Spirituality in practice: using personal reflection to prepare occupational therapy students.
Abstract: Introduction: The study examines whether directed study and reflection on spirituality can improve occupational therapy students' confidence in addressing clients' spiritual needs.

Method: In this qualitative study, questionnaires were distributed to a convenience sample of 12 students. In a quasi-experimental design using a pre-test and post-test approach, participants answered questions before and after reading about spirituality and completing a personal reflection.

Results: Nine participants (75%) believed that the reflection increased awareness of their spirituality. Of these, 78% felt more confident to address spiritual needs.

Conclusion: This study suggests that directed study and personal reflection upon spirituality can enhance personal professional development, increasing students' confidence in this core domain.

Key words: Spirituality, students, personal reflection.
Article Type: Report
Subject: Spirituality (Educational aspects)
Professional development (Methods)
Occupational therapy (Study and teaching)
Authors: Barry, Emily
Gibbens, Richard
Pub Date: 04/01/2011
Publication: Name: British Journal of Occupational Therapy Publisher: College of Occupational Therapists Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 College of Occupational Therapists Ltd. ISSN: 0308-0226
Issue: Date: April, 2011 Source Volume: 74 Source Issue: 4
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 254827349
Full Text: Introduction

Since the early 1990s, spirituality has acquired increased importance in occupational therapy literature and theory (Wilding 2001). The adoption of spirituality as a core concept within the Canadian Model of Occupational Performance in 1991 sparked debate about whether spirituality lies legitimately within the remit of occupational therapy (Hasselkus 2002). As Wilson (2010) argued, spirituality is an important dimension of practice, amply warranting investigation in a profession that espouses client-centredness (Creek 2002).

In recent years, researchers in occupational therapy have discussed the place of spirituality in practice (Rose 1999) and the attitudes of therapists towards its inclusion (Taylor et al 2000, Egan and Swedersky 2003). Several authors, in both occupational therapy and nursing, have suggested that clinicians who have developed an awareness of their own spirituality are more confident and skilled at addressing such needs (Govier 2000, Kirsch et al 2001, Belcham 2004, Thompson and McNeil 2006).

'Spirituality', however, has a variety of culturally and individually influenced meanings. This ambiguity is mirrored in the debate over the definition of terms such as 'spirituality' and 'religion', seen as early as the turn of the twentieth century (James 1902). From a social work perspective, Canda and Furman (2010) reflected this diversity of meaning in their pluralist description of spirituality as:

Reflecting this elusiveness and diversity, no attempt was made to embed within the present investigation a single definition of spirituality. Instead, Kang's (2003) seven definitions of spirituality were offered to participants as a convenient means of stimulating their personal constructions of the concept. It was felt that this would enhance the personal meaningfulness of the study activities.

The degree to which spirituality is included in practice has been investigated by, for example, Rose (1999), Wilding (2001), Belcham (2004) and Johnston and Mayers (2005). These studies identify a large theory/practice divide. Wilding (2001) attributed this to a lack of understanding about spirituality and how it could be included in occupational therapy practice. Additionally, Enquist et al (1997) and Egan and Swedersky (2003) invoked a lack of confidence or training.

Kirsch et al (2001) and Thompson and McNeil (2006) sought to address these concerns by identifying the best methods of preparing occupational therapy students to address clients' spiritual needs. Both studies involved inviting students to reflect upon their personal spirituality. In Kirsch et al (2001), 63% of the 46 participants agreed that their own spirituality affected their interactions with clients. Many of their participants emphasised how reflection on personal spirituality improved awareness of self and others. Arguably, these data should be treated with caution due to a lack of information about the method of analysis. However, they do provide an interesting insight into the relationship between self-awareness and occupational therapy.

Thompson and McNeil (2006) used focus groups to investigate the lived experiences of 11 occupational therapy students who completed a seminar on spirituality in occupational therapy. Whilst this study lacked acknowledgement of possible subject bias (Robson 1993) arising from the lecturer/student relationship, several participants reported changes in their attitudes towards spirituality as a result of self-reflection.

These studies suggest that education and reflection regarding the use of spirituality improves confidence in addressing clients' spiritual needs. The present authors extend this previous work by focusing specifically on directed study and reflection on personal spirituality, to the exclusion of other educational methods, and by measuring the change that this may produce. Additionally, this study provided an opportunity for participants to study spirituality, thus encouraging personal professional development. It examined whether directed study and reflection on personal spirituality could improve students' confidence in addressing clients' spiritual needs.


This qualitative, social group case study (Robson 1993) investigated the effects of reflection on personal spirituality, and of reading about spirituality, on students' confidence in addressing clients' spiritual needs. A convenience sample of 13 postgraduate pre-registration occupational therapy students at a United Kingdom university was used, of which 12 participated in the study (92%). For reasons beyond the researchers' control, these students happened to belong to a culturally and ethnically homogeneous group.

Ethical approval was gained from the participants' university, and the relevant Code of Ethics and Professional Conduct (College of Occupational Therapists 2005, revised 2010) was adhered to. Anonymity is particularly important for an intimate research topic, such as personal spirituality (Gray 2004). Therefore, participants were provided with stamped addressed envelopes for the return of questionnaires, which could be completed in private to limit researcher bias (Drummond 1996).

Each participant received a questionnaire with instructions on when to read the information sheet and complete the enclosed reflection on personal spirituality. This information sheet provided, first, details of the place that spirituality has had in occupational therapy; secondly, seven possible definitions of spirituality, as summarised by Kang (2003); and, thirdly, ways in which spiritual needs could be addressed in practice, as proposed by Egan and Swedersky (2003). Participants were later invited to reflect upon their own concept of life meaning, significant relationships and beliefs, cited from Govier (2000).

Thus, a quasi-experimental design using a pre-test and post-test format was used, where questions alternated with activities, in this case reading and reflection on personal spirituality. This design was intended to examine the effectiveness of an educational intervention (study and personal reflection) that could contribute to participants' personal professional development. To describe this intervention, the term 'sandwich approach' has been used as a metaphor for a beneficial activity (the nutritious filling) framed by two sets of questions (bread).

The questionnaire employed mixed data collection tools, including open questions and 150mm visual analogue scales. Open questions were subjected to content analysis (Robson 1993), and the scales were plotted on graphs. Themes were identified, sorted into categories and subjected to basic numerical analysis. Pre-test and post-test visual analogue scales were compared in order to identify changes.


Participants' confidence to address clients' spiritual needs

Participants were asked to indicate on visual analogue scales their confidence about addressing clients' spiritual needs. This was carried out before and after reading the information sheet and completing the reflection. The repetition sought to show whether the directed study and personal reflection had affected the participants' confidence. Fig. 1 illustrates the responses to these two questions.

Fig. 1 shows how the number of participants placing themselves in the lowest third of the scale (0-50mm) fell from 42% to 8%, while those placing themselves in the highest third (100-150mm) rose from 8% to 33%. Ten out of the 12 respondents, or 83%, reported an increase in their level of confidence after the directed study and personal reflection. One respondent reported a fall, and one respondent gave the same answer to both. The average increase in confidence was represented as 35.5mm on the visual analogue scale, approximately 24% of its length.



Participants were also asked to mark on a visual analogue scale the extent to which they felt that they understood their personal spirituality. Fig. 2 plots each participant's response in the foreground, together with his or her pre-test confidence level behind it. It indicates no relationship between those who rated themselves as having a good understanding of their own spirituality and those who had a high level of confidence in their ability to deal with the spiritual needs of clients.

The effectiveness of the personal reflection

Participants were asked whether they felt that the reflection had been effective in increasing their awareness of their own spirituality. Nine participants (75%) answered yes and 3 (25%) answered no. Those who answered yes were asked whether they felt that this awareness would improve their ability to address the spiritual needs of their clients in practice, to which 7 (78%) answered yes and 2 (22%) answered no.

Table 1 shows participants' responses when asked to comment on how they thought that the reflection might benefit their practice, grouped into themes. The number (n) of responses which reflect each theme, along with the percentage of the total number of participants, appears in the two right-hand columns.


After completing the directed study and personal reflection, 83% of participants felt that their confidence to address the spiritual needs of their clients had grown. Furthermore, of these, 78% agreed that this would improve their ability to deal with the spiritual needs of their clients in practice. This supports the findings of Thompson and McNeil (2006). However, causality can only be inferred (Bell 2005) as there is a range of variables that the authors did not attempt to control for, such as participant-observer biases; for example, the Hawthorne effect.

There was a positive response to the reflection, both in terms of the number who said that they felt it had increased their awareness of their spirituality (75%, n = 9) and the positive nature of participants' comments. This indicates the value of personal reflection in preparing students to address the spiritual needs of their clients.

As Fig. 2 shows, this study found no linkage between those who rated themselves as having a good understanding of their own spirituality and those who had a high level of confidence in their ability to deal with their clients' spiritual needs. This indicates a possible discrepancy with Belcham's (2004) finding that occupational therapists with strong spiritual or religious beliefs were the most confident at dealing with the spiritual needs of patients. However, on closer examination, no causal relationship between these two findings can be inferred, as one cannot assume a relationship between insight and strength of belief. This may be an avenue for further research.

This raises the interesting question as to whether awareness of one's personal spirituality is a prerequisite to facilitating spiritual reflectiveness with clients. There is no evidence of a causal link between the therapist's spiritual awareness and his or her effectiveness in the spiritual dimension of occupational therapy. However, intuitively one may expect a link on the assumption that personal awareness will increase empathy and understanding for the client's spiritual journey. This may facilitate a more sensitive and effective approach.

A potential asset highlighted by this study is the 'nutritious' or beneficial aspect of the 'sandwich' approach (directed study and personal reflection). This may offer an accessible and cost-effective way to increase professional awareness and confidence. Thus it may be of interest to other professional disciplines where increased awareness and confidence are sought.

Another feature of the study is the provision of the opportunity for participants to use any of Kang's (2003) seven definitions for the term 'spirituality', with the intention of increasing the personal meaningfulness of participation. This reflects a constructivist approach, according to which adult learning is a process of individual development building on pre-existing understandings (Fry et al 2009); in this case, the meaning of 'spirituality'. However, this ambiguity increases the nebulous nature of the results, therefore limiting the conclusions that can be drawn. Thus, although a growth in confidence can still be inferred, it cannot be claimed that participants have developed competence in specific skills or interventions. This is because they may have been working with different interpretations of the phrase 'to address clients' spiritual needs'. Using focus groups or interviews might allow these uncertainties to be followed up (Gray 2004).

Future studies might benefit from overcoming certain methodological limitations acknowledged by the present authors. Pre-test and post-test questions could be administered sequentially rather than together, to reduce the risk of bias through participants referring to their previous answers. The use of a larger and more culturally diverse sample would improve reliability and generalisability. Also, the use of a sample of students unknown to the researcher would improve validity by reducing subject bias.

The participant responses indicated that participants had thought deeply about the place of spirituality in occupational therapy and reported having benefited from their participation. This positive response suggests the potential value of directed study and personal reflection within occupational therapy education.


The majority of participants reported that reflection improved awareness of personal spirituality and felt that this would improve their ability to address clients' spiritual needs. This supports previous studies of this kind. However, the present study showed no clear relationship between initial awareness of personal spirituality and confidence. This study also suggests the potential of directed study and personal reflection to raise awareness of spirituality among pre-registration occupational therapy students, thereby fostering their personal professional development.

Further research is recommended into the relationship between reflection on personal spirituality and confidence in addressing clients' spiritual needs. This could be through follow-up studies of these participants to ascertain the perceived effect of this study on them after a year's practice. Additionally, in the therapeutic relationship, attention to the spiritual dimension has the potential to offer personal enrichment to both therapist and client. This may provide the opportunity for personal growth and wellbeing and is certainly a core aspect of occupational therapy (Hasselkus 2002).


We would like gratefully to acknowledge the work of the two anonymous BJOT article reviewers.

Conflict of interest: None declared.

Key findings

* Directed study and reflection upon personal spirituality improved participants' awareness of their spirituality and perception of ability to address spiritual needs.

* No clear relationship was apparent between pre-existing awareness of personal spirituality and confidence to address spiritual needs.

What the study has added

This 'sandwich' approach may contribute to other aspects of practice, where increased awareness and confidence are sought.


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Focus on research

Theses donated to the COT Library are available for loan, but are not downloadable. Please contact the Library for details.

Nichola L A Gadsby

A systematic literature review exploring the impact of chronic pain upon the quality of life for children and young people with a physical disability.

University of Northampton, 2009. MSc Advanced Occupational Therapy.

Background: Although research is growing into the impact of chronic pain for children and young people, there is still limited evidence in relation to pain experiences for children with physical disabilities. This group of children are likely to experience 'total bodily pain' resulting from the consequence of their delayed development, in addition to numerous therapeutic/medical procedures they regularly undergo.

Method: The purpose of this systematic literature review is to summarise what is currently known about children with physical disabilities, specifically those with cerebral palsy, muscular dystrophy and spina bifida, and the impact chronic pain has upon their quality of life. Due to the paucity of literature within this area, the review compared the evidence with those children with unspecified chronic pain and the impact it has upon their childhood occupations.

Findings: Several themes emerged from the review. These findings suggest there are significant differences with how children with physical disabilities perceive the severity of their pain, and the coping mechanisms they adopt, compared to that of their typically developing peers. There were apparent differences in how chronic pain was perceived by families/ carers who believed it had a significant impact upon their wellbeing, as well as gender differences in pain experiences.

Conclusion: The existing literature clearly indicates that many young people with physical disabilities regularly experience chronic pain but are still able to engage in meaningful activities. The evidence suggests that they develop a strong sense of identity, with pain not impeding upon their life. These children are more readily able to adapt to the effects of their disability and, therefore, are able to accept that their pain has become a part of their lives. However, clinicians and carers cannot be complacent that pain will not have a significant impact for these children due to their inherent coping skills, and must utilise their expertise in appropriately assessing and supporting the effects that pain may present. The literature indicates that occupational therapists have a role in supporting children and their families to adapt to the impact chronic pain has upon their lives, by empowering young people to take control of their health through health education promotion to encourage active participation, equality, and to create meaning in their lives through the occupations in which they engage to restore health and wellbeing (Hocking 2001). If the appropriate interventions are not managed successfully, it is likely to have dire effects as these children transition into adulthood. [Author abstract]

Emily Barry (1) and Richard Gibbens (2)

(1) Occupational Therapist, Chorley and West Lancashire Memory Assessment Service, Beechurst Unit, Chorley and South Ribble District General Hospital, Chorley, Lancashire.

(2) Senior Lecturer in Occupational Therapy, University of Cumbria, Lancaster.

Corresponding author: Emily Barry, Occupational Therapist, Chorley and West Lancashire Memory Assessment Service, Beechurst Unit, Chorley and South Ribble District General Hospital, Preston Road, Chorley, Lancashire PR7 1PP. Email: emily.barry@lancashirecare.nhs.uk

Reference: Barry E, Gibbens R (2011) Spirituality in practice: using personal reflection to prepare occupational therapy students. British Journal of Occupational Therapy, 74(4), 176-180.

DOI: 10.4276/03080221 1X13021048723219

Submitted: 29 May 2009.

Accepted: 18 October 2010.
... a universal quality of human beings and their cultures related
   to the quest for meaning, purpose, morality, transcendence,
   well-being, and profound relationships with ourselves, others, and
   ultimate reality (p5).

Table 1. Participants' statements about anticipated benefits of
the reflection on their practice, grouped into themes

Theme                                                   n      %

Increased awareness of the client's spiritual need      6      50

Better awareness of considerations when addressing
spiritual needs                                         5      42

Increased understanding of own spirituality             4      33

Aware of need to assist clients to develop an
awareness of their spirituality                         2      17

Greater openness to the idea of addressing
client's spirituality                                   1       8

Amount of benefit reduced due to large workload
on course                                               1       8
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