions
• Conceptual framework
  • The structure content and the process of teaching and learning
• Literature review
• Research methodology
  • Sample
  • Data collection and analysis
• Findings
• Discussion
  • Updating with knowledge on the spiritual dimension in care
    • Increasing knowledge on spirituality and spiritual coping in illness
    • Understanding the holistic impact of illness on patients’ life
  • Self-awareness on the nurse’s role in spiritual care
    • Becoming aware of own spirituality and nursing care
    • Acknowledging the nurses’ role as change agents
  • Limitations of the study unit
  • Future implications
• Conclusion
• Acknowledgement
• References
• Copyright

Abstract 

This study unit as part of the Continuing Professional Development (CPD) programme aimed at reviving the spiritual dimension in nursing care. This paper discusses the perceived impact of the study unit Spiritual Coping in Illness and Care on qualified nurses. The paucity of literature demonstrates some benefits perceived by the learners namely, clarification of the concepts of spirituality and spiritual care, self-awareness of personal spirituality and their current clinical practice which neglects the spiritual dimension. The ASSET model [Narayanasamy, A., 1999. ASSET: a model for actioning spirituality and spiritual care education and training in nursing. Nurse Education Today 19, 274–285] guided the teaching of this study unit. The nature of this study unit demanded an exploratory method of teaching to encourage the nurses to be active participants. Qualitative data were collected by a self-administered questionnaire from the three cohort groups of qualified nurses who undertook this study unit in 2003–2004 (A: n=33), 2004–2005 (B: n=35) and 2006–2007 (C: n=35).

Learners found the study unit as a resource for updating their knowledge on spirituality in care and increased self-awareness of their own spirituality and nursing care. They acknowledged their role as change agents in order to implement holistic care in collaboration with the multidisciplinary team. Recommendations were proposed to integrate the spiritual dimension in education and patient care.

Keywords: Spirituality, Spiritual care, Spiritual coping, Teaching, Impact, Education, Post-graduate learners, Continuing Professional Development (CPD)

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Introduction 

Literature criticised nursing care for giving minimal attention to the spiritual dimension in patient care (McSherry et al., 2008, Baldacchino, 2008c, Mitchell and Hall, 2007). This may be due to lack of time, work overload, feelings of incompetence to deliver spiritual care and lack of education in the undergraduate and CPD curricula (Baldacchino, 2006, Keefe, 2005, McSherry, 1998). Bradshaw (1997) argues that spiritual care is caught from role-models in the clinical area rather than taught. However, since spiritual care is not being given the merited attention, learning on the spiritual dimension in care through role-modelling appears to be impracticable.

The study unit was oriented towards spiritual coping in illness and spiritual care. Experiences of spirituality may be derived from within or outside formal religion (Tse et al., 2005, Knestrick and Lohri-Posey, 2005). Thus, spiritual coping consists of religious methods such as, prayer and non-religious strategies like, talking to other patients with similar ailments (Baldacchino and Draper, 2001). Patients may turn to others for bio-psychosocial and spiritual support in order to cope and feel more in control of their situation (Koenig, 2004, Baldacchino, 2003).

Through the author’s networking experience, it could be said that although some universities in the U.K., U.S.A. and Canada are known to teach on spirituality and spiritual care, few published articles were traced to date on evaluation results of the study units. Thus, this study attempts to fill in this gap by evaluating a CPD study unit.

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Aim 

This paper discusses the perceived impact of the study unit on Spiritual Coping in Illness and Care on qualified nurses.

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Definitions 

Spirituality is the unifying life force which integrates the biological, psychological and social components which includes or excludes the religious component according to the individual belief system (Baldacchino, 2010). Thus, spirituality applies to both the believers and non-believers. While considering the individuality in the definition of spirituality, all individuals may possess the potential to experience spirituality (McSherry, 2006). The ultimate outcome of spirituality is to help individuals to find meaning and purpose in life (Chan et al., 2006).

Spiritual care is being as opposed to doing (Baldacchino, 2010, Halm et al., 2000, Bradshaw, 1994). Hence, spiritual care is oriented towards therapeutic communication by the caregiver’s availability and actual presence to patients (DiJoseph and Cavendish, 2005, Ross, 1996). Spiritual care may help patients to explore strategies to cope with their illness to enable patients find meaning and purpose in life (Baldacchino, 2003). Thus, research recommends that spiritual care should be integrated in nursing education and nursing practice as a philosophy of care in order to enable delivery of holistic care (Sawatsy and Pesut, 2005; Baldacchino, 2010).

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Conceptual framework 

Following analysis of various humanistic theories of learning of Carl Rogers, Abraham Maslow, Malcolm Knowles and Paolo Freire, the Actioning Spirituality and Spiritual are Education and Training model (ASSET) (Narayanasamy, 1999) was selected. The ASSET model encompasses a tripod of structure content, process of learning and outcome of education. This was considered the most appropriate as it provided a complete cycle of the teaching and learning processes of qualified staff who tended to overlook the spiritual needs of clients (Hubbell et al., 2006, Koenig, 2004).

The structure content and the process of teaching and learning 

The study unit was developed by the author and based on the literature, research and feedback from the undergraduate students who had completed the study unit on ‘The spiritual dimension in care’ (Baldacchino, 2008a). It consisted of 4 European Credits Transfer System (ECTS) incorporating 28h of teaching sessions which included the four-hour seminar (Table 1). The study unit was submitted by the CPD Curriculum Development Committee at the Institute of Health Care (IHC). Eventually, this unit was approved by the IHC Board and the Senate of the University of Malta.

Table 1. Study unit outline: spiritual coping in illness and care.

This study unit had a monotheistic religious orientation since 95% of the local population are registered as Roman Catholics (Malta Archdiocese, 2007) and the displaced immigrants are registered as Christians or Moslems (Jesuits’ Refugees Services, 2007). The learners had diverse clinical experiences (Table 2). This diversity enhanced their participation in the group discussions of patient case studies. This gave them the opportunity to reinforce the theory learnt by identifying individual spiritual problems/needs and spiritual coping, supported by ways of meeting patients’ holistic needs.

Table 2. Demographic data of the three cohort groups of nurses.

Characteristics	Group A	Group B	Group C
	2004	2005	2007b
	(n=33)	(n=35)	(n=35)
Male	9	8	6
Female	24	27	29
Mean years of clinical experience	17.5	14.8	16.6
Diversity in clinical experience	Community Geriatrics Medical Obstetrics Oncology Outpatient clinics Surgical Specialised carea	Community Geriatrics Medical Obstetrics Oncology Paediatrics Surgical Outpatient clinics Specialised carea	Community Geriatrics Medical Obstetrics Outpatient clinics Surgical Specialised carea

The sessions were repeated twice weekly for twelve weeks to accommodate different duty rota. This facilitated active participation in small group discussions and sharing of experiences. The students were assessed by means of a case study presentation (Table 1). Precautions were taken to safeguard patients’ health by obtaining institutional permissions and patients’ consent. The Hospital Psychologist and/or the Hospital Chaplain were available for assistance in case of stress following the interview. Through the active participation in the assessment of patients, the learners became aware of the complexity of spiritual care and yielded a reflective mode of learning (Jarvis, 1995). A humanistic environment was created and an active teaching and learning process was similar to the study unit delivered to the undergraduates which is already published (Baldacchino, 2008a).

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Literature review 

Literature suggests the importance of evaluating study units, modules and curricula in order to identify the extent to which planned goals are achieved (McKie et al., 2008) and effectiveness of teaching (Mooney and Timmins, 2007, Harrison et al., 2004). Although teaching on spirituality and spiritual care entails several ethical issues such as individuality and respect for diverse religious affiliations (McSherry et al., 2008), positive impact on learners is documented such as increased self-awareness and knowledge of spiritual care with personal spiritual growth (Table 3).

Table 3. Summary of published evaluation of teaching on spirituality and spiritual care.

Author, year, country	Sample and teaching programme	Findings
Wallace et al. (2008), USA	Undergraduate junior and senior students (n=unknown) A weekend programme on spirituality and spiritual care	•Significant differences in knowledge on spirituality and attitudes among senior-level nursing students (t=−3.059, p=0.004).
Baldacchino, 2008a, Baldacchino, 2008b, Baldacchino, 2008c, Malta	Final year undergraduate nursing students (n=65) A study unit on the spiritual dimension in care	•Increased self-awareness of their personal spirituality; counted their blessings in life; •Increased knowledge of the concepts of spirituality and spiritual care; •Became more sensitive to patients’ needs.
Bush (1999), Australia	A Group of mature nurses aged over 25 years (n=unknown) Teaching programme on spirituality and spiritual care	•Effective teaching and learning occurred through sharing of experiences and knowledge between the group members and between the educator and the group.
Pesut (2002), Canada	1st and 4th year undergraduates (n=unknown) Teaching on spirituality and spiritual care	Similar findings between the two groups: •Developed a strong awareness of their personal spirituality oriented towards a relationship with a higher being, reason for living, spiritual growth and the importance of community in their spiritual development; •Had a high level of spiritual well-being; •Patient-centred care was characterised by emotional presence, listening, prayer and facilitating connections with those of similar beliefs; •The reciprocal nature of spiritual learning in the nurse-patient relationship enhanced their spiritual growth.
Hoover (2002), Wales	Nursing students undertaking part-time degree (n=25) A module on nursing as a human caring including spirituality	•Increased self-awareness about their relationship with self and others; •Finding meaning and purpose in life; •Appreciated more their values in life; •Increased knowledge of the caring theory, and holistic approach to care; •Enhanced caring practice by implementing patient-centred care.
Shih et al. (1999), Taiwan	Qualified nurses working in Intensive Care Unit (n=64) A lecture on spiritual care to patients	•Understood spirituality as part of holistic care; •Clarified the concepts of spirituality and spiritual care; •Increased awareness of personal beliefs and spiritual needs.

Teaching on spirituality and spiritual care revealed a positive impact on the learners’ personal life, academic achievement and professional care. Additional to the content of teaching, several factors might have fostered learning such as teaching methods for example, reflective exercises, small group discussions (Baldacchino, 2008b, Bush, 1999); exposure to clinical experience (Pesut, 2002, Shih et al., 1999) and students’ age and maturity (Hoover, 2002, Wallace et al., 2008). Data collection method might have influenced recollection of experiences such as journaling (Bush, 1999), freedom in expression of experiences safeguarded anonymous self-administered questionnaires (Baldacchino, 2008b, Bush, 1999) and in-depth exploration of experiences such as by focus group technique (Hoover, 2002).

Learning on the spiritual dimension in care may help the professionals realise their current care which may motivate them to become change agents by implementing patient-centred care (Hoover, 2002) and meeting patients’ needs holistically (Narayanasamy, 1999).

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Research methodology 

The descriptive exploratory study evaluated the study unit on Spiritual Coping in Illness and Care by investigating the perceived impact of the study unit on the three cohort groups of students at the end of the study unit.

Sample 

The study unit was taught to three different cohort groups of qualified nurses (A: n=33, B: n=35, C: n=35), in Semester 2 of 2004, 2005, 2007 respectively (Table 2). The majority of the nurses were females (Group A: 24 females, 9 males; Group B: 27 females, 8 males; Group C: 29 females, 6 males) which represents the overall nurses’ gender ratio in Malta (Table 2).

Data collection and analysis 

Evaluation of the CPD study units forms part of the Quality Assurance Auditing, requested by the University of Malta. Additional to the general evaluation conducted by the Nursing CPD Unit, the author collected qualitative data specifically on this study unit since it was new to the CPD programme. Institutional and ethical permissions were granted by the Chairperson of the Institute of Health Care, University of Malta. Thus, on completion of the study unit, the nurses were asked to fill in a self-administered questionnaire on voluntary basis. The questionnaire consisted of five open-ended questions (Table 4).

Table 4. Study unit evaluation questions.

The questionnaires were returned to the author, separate from their assignment write-up to maintain confidentiality and to enhance trustworthiness of data. An index number, not related to their names, was given to the questionnaire solely for publication purposes. Students consented to have their data analysed to be disseminated in nursing journals and conferences. The high response rate (A: 82% n=27; B: 91% n=32; C: 86%, n=30), appeared to demonstrate the learners’ interest in this study unit.

The data underwent thematic analysis manually guided by the procedural steps of Burnard (1991). To enhance credibility of the findings, data were analysed independently and concurrently by the author and the research assistant who agreed on the two themes identified.

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Findings 

The impact of the study unit on the learners is demonstrated by the following two themes and four categories which emerged from the data (Table 5).

Table 5. Findings: themes and categories.

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Discussion 

The discussion of these themes is supported by the learners’ excerpts and are compared with the limited published research on teaching spirituality/caring.

Updating with knowledge on the spiritual dimension in care 

Increased knowledge was reported to be about clarification of the definition of the term ‘spirituality’ which had been conceptualised solely with religiosity:

‘This study unit helped me understand better the nature of patients’ spiritual needs. I learnt that spirituality incorporates not only religiosity but any other coping strategy which may help the individual to find meaning and purpose in life’.(B15)

A broader definition of ‘spirituality’ was applied also to understanding spiritual coping which includes both religious and non-religious strategies. The importance of identifying spiritual needs appeared to be recognised, which eventually seemed to motivate the nurses to learn more about spirituality in order to enhance nursing practice:

‘This study unit made me conscious of the spiritual needs of patients. It stimulated me to search more literature about the spiritual needs of patients. This study unit is fundamental for nursing care as we were not exposed to the spiritual aspects of care during my training’.(A2)

Following reflection on the clinical practice which revealed minimal attention to the spiritual dimension of care, the learners considered this study unit as an opportunity to update themselves with new knowledge on spirituality in illness and holistic care. Additionally, students demonstrated increased motivation to further their learning. Similar findings were found in research whereby an increase in knowledge appeared to trigger further learning which may contribute towards holistic care (Baldacchino, 2008b, Greenstreet, 2005).

Being a small group in class and supported by a trustful collegial relationship, the learners appeared to be comfortable to clarify misconceptions and share their clinical experiences throughout the sessions of the study unit.

‘My experience in this study unit has been a big eye-opener regarding the quality time in our nursing care. When patients have the opportunity to share their concerns with us nurses, it can help them to cope with their illness’.(A18)

The importance of listening to patients was identified by Ross (1997: 714) who was impressed by patients’ desire to ‘unburden themselves through talking to someone who had time to listen’. While admitting the limitations encountered in their nursing practice, such as being busy with meeting medical and physical needs, the study unit appeared to help them acknowledge the importance of delivering holistic care. This is consistent with research whereby undergraduates and qualified staff were found to increase their knowledge on the spiritual dimension in care which may clarify the concept of spirituality and spiritual needs (Baldacchino, 2008b, Wallace et al., 2008, Hoover, 2002). However, a difference is noted between the impact on undergraduate and qualified nurses of the same culture in the study conducted in Malta by Baldacchino (2008b) whereby fourth year students equated the increase in knowledge with their academic achievement whereas qualified nurses considered it as a resource to help their colleagues and students to meet patients’ needs holistically.

Assessing patients’ medical/surgical needs without addressing the spiritual needs impairs holistic care. The study unit assessment requested the learners to address directly the individual patient’s spiritual distress and spiritual needs which were reported to help them identify the impact of illness on the patient’s life:

‘This study unit helped me to have a deeper understanding of the impact of illness on patients, especially patients with cancer, and their ability to adapt and respond to the chaos brought about by cancer diagnosis’.(B5)

The written assignment requested them to dedicate time for the face to face interview. Students explored signs of spiritual distress, methods of spiritual coping and how nurses and members of the multidisciplinary team could deliver spiritual care. This interview appeared to help them understand better spiritual distress and how patients may cope with their illness:

‘It gave me insight into other people’s feelings and problems and the various coping strategies which could be used in life. Very often we are so much caught up with our nursing duties that we are too busy to address the spiritual emotions of patients’.(C20)

Dedicating time to listen and reflect on patients’ statements appeared to make them aware about the importance of giving priority to meeting also patients’ spiritual needs which was envisaged to enhance holistic care:

‘On considering the wholeness of spirituality in life, implementing spiritual care may facilitate holistic care which may enhance recovery of the whole person, irrespective of the specific illness’. (C4)

Increased knowledge about the spiritual concepts of spirituality, spiritual distress, spiritual well-being, spiritual coping and spiritual care appeared to help the learners see the possibility of meeting patients’ needs through the implementation of holistic care. This study unit seemed to enable the learners to be active participants in the learning process which motivated them to explore further the spiritual dimension in care and analyse critically the reality of nursing care which underestimates patients’ spiritual needs. This is parallel with the findings of Hoover (2002) who found that nurses comprehended better the concept of caring and reported their willingness to implement patient-centred care.

Self-awareness on the nurse’s role in spiritual care 

The learners’ experience of undertaking the study unit appeared to confirm the essence of spirituality in life:

‘I have always felt that spirituality was not given the merited importance when caring for our patients and this was one of the reasons why I applied for this study unit… This study unit has instilled in me an increased awareness of the crucial role spirituality may have in bringing about and influencing healing of the person as a whole’.(B6)

The study unit was reported to be beneficial as the learners had time to think critically about their own spirituality and their current clinical practice:

An interesting study unit, not only in helping nurses to care for patients’ needs but I confess that it helped me immensely to tackle my personal life in harmony. Very often a small amount of hope can be the medicine to help individuals to recover or to complete his/her journey into the unknown’. (C6)

Self-awareness exercises appeared to enable the learners to reflect on their own spirituality and personal value system whereby they seemed to appreciate their own life better by counting their blessings in life.

‘The study unit was excellent as it helped me become not only more sensitive to others’ needs but also to my own spiritual needs by looking at my life in a different way, appreciating my life better and learning to count my blessings in life’.(C9)

Awareness of the nurses’ personal spirituality with spiritual growth is consistent with the findings of Pesut (2002) who found that both first and fourth year students were found to have a stronger awareness of their personal spirituality with spiritual growth that is finding meaning in life and importance of relationships with their community.

Furthermore, sharing of experiences in small groups enabled learners to develop reflective skills in an attempt to recognise their learning and clinical practice as a reflective journey as demonstrated by research (Gustafsson and Fagerberg, 2004, Chapman and Howkins, 2003, Glaze, 2002).

Literature suggests that nursing care may be enhanced by reflection in action when assisted by clinical supervision or mentorship (O’Callaghan, 2005, Clouder and Sellars, 2004). However, learners could not be mentored in their clinical practice to reinforce the theory for various reasons such as, the nature of the local current short CPD courses based mainly on theory, the limited number of educators with expertise in spiritual care and the diverse spread of clinical placements of the group undertaking this study unit.

The study unit appeared to help the nurses to consider their responsibility of learning on spiritual care so as to become a resource of knowledge to their colleagues in order to facilitate holistic care:

‘You can do nothing to inspire the person under your care if you do not inspire yourself. Unless the health care professionals become interested in holistic care and teamwork, the spiritual dimension in care will remain unnoticed.’(B1)

The new concepts of spiritual distress, spiritual well-being, self-transcendence and spiritual coping appeared to trigger the learners to share their experience with other colleagues. They attempted to introduce change in patient care by liaising with the multidisciplinary team in order to meet patients’ spiritual needs:

‘Very often I found myself discussing these new spirituality concepts with my colleagues. Nurses are to be knowledgeable enough and equipped professionally in order to start delivering spiritual care….. After all, it is the nurse who is day and night with patients….. However, this needs teamwork…… The nurse may be the liaison person between the various members of the interdisciplinary team’.(C5)

This study unit appeared to enable the nurses to consider their position as change agents whereby they could help their colleagues to become aware of their status quo (Freire, 1972) and introduce change gradually by implementing spiritual care. Additionally, apart from giving care, the personal benefit of patient care was identified:

‘Sitting by the patient talking about his experience brought me face to face with reality. I have learnt a lot from the case study of my assignment! In struggling with our own spiritual journeys through different experiences in life, such as nursing care, we can recognise that in fact we receive more than we give when we care for others’.(A1)

This study unit appeared to help the nurses acknowledge their role as change agents. Thus, transformation was apparent in the learners whereby they showed commitment to address spiritual needs of patients in liaison with the multidisciplinary team. This is consistent with research whereby, having undertaken study units on spiritual care, nurses and midwives acknowledged the current neglect of the spiritual dimension in care and professed their intention to provide holistic care (Wallace et al., 2008, Hoover, 2002). However, to put theory to practice, mentorship is needed to sustain nurses to practise what they learn (Swain et al., 2003) and guide them on long term basis during implementation of holistic care.

Limitations of the study unit 

This study unit formed part of the CPD programme and thus the learners were qualified staff with diverse age, personal and clinical experiences (Table 2). Whilst this diversity enhanced learning from each others’ experiences, the group discussions on patient case studies utilised quite an amount of time with positive outcome whereby the theory on spirituality and spiritual care could be integrated into the clinical component. Time was a problem throughout the course of the study unit! Although the teaching sessions were organised twice weekly in the afternoon, the author and the learners used to be tired but the various teaching methods enhanced active participation.

The three cohort groups of learners were all Christians. However, this study unit oriented teaching towards monotheistic religions of Christianity, Judaism and Islam. This was an attempt to address the diverse religious needs of displaced patients coming to Malta from various countries. Thus, these findings should be interpreted with caution as the cultural aspects were limited mostly to the Maltese patients.

Evaluation data of this study unit were derived from open-ended questions in a self-administered questionnaire. Although the use of a questionnaire enhanced anonymity, lack of supervision might have influenced the findings. Had data been collected by the use of journaling, face to face interview or a focus group technique, in-depth data could have been recalled better.

Future implications 

These findings shed light on the positive impact of this study unit on nurses. However, the definition of spirituality is still undergoing exploration in research. Therefore, application of this concept in education and clinical practice is a challenge (McSherry et al., 2005).

Since spiritual care involves the multidisciplinary team, this study unit may be organised inter-professionally in order to enhance sharing of experiences, teamwork and holistic care (Stern and James, 2006, Tucker et al., 2003).

Therefore, other members of the multidisciplinary team including the patients may be involved in teaching. The study unit may include other coping strategies which could be used by patients and nurses, such as meditation and support groups, to foster self-transcendence and harmony in life:

‘Maybe if we learn to meditate, it can help us to empty ourselves and transcend to a higher power before starting the day’s work. This exercise could be an effective way to motivate ourselves to give help to others altruistically’.(C24)

This study unit was found as an eye-opener for the learners by becoming conscious of their own spirituality which was recommended as a priority in education and clinical practice:

‘I suggest that more study units of this sort be available at least every year. If we feel good and strong spiritually, we can respond better to patients. Eventually, we learn how to express ourselves in a caring presence by being with the patient and providing comfort in stressful situations’.(B4)

This study unit may be extended to a module including both theory and practice. The practical component may request the learners to initiate a practical change in the clinical area, such as facilitation of a spiritual coping strategy, for example, organising individual/group reflective exercises. Integrating theory with practice may reinforce learning and may also facilitate collaboration between the teacher, learner and practitioners (Wallace et al., 2008).

Finally, suggestions for future study units included more self-reflective exercises, mentorship on the clinical area and organisation of regular seminars and conferences, open to all members of the multidisciplinary team. Since nurses are present with patients twenty-four hours a day, the nurse was suggested to be the liaison person for consistent care (Baldacchino, 2006).

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Conclusion 

The study unit on Spiritual Coping in Illness and Care was delivered to three cohort groups of qualified nurses. The positive impact was demonstrated by the two themes which emerged from the data namely, increase in knowledge on the spiritual dimension in care and self-awareness on the nurse’s role in spiritual care.

The positive impact on nurses could have been due to several strengths of this study unit. The exploratory, reflective teaching methods triggered active participation; the learners’ maturity and voluntary registration appeared to sustain their interest till the end; the diversity in the nurses’ clinical experience fostered analysis of the concepts and clinical case studies; and the Christian and Islam content orientation provided a broader perspective to the religious dimension of spiritual care. Thus, these strengthens appeared to outweigh the limitations encountered namely, time constraints in the duration of the study unit (4 ECTS) which limited discussion periods and provided short self-reflective exercises; the learners who analysed a personal crisis situation, presented it solely to the author or the hospital chaplain at the concluding seminar and so this lessened learning of the entire group; and the learners were mainly nurses which limited the discussions with their partners in care from the multidisciplinary team.

Since the learners were qualified nurses, the study unit seemed to help them acknowledge the neglect of the spiritual dimension in care which inhibits delivery of holistic care (Ross, 2006, Baldacchino, 2010). This may be due to secularisation of the contemporary society and lack of education. Eventually, they may change their behaviour to challenge this neglect and transform their medically oriented care to holistic care by further education and teamwork (Wallace et al., 2008, McKie et al., 2008).

The findings demonstrate that the objectives of this study unit (Table 1) appeared to be achieved, whereby increased knowledge and awareness on the spiritual dimension in care were reported. However, literature suggests that learning may be an outcome of a combination of what the learners were taught and the learners’ individual efforts to learn which is highly acceptable and recommendable (Harrison et al., 2004).

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Acknowledgement 

The author appreciates the cooperation of Professor J. Rizzo Naudi, the Chairperson, Dr Sandra Buttigieg, the Director of the Institute of Health Care, University of Malta; Ms G.A. Jaccarini, the Coordinator of the Nursing/Midwifery Department, Mr J. Sharples, the Nursing Director for integrating this study unit in the CPD Programme; Ms C. Farrugia and Ms L. Bonello for proof reading; Family Attard for providing me with a quiet reflective seaside environment to report these findings; and Dr L. Ross, University of Glamorgan Wales for her invaluable feedback on this manuscript and the two anonymous reviewers.

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