Spiritual wellbeing, Attitude toward Spiritual Care and its Relationship with Spiritual Care Competence among Critical Care Nurses.

INTRODUCTION: Nurses' spiritual wellbeing and their attitude toward spirituality and competence of nurses in providing of spiritual care can affect the quality of care in nursing. The aim of this study was to evaluate spiritual wellbeing, attitude toward spiritual care and its relationship with the spiritual care competence among nurses.
METHODS: This was a correlational descriptive study conducted on 109 nurses working in the Intensive Care Units of Imam Reza and Madani hospitals in 2015, Tabriz, Iran. Data collection tools were a demographic data form and three standard questionnaires including Spiritual Wellbeing Scale, Spirituality and Spiritual
Results: The mean score of the spiritual wellbeing was 94.45 (14.84), the spiritual care perspective was 58.77 (8.67), and the spiritual care competence was 98.51 (15.44). The linear regression model showed 0.42 variance between the spiritual care competence scores which were explained by the two aspects of spiritual wellbeing (religious health, existential health) and three aspects of spiritual care perspective (spirituality, spiritual care, personalized care). The spiritual care competence had a positive relationship with spiritual wellbeing and spiritual care perspective.
CONCLUSION: Because of the nature of nursing and importance of close interaction of nurses with patients in ICUs, the higher nurses' SW and the more their positive attitude toward spiritual care, the more they can provide spiritual care to their patients.

Introduction

World Health Organization (WHO) points out to the physical, psychological, social, and spiritual aspects as the main aspects of human existence which are closely involved in the development of human beings.[1]

Spirituality is the essence of human existence which includes immaterial aspects of human life and is experienced through the relationship of human’s life with God, him or herself, others and nature.[2] Spirituality and three other aspects are very

important for understanding the beliefs, attitudes, and healthy behaviors, especially in vulnerable people.[3]

The spiritual wellbeing is one of the most important factors in human health and healthy lifestyle. It provides a coordinated and integrated connection between the internal forces. It is identified with features of stability in life, peace, harmony, and coordination, feeling close relationship with himself, God, society, and the environment.[4,5] It can also lead to the happiness and a meaningful life and provides energy to a sustain life.[6] When spiritual wellbeing is endangered in an individual, he or she will suffer from severe mental disorders such as loneliness, depression, and loss of meaning in life.[7,8]

Studies have shown that without SW, other biological, psychological, and social aspects of an individual cannot have a proper performance.[9] People with high spiritual wellbeing have a holistic approach to life and they deal with the issues around them with an open mind, and are more flexible.[10] Moreover, spirituality and spiritual wellbeing provide important information about the health care needs, the ability of people to cope with spiritual stresses, and necessary interventions for adaptation and coping with the crises of health care.[2] Health care workers, especially nurses, are subject to such crises.[1] Paying more attention to the subject of spirituality and the factors influencing the spiritual care in the nursing profession increases the chance of improving the quality of health care in the health centers.[11] Addressing the spiritual wellbeing is an essential component of holistic nursing care; and most of nursing patterns emphasize the importance of spirituality.[12]

Positive attitude toward spiritual care can increase the satisfaction of patients and nurses, nurses with high levels of spiritual wellbeing have a positive attitude toward spiritual care; and usually use the spirituality in their care plan to the patients.[13]For holistic care, it is required to combine or integrate the spiritual care with nursing care. To provide better care services to the clients, while preserving the human and moral dignity, paying more attention to the spiritual aspect, as an important aspect of health with a significant impact on human health, is necessary which requires care competence.[14]In addition to the skills needed for nursing care, competence and skills acquisition in the field of spiritual care also seems necessary.[12] Competence, as a complex concept, is one of the most controversial topics in the field of health care and it is also important in different fields of nursing. Competence is a set of attributes that are the basis for optimal performance.[14]

Spiritual issues play an important role in the quality of life and the process of patients’ compliance, especially those with severe and life-threatening diseases.[15,16]

Therefore, taking care of the spiritual and emotional needs of patients can generally be considered as a component of quality care which demands the special attention of nurses.[17]One of the most sensitive units of hospitals is Intensive Care Unit (ICU). Due to the complex and critical situation of patients in these units, caring behaviors are of great importance. Because of involvement in tension and crisis and being exposed to more stressors in the workplace, nurses working in the ICUs have lower life satisfaction than their counterparts working in general units, various aspects of their health are at risk, and they face numerous problems.[18]The study conducted by Suhonen et al., showed that the critical situation of patients is the most important factor influencing the health of nurses.[19]

Despite such problems, nurses of these units should have clinical skills and special personality traits for providing spiritual care as well as having sufficient knowledge in caring the patients. In addition, they should have sufficient incentive to provide such cares to perform the holistic care.[20]

Despite the importance of spiritual care in the intensive care units and the role of spiritual wellbeing and nurses’ attitudes toward spiritual aspects of care in effective provision of health care, limited research has been conducted in this area, and most studies have been done on patients.

Therefore, the aim of this study was to determine the spiritual wellbeing status of nurses working in ICU, their attitude toward spirituality and spiritual care and its relationship with the spiritual care competence.

Materials and methods

This is a correlational descriptive study conducted in 2015 on the nurses working in CCU and ICUs of Shahid Madani and Imam Reza Hospitals, affiliated to Tabriz University of Medical Sciences, Tabriz, Iran. Shahid Madani Hospital is the only specialty and subspecialty hospital for Cardio-Care Unit and Imam Reza Hospital is the largest domestic specialty and subspecialty center for medical surgical in Tabriz. These two centers provide services to patients residing in Tabriz as well as to all patients referred from northwestern region of Iran.

Therefore, these two centers were selected as the research environment. The main inclusion criteria included nurses having at least a bachelor's degree and at least 1 year work experience in ICUs and the main exclusion criteria included passing the formal spiritual care training courses. A total of 114 out of 145 nurses were included in the study using census method. Of nurses participating in the study, 5 participants refused to participate in the study because of failure to fill out the data collection tools completely. Finally, 109 nurses filled out social and demographic form as well as the 3 questionnaires of spiritual wellbeing, Spirituality and spiritual care rating scale and spiritual care competence (The study population participation rate = 78.6%). The Statistical Package for the Social Sciences (SPSS) version 13 was used for data analyses using descriptive (Percent, mean, and standard deviation) and inferential (Linear regression and Pearson’s correlation coefficient) statistics methods. Multiple linear regressions (Enter method) were used to determine predictors of the spiritual care competence. The P value less than 0.05 was considered as meaningful. All main variables include spiritual wellbeing, attitude to spirituality and spiritual care, spiritual care competence and their subscales were normally distributed (K-S P>0.05). Multiple liner regression analyses by enter method were conducted to assess the importance of demographic information and spiritual wellbeing, attitude to spirituality and spiritual care in relation to spiritual care competence. For ease of interpretation and to reduce the amount of analyses conducted, the relationship between spiritual care competences, attitude to spirituality and spiritual care, spiritual wellbeing variables and demographic information were examined using independent t-test, bivariate Pearson’s product moment correlation (r), ANOVA test depending on if the data were categorical or continuous. These analyses were used as a basis of entry into the regression analyses. Then spiritual wellbeing, attitude to spirituality and spiritual care and their subscales were entered into the equation model after demographic information to control for their effect at every stage to detect any significant associations (e.g. reductions in beta values).

Data collection tools included 1 demographic form (developed by the researchers), and 3 questionnaires including spiritual wellbeing, Spirituality and Spiritual Care Rating Scale and Spiritual Care Competence. The demographic characteristics included questions about nurse's age, gender, educational level and marital status, and employment status, work experience in nursing, work experience in ICU, financial status, and health status. Paloutzian and Ellison’s spiritual wellbeing questionnaire consists of 20 items; 10 questions of which evaluate the religious health and another 10 questions evaluate existential health.

The total score is obtained through summing up the scores. Questions were answered based on 6-item Likert scale: completely agree to completely disagree.

When the nature of the question is positive, the answer “completely disagree” is scored 1 and the answer “completely agree” is scored 6. Therefore, the range of spiritual wellbeing scores was assessable between 20 and 120, and the SW in religious and existential dimensions was also assessed between 10 and 60. The spiritual wellbeing was also classified into three levels of low (scores between 20 and 40), moderate (scores between 41 and 99), and high (scores between 100 and 120).

This questionnaire has been used in various studies inside and outside the country; and its validity and reliability have been confirmed. For example, it has been validated by Ellison and Paloutzian; and Cronbach's alpha coefficient for religious and existential health and the total scales has been reported to be equal to 0.91, 0.91 and 0.93, respectively.[21]Allah Bakhshiyan et al., and Rezai et al., reported the alpha coefficient as equal to 0.82 using Persian version of the tool. The validity of this questionnaire was studied and confirmed by the content validity.[22,23]

Spirituality and Spiritual Care Rating Scale introduced by Mc Sherry includes 17 questions in four subscales of spirituality, spiritual care, religiosity and Personalized Care, the five-item Likert scale was used for scoring (1 = strongly disagree, 2 = disagree, 3 = I am not sure, 4 = agree, 5 = strongly agree).[24] The highest score was 85 and the minimum score was 17. Four items in the questionnaire were reversed–score item. Mazaheri et al., confirmed the validity of the Persian version of this questionnaire through content validity and determined its reliability through Cronbach's alpha coefficient as 0.85.[25]

The Spiritual Care Competence Scale, introduced by the Van Leeuwen & Cusveller was also used in this study. This scale consists of 6 dimension of assessment and implementation of spiritual care, professionalization and improving quality of spiritual care, personal support and patient counseling, referral to professionals, attitude toward patients’ spirituality, and communication. The answers were ranked based on a 5-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = neither agree nor disagree, 4 = agree, 5 = strongly agree). The total score of this scale is between 27 and 135. The scores of 27 to 62 indicate low intellectual competence, 63 to 98 moderate competence, and the scores higher than 98 indicates a high spiritual competence.[26]Nasehi et al., confirmed the validity of the Persian version of this questionnaire through content validity and the reliability of this scale was determined through the Cronbach's alpha of 0.78.[27]In this study, the tools were translated and culturally adapted using the method of Wilde et al.[28]

To determine the validity, content validity and face validity were used while applying CVI and CVR indices. In this phase, the tools were submitted to the 10 academic members of Medical Sciences Department of Nursing faculty, specialized in the research methodology and instrument development, to examine and confirm the questions of the tools in terms of simplicity, clarity, and relevance. After their review, necessary amendments were performed in the phrases of the data collection tools. To evaluate the reliability of the tools, the internal consistency reliability method was used. Cronbach's alpha coefficient for the spiritual wellbeing, spirituality and spiritual care perspective scale, and spiritual care competence questionnaires were calculated as 0.90, 0.78 and 0.92, respectively.

Results

The mean age of the participants was 36.36 years (SD=6.85) and most of the nurses were female (83.5%). The majority of the nurses were married (80.7%). Most of the participants had a Bachelor’s degree (95.4 %) and only 4.6 % of them had MSc degree. The mean length of clinical experience in the intensive care units was 8.93 years (SD= 4.97). More than half of the participants were alliance employment (63.3%) and 30.3 % of them were official employment. Nearly half of the nurses had a good health status (47.7%) and 37.6% of them had a moderate health status.

By analyzing the results of spiritual wellbeing, a possible total score of 120, 94.45 (SD=14.84) was observed. Also a possible total score of 85 for attitude to spirituality and spiritual care, the mean of 58.77 (SD=8.67) was obtained. Furthermore, for Spiritual Care Competence with a possible total score of 135, the mean of 98.51 (SD=15.44) was observed. In addition, the mean of subscales of spiritual wellbeing, attitude toward spirituality and spiritual care and Spiritual Care Competence are summarized in Table 1.

Table 1

Spiritual wellbeing, attitude to spirituality and spiritual care and spiritual care competence of participants

Variables	Mean (SD)
Spiritual wellbeing	94.45 (14.84)
religious	51.71 (6.61)
existential	42.74 (9.69)
Attitude to spirituality and spiritual care	58.77 (8.67)
Spirituality	23.54(4.38)
Spiritual care	18.37 (3.59)
Religiosity	10.43 (1.77)
Personalized care	6.42 (1.62)
Spiritual Care Competence	98.51 (15.44)
Attitude towards patient’s spirituality	16.85(2.36)
Communication	8.20 (1.39)
Assessment and implementation of spiritual care	21.75 (4.36)
Referral to professionals	10.32 (2.25)
Personal support and patient counseling	20.66 (4.52)
Professionalization and improving quality of spiritual care	20.71 (4.56)

Results of correlation analyses with multiple linear regressions show that only SW and its subscales (religious and existential), attitude to spirituality and spiritual care and three subscales of this (spirituality, spiritual care and religiosity) correlate with spiritual care competence. All significant and none significant relationships with spiritual care competence are displayed in Table 2.

Table 2

Pearson’s correlations between SW, attitude to spirituality and spiritual care and their subscaleswithspiritual care competence

Spiritual Care Competence	Spiritual wellbeing	Religious	Existential	Attitude to spirituality and spiritual care	Spirituality	Spiritual care	Religiosity subscale	Personalized care
Correlation coefficient(r)	0.51*	0.45*	0.47*	0.47*	0.47*	0.44*	0.16	0.08
P	0.00	0.00	0.00	0.00	0.00	0.00	0.04	0.19

* Correlation is significant at the 0.01 level

The final regression model demonstrated that the independent variables (predictors) of religious, existential, spirituality, spiritual care and personalized care could explain the variations of dependent variable (spiritual care competence) among the nurses. These variables were accounted for 0.42% of changes in variance of spiritual care competence (adjusted R square=0.422; F=14.15; P=0.00). Predictors of spiritual care competence in participants are shown in Table 3.

Table 3

Predictors of spiritual care competence among participants

Predictors	B	SE B	b	T	Sig	95% Confidence Interval for B		Adj.R 2
						Lower	Upper
Constant	20.19	11.24		1.79	0.07	-2.11	42.50
Religious	0.46	0.23	0.19	2.02	0.04	0.01	0.92
Existential	0.41	0.15	0.26	2.62	0.01	0.10	0.73
Spirituality	1.23	0.34	0.35	3.59	0.001	0.55	1.91
Spiritual care	0.81	0.40	0.18	2.00	0.04	0.01	1.61
Religiosity	0.45	0.70	0.05	0.65	0.51	-0.93	1.85
Personalized care	-1.90	0.80	-0.20	-2.36	0.02	-3.50	-0.30	0.42

Discussion

The findings revealed that there was a positive and significant correlation between the spiritual wellbeing and attitude toward spirituality with the spiritual care competence in critical care nurses. This findings is consistent with the results of Zare and Jahandideh which indicated a significant relationship between spirituality and spiritual care.[29]Also this finding is consistent with Fai Chan who claimed that there is a positive correlation between spiritual care perception and spiritual care practice among nurses, which means that the greater the nurse's spiritual care perceptions, the more frequently spiritual care is included in that nurse's practice, this correlation is vital and meaningful; it can drive hospitals to promote nurses' awareness of spiritual care to improve the quality of their spiritual care practice.[30] In the study conducted by Stranahan on nursing students, a positive and significant correlation between spiritual understanding, attitude toward spiritual care and providing spiritual care was found which is in line with the results of the present study.[31] The study conducted by Hamid and Dehghaninejad also showed that the nurses’ spiritual wellbeing was related to the quality of their performance in providing patient care and their attitudes toward spiritual care. A positive attitude to spirituality and spiritual care among nurses can significantly predict job performance of nurses.[32] Also, Khorrami Markany et al., showed that nurses with high spiritual wellbeing had positive attitude toward spiritual care.[1] In another study conducted in 2009 by Dunn et al., significant positive correlation were found between spiritual perspective and spiritual wellbeing as well as religious and existential wellbeing, but religious attendance was more significantly correlated with spiritual perspective from than existential wellbeing.[33] The consistency of our findings with other studies in the cultural context of different religions may indicate that the spirituality is a global issue and practicing spiritual recommendations in all religions shall provide the basis for human development.

The results indicate that the nurses’ attitude toward spirituality and spiritual care influences the providing spiritual care.

Spiritual care attitude is rooted in the faith and spiritual beliefs, under which the nurses consider spiritual care as a professional responsibility which must be accompanied by sacrificing themselves for patients.[34]According to this professional responsibility, the first step in increasing awareness and sensitivity to the spiritual needs of patients is that the nurses reach peace, spiritual wellbeing and positive attitude.[35] Mc Sherry believes that spirituality and spiritual wellbeing of nurses affect their personal and professional lives and promote their ability to participate in holistic nursing as a result of the spiritual development.[35] If nurses neglect their spiritual wellbeing, they encounter some problems in identifying spiritual needs of patients and then providing spiritual care to them.[36]

Our results showed desirable level of SW among the nurses working in ICUs which is consistent with the findings of the studies of Asaroudi et al., on the nurses, Allahbakhshiyan et al., on M.S. patients and Rezai et al., on the patients with cancer.[36,22,23] Allahbakhshiyan et al., showed that the score of existential health was higher than that of religious health, which was not consistent with the results of the present study, the reason of which could be the difference between the research communities of the two studies. And other reason is that during the treatment periods the patient may have emotional distress, anxiety, helplessness, hopelessness, and fear of death all detract from spiritual wellbeing specially in religious domain and some of the patients might be unable to perform religious practices.[7]In a study conducted by Hsiao et al., the SW of nursing students was reported to be suitable.[37]

This finding was in agreement with Cetinkaya et al., results, in which the spirituality and spiritual care rating scale point average for nurses was determined to be 62.43 (7.54), it might be that nurses do not receive any training on the spiritual care, before and after graduation.[38] In the study of Li-Fen et al., they reported that participants who had taken spirituality or spiritual care courses had an interest in nursing and had a significantly better spirituality knowledge and spiritual care attitudes than other participants.[39]In another study conducted by Mazaheri et al., the results showed a high level of nurses' attitude. However, their study was conducted on the psychiatric nurses.[25]In explaining the better condition of psychiatric nurses’ attitude toward spiritual care, compared with other nurses, Mack and Schmidt argued that psychiatric nurses more tend to evaluate the spiritual needs of patients, compared with other nurses as they have more time and are accustomed to advising patients.[6] Finding suggest that nurses have diverse understanding of spirituality and the majority consider spirituality to be an integral and fundamental element of the nurses’ role.[40]

Moreover, our findings showed that the nurses have appropriate level of competence to provide spiritual care.

According to the American Association of College of Nursing (AACN), one of the responsibility of nursing education is to prepare nurses to identify spiritual distress and to provide spiritual care.[41] Ross et al., concluded that students who participated in an extensive program of spirituality and spiritual care had more competence to provide spiritual care compared with other students; and they had a high level of spiritual wellbeing and more positive attitudes toward spirituality.[42]

Unfortunately, some researches shows that many nurses in the work place feel that they inadequately prepared to provide spiritual care due to various reasons, including lack of education on spiritual care, lack of inter-professional education, work overload, lack of time, different cultures, ethical issues and unwillingness to deliver spiritual care.[41]In this study spiritual care competency in critical care nurses is good, especially in the subscale of assessment and implementation in spiritual care 21.75 ( 4.36). The critical care unit is most vulnerable because the intensity of illness, creating an environment of compassion.[44] where patients feel that their emotional and spiritual needs are met, is the heart of holistic care Critical care nurses’ experiences of providing spiritual care emerged as integral and inseparable behaviors imbedded in the everyday nursing care of others, also critical care nurses experienced heightened awareness and responsiveness to patients and family spiritual needs during life threatening situation.[44]

There was no significant relationship between demographic variables such as age, sex, marital status, work experience, and financial condition with spiritual wellbeing, competence to provide spiritual care, and attitude to spirituality and spiritual care. This finding was consistent with the findings of the Allahbakhshiyan et al., Mazaheri et al, Bussing et al.[22,25,45]In contrast, Rezai et al., and Rowe & Allen showed that increasing age increases spiritual wellbeing level in patients suffering from cancer.[23,46]Therefore, further studies are needed on this topic.

Like other studies in Iran, in present study also the majority of the nurses believed about the spirituality and spiritual care, regardless of the different demographic and occupational environment.[47,48] This can be attributed to the significant importance of spiritual life in all aspects of life in the Islam. This means that spirituality has been considered more prominent and beyond the influence of each specific contextual variable. Another finding of this study is the nurses' attitude toward spirituality and spiritual care which is in agreement with other studies. The nurses participated in the present study had quite similar attitude toward spirituality and spiritual care as their counterparts from other races and religions. This indicates that spirituality is beyond color, race and geographical boundaries, and it unifies the individuals with other people, the world around them and God.[49]

As emphasized in the literature, it is expectable that nurses who have high perception of spirituality and spiritual care is as a result of their spiritual sensitivity and competency to providing spiritual care.[28,29] High spiritual wellbeing in the nurses affects their attitude toward spirituality and promotes their ability to provide spiritual care.[33] In a study, it was found that nurses’ spiritual wellbeing and their positive attitude toward spirituality promote spiritual care competence.[35]

By acknowledging the importance of spiritual care education, it might be possible to increase the efficiency of the assessment process by employing measures to facilitate the application of the nursing process to spiritual care. In addition, relevant training courses should be provided for nurses to enable them to learn the necessary skills for providing spiritual care. As it is repeatedly recommended to provide spiritual care training courses in the universities, it is necessary to provide appropriate educational content and learning environment for this purpose. It is suggested that spirituality, spiritual wellbeing and spiritual care to be included in nursing educational curriculum. To facilitate collaboration between nurses and clergy and promotion of spiritual wellbeing, it might be beneficial for nurses to communicate more with the clergy, include profile discussion and treat clergy as members of the health care team. Educating nurses in matters concerning spirituality seems to be a perpetual theme and source of contention. Despite a great deal awareness rising, nurses still report feeling inadequately prepared to meet patients' spiritual needs. Paying more attention to the nurses’ spiritual wellbeing and the approaches to promote spiritual health is of prime importance.

The main limitation of this research was the small sample size. Furthermore, this study used a self-report questionnaire to collect data, which may have caused possible response bias from each responder, for example, respondents may give socially acceptable answers.

Conclusion

The research finding suggests that nurses’ spiritual wellbeing were desirable. Nurses’ perception of spirituality and spiritual care were moderate and favorable and they have appropriate level of competency to provide spiritual care. Also a significant correlation was found between spiritual wellbeing and attitude toward spirituality and spiritual care with spiritual care competence in the nurses and the most predictors of spiritual care competence among nurses were subscales of spiritual wellbeing (religious and existential) and three subscale of attitude toward spirituality and spiritual care (spirituality, spiritual care, personalized care). Because of the nature of the nursing and importance of close interaction of nurses with patients in ICUs, the higher nurses’ SW and the more their positive attitude toward spirituality and spiritual care, the more they can provide spiritual care to their patients.

Acknowledgments

The authors would like to thank the nurses who volunteered to participate in this study. Thanks for authorities of Imam Reza and Shahid Madani Hospitals who participated in this study. Also, we would like to thanks the Research Vice-chancellor of Tabriz University of Medical Sciences who funded this study (Grant No. : 93,115).

Ethical issues

There was no ethical issue.

Conflict of interest

The authors declare no conflict of interest in this study‏.