Explaining the Relationship between Moral Intelligence and Professional Self-Concept with the Competency of Nursing students in Providing Spiritual Care to Promote Nursing Education.

BACKGROUND AND AIM: Several factors are involved in obtaining the competence of providing spiritual care in nursing students. The purpose of this study was to explain the relationship between moral intelligence and the professional self-concept with the competency of the nursing students in providing spiritual care to promote nursing education.
MATERIALS AND METHODS: The present study was descriptive-analytics and the participants were the 7th and 8th semester nursing students of the processing district 6 of the medical sciences universities. The data were collected using questionnaires "Nursing student competencies for providing spiritual care," "Nursing professional self-concept" and "Moral intelligence" questionnaire and analysed using correlation and regression tests.
RESULTS: The results showed that there is a significant relationship between the moral intelligence and the students competency in providing spiritual care (r = 0.24, P < 0.001), while this relationship was not significant for the professional self-concept (r = 0.045). Furthermore, based on the results of multiple regression analysis, the moral intelligence (B = 0.28, P = 0.001), gender (B = -4.23, P = 0.048), place of living (B = 10.59, P = 0.046), and adherence to religion (B = -11.82, P = 0.002) were the predictors of students' competency in providing the spiritual care.
CONCLUSION: According to the results of this study, it is suggested that by applying strategies to strengthen the moral intelligence of the students, such as holding-related workshops as well as reinforcing religiosity, the student's competency in providing the spiritual care to the patients is reinforced. Copyright:

Introduction

Addressing the dimension of spirituality in the field of health has important effects for humans, including the healing effect, the prevention of diseases, the increase of tolerance to diseases, and the rapid recovery of the patient.[123] Studies have shown that at the time of illness, a person is more interested in the spiritual and the religious matters and requires care from the healthcare providers.[4] Since spiritual care is the essence of nursing, nursing theories emphasize on holistic care of the patient.[5] Therefore, spiritual care is a part of nursing holistic care that the clinical nurses should provide such care to the patients admitted to the hospitals and the health centres.[36]

The word “competency” is considered as a complex and multidimensional concept in the field of the healthcare system.[5] Competency is a set of the attributes and the characteristics that are the basis of the desirable performance of the person and deserve for him/her. Competence in spiritual care is referred to as a set of the actions and skills that are used by nurses in the clinical nursing process.[7] On the other hand, the professional self-concept is influential on the way of thinking and evolving the role, behavior, and professional performance of the individual.[8] The professional self-concept means the perception of the individual of himself/herself as a professional person and has a positive relationship with the job satisfaction and adaptability and is effective on the employee perceptions of his/her job and the ability to success.[9] The nurses' self-concept includes the information and the beliefs that they have about their role, values and behaviors,[10] and they need to have a high self-concept to be able to perform their duties.[11] Furthermore, according to the results of the conducted studies, nurses with higher professional self-concept have more responsibility to the patients and their outcomes.[91213] Certainly, the intelligence and moral each alone affect different aspects of human life and determine and stabilize their position in society. The moral intelligence is a new concept that has been popularized in the psychology and management research texts in recent years; it means attention to the human life and nature, the economic and social well-being, and the free and honest communication and the citizenship rights.[14] By using the moral intelligence, human being approaches to learn intelligent works and access to the most suitable action and in every part of life has access to the best information, minimizes the risks, and hence that people with high moral intelligence do the right thing.[15] It describes the moral intelligence as “the capacity and ability to distinguish right from wrong one, to have strong moral beliefs and to act toward them, and to behave in the right and proper direction,” and believes that the four principles of moral intelligence include: Integrity (that is, the creation of a harmony between what we believe in and what we act on. Doing what we know that is right and telling the truth at all times), responsibility (it means that a person has a high moral intelligence, accepts responsibility for his or her actions and its consequences, as well as mistakes and failures), compassion (that is, paying attention to others that have an interactive effect) and forgiveness (that is, the awareness of the imperfections and mistakes of oneself and others, and to forgive oneself and others), all of them are necessary for the continuous organizational and personal success.[1617] The role of the moral intelligence and its importance in styling and improving the interpersonal and social relationships, especially in the occupations related to the field of medicine and nursing, which directly deal with individuals and their lives, are of high prominence.[18] The nursing students who work in clinical education environments, in addition to the technical competencies, must have the appropriate mental and emotional characteristics and have optimum moral values.[19] The results of a study by Parandavar et al. showed that nurses obtained 48.8 ± 0.33 score for professional self-concept of 8 and 4.08 ± 0.08 score for the professional ethics out of 5.[20]

One of the important goals of nursing is to maintain and promote health and prevent diseases. Providing spiritual care is one of the important ways to achieve this. Considering that the nursing students as future nurses of the health system are required to acquire the competence to provide the spiritual care during their studies to be able to provide the comprehensive care with an emphasis on the aspects of the spiritual care, the need for conducting the research on explaining the relationships between the moral intelligence and the professional self-concept with the competence of providing spiritual care by nursing students, is felt.

Materials and Methods

The present study was a cross-sectional descriptive-analytic study, and the research population included all undergraduate nursing students from Alborz, Qazvin, Zanjan, Saveh, Arak, Khomein, and Qom Universities of Medical Sciences. The students of 7th and 8th semesters of these universities were research sample. The sample size was determined 400 persons by the opinion of the statistician and by using the sample size determination formula and census sampling was performed. Of the 400 distributed questionnaires, 312 questionnaires were completed and delivered. The criteria for entering the study included the willingness to participate in the study, Iranian citizenship, not participating in workshops related to the moral intelligence, the professional self-concept, and the competence of providing spiritual care, and the criteria for exclusion of the study were refusal to continue the study and incomplete completion of the questionnaire. The data collection instruments were three questionnaires: “Nursing student competencies for providing spiritual care,” “Nursing professional self-concept,” and “Moral intelligence.” Questionnaire “Nursing undergraduate Competencies for Spiritual Care” was the main version of the questionnaire for Van Leeuwen et al.[21] The questionnaire consists of six dimensions related to nursing competence in providing spiritual care as follows: evaluation and implementation of spiritual care, professionalism and improvement of spiritual care, personal support and counselling with the patient, referral to specialists, and attitude toward religious spirituality of the patient and the communication. The competency level of the nurse in providing spiritual care was measured based on the Likert scale (very high = 5, very low = 1). The highest total score of this questionnaire is 135 and the lowest score is 27. In this research, the scores of 100–135 were considered high and favorable, the scores of 64–99 moderate and somewhat favorable and the levels of 27–63 were considered as low and undesirable levels of spiritual care. Validity and reliability of the questionnaire were evaluated by Khalaj et al. in undergraduate nursing students. The results of this study showed that exploratory factor analysis explains six factors with 63.18% variance for the questionnaire. The confirmatory factor analysis also confirmed these six factors. Cornbrash's alpha coefficient for the total tool was calculated, and it was 0.77.[22] Cowin professional self-concept of the nurse questionnaire contains 36 questions and evaluates nurses' professional self-concept in six dimensions of general nursing self-concept (self-confidence), care, knowledge, interaction with colleagues, communication, and leadership (each dimensions includes six items). The items were placed in the subscale as follow: care 1, 20, 23, 29, 31, 34, communications 7, 13, 26, 30, 36, knowledge 4, 10, 14, 19, 25, 35, leadership 5, 8, 17, 22, 28, 33, interaction with colleagues 2, 11, 15, 24, 32, 9-general self-concept of nurses 3, 6, 12, 16, 18, 27. The scale of the questionnaire was based on the 6-point Likert Scale and the total score was calculated with the sum of the value of all items. The range of scores obtainable for the whole self-concept questionnaire was 36–216 and for each dimension was 6–36. The higher the level, the more a person has a positive self-concept. In Iran, this questionnaire was translated in the research by Bedieh Payma et al. for the first time, and its validity and reliability were evaluated. The results of factor analysis by using the principal components method and using the Euqamax rotation showed that this questionnaire has six factors including nursing self-esteem, communication, leadership, knowledge, care, and interaction with colleagues, and these factors explain >76.6% the total variance. To determine the reliability of the questionnaire, internal consistency, and split-half methods were used. The reliability of the tool showed that Spearman Brown's correlation coefficient and Cronbach's alpha were 0.84 and 0.97, respectively.[12] To measure moral intelligence, “moral intelligence” self-assessment questionnaire of Lennick and Kiel were used. This questionnaire measures spiritual intelligence with 40 phrases in four main dimensions, including integrity, responsibility, forgiveness, and compassion. The subjects determine the rate of their agree or disagree about the phrases test by 5-points Likert scale as never, rarely, sometimes, often, and always (1–5). To obtain the total score of the test, the scores of all phrases were summed. The person's moral intelligence score is obtained from the sum of four dimensions divided by 2, and the lowest and the highest score of the questionnaire is 20 and 100. In the ranking of the scores, the 90–100 scores were evaluated as excellent, the scores of 80–89 as very good, the scores of 79–70 as good and 69 and less as weak. This method of ranking was suggested by Lennick and Kiel. Alavi et al. have estimated the reliability of the Persian version of this scale using the Cranach's alpha coefficient of 0.88. The face validity was confirmed after some changes to some questionnaire questions. The results of factor analysis in this study showed that all questions were loaded in one factor. Therefore, a total score for each subject was calculated and the subscales were eliminated.[23] To conduct the research, the questions were sent via E-mail to the deans of the Nursing and Midwifery Faculties of the processing district 6 of the country, including the universities of medical sciences of Alborz, Qazvin, Zanjan, Saveh, Arak, Khomein, and Qom. In this way, questionnaires were provided to nursing students at the universities of processing district. The questionnaires were completed by self-report and then sent to the research implementer by mail.

This paper follows the research project approved by the Vice Chancellor for Research of Qom University of Medical Sciences with the Code of Ethics Committee IR.MUQ.REC.1396.65. Researchers observed ethical considerations at all stages of the research so that the participation in this study was optional, the confidentiality principle was met, and the participants were assured that they could withdraw from the study at any time. Data were analysed using SPSS software version 21 of Company IBM in the United States and descriptive statistics (mean and standard deviation) and inferential tests (correlation, t-test, ANOVA, and multiple regressions).

Results

The participants included 312 undergraduate nursing students at 7th and 8th semesters with mean age of 23.51 ± 11.67 years, of whom 188 (60.3) were female and 115 (36.9) were male. About 92.3% of the participants were Shiite, 3.2% said they used cigarette, and 86.9% of the participants estimated their financial status as medium. Table 1 shows the frequency of demographic variables and their relationship with students' competencies in providing spiritual care. The level of competency of male students in providing spiritual care is significantly higher than that of the female students (P = 0.032).

Table 1

The frequency of demographic variables and their relationship with students’ competencies in providing spiritual care

Items	n (%)	Mean±SD/r*	P
Gender
Female	188 (60.3)	85.10±18.68	0.032*
Male	115 (36.9)	89.84±17.98
Accommodation
City	290 (92.9)	87.21±18.54	0.103*
Village	12 (3.8)	78.33±15.07
Educational term
7	178 (57.1)	85.98±17.74	0.58*
8	105 (33.7)	87.73±18.36
Economic status
Low	17 (5.4)	80.00±17.22	0.41**
Moderate	205 (65.7)	85.91±17.69
Good	14 (4.5)	85.78±16.82
Religious adherence
Low	26 (8.3)	78.03±19.08	<0.001**
Moderate	178 (57.1)	84.93±16.93
High	100 (32.1)	92.87±19.86
Age	-	−0.06	0.28***

*t-test. **ANOVA. ***Spearman correlation. SD=Standard deviation

The results of the correlation test showed that there is a significant relationship between moral intelligence and students' competency in providing spiritual care (r = 0.24, P < 0.001), while this relationship was not significant for professional self-concept (r = 0.045, P = 0.42).

The variables which had significant level of <0.2 in univariate test were included in the multiple linear regression model. Table 2 shows the results of multiple linear regression tests aimed at identifying the students' competency predictors in providing spiritual care. Based on the results of this test, moral intelligence (B = 0.28, P = 0.001), gender (B = −4.23, P = 0.048), accommodation (B = 10.59, P = 0.046) and religious adherence (B = −11.82, P = 0.002) were the competency predictors of the students in providing the spiritual care. Hence, higher moral intelligence was associated with higher competency in providing spiritual and the competency in providing spiritual care among men and residents of the city as well as those with a better economic status was more.

Table 2

Factors related to the level of competence of providing spiritual care using multiple linear regression models

Variable	Class	β (SE)	P
Self-concept		0.031 (0.022)	0.18
Moral intelligence		0.28 (0.086)	0.001
Gender	Female	−4.23 (2.15)	0.048
	Male	Reference
Accommodation	City	10.59 (5.30)	0.046
	Village	Reference
Religious adherence	Low	−11.82 (3.91)	0.002
	Medium	−7.46 (2.26)	0.001
	High	Reference

SE=Standard Error

To investigate the relationship between professional self-concept and moral intelligence as well as the demographic variables with competency of the students in providing spiritual care, the professional self-concept sub-scales were introduced into the regression model and the results of which are presented in Table 3. The scope of general self-concept of the students of the professional self-concept questionnaire (B = 0.63, P = 0.017), gender (B = −4.90, P = 0.024), and adherence to religion (B = −11.21, P = 0.004), were competency predictors of the students in providing spiritual care. As it can be seen, the scores in the general self-concept of the nurses, male gender, and adherence to religious principles are significantly competency predictors of the students in providing spiritual care.

Table 3

The relationship between the professional self-concept and the moral intelligence fields and the demographic variables with the competency level in providing the spiritual care using the multiple linear regression model

Variable	Class	β (SE)	P
Professional self-concept of the nurse in the field of the care	-	−0.031 (0.44)	0.94
Professional self-concept of the nurse in the field of the communication	-	0.47 (0.43)	0.27
Professional self-concept of the nurse in the field of the knowledge	-	−0.38 (0.44)	0.38
Professional self-concept of the nurse in the field of the leadership	-	0.36 (0.30)	0.23
Professional self-concept of the nurse in the field the interaction with colleagues	-	−0.16 (0.44)	0.70
Professional self-concept of the nurse in the field of the general self-concept of the nurses	-	0.63 (0.22)	0.017
Moral intelligence in the field of the integrity	-	0.29 (0.20)	0.16
Moral intelligence in the field of the responsibility	-	−0.39 (0.28)	0.18
Moral intelligence in the field of the forgiveness	-	0.76 (0.32)	0.051
Moral intelligence in the field of compassion	-	−0.15 (0.45)	0.73
Gender	Female	−4.90 (2.17)	0.024
	Male	Reference
Accommodation	City	8.41 (5.34)	0.11
	Village	Reference
Religious adherence	Low	−11.21 (3.93)	0.004
	Medium	−6.84 (2.26)	0.003
	High	Reference

SE=Standard error

Discussion

The results of this study showed that there is a significant relationship between moral intelligence and the competency of the nursing students in providing spiritual care, while this relationship was not significant in the case of professional self-concept. Furthermore, based on the results of multiple linear regression analysis of moral intelligence, male gender, accommodation, and adherence to religion were the competency predictors of the students in providing the spiritual care.

Studies have shown that the person pays more attention to his/her spiritual dimension at the time of illness and the hospitalization and requires the provision of spiritual care by the nurses.[2224] Since the care is essence of the nursing and the nursing theories emphasize on the holistic care of the patient.[23] therefore, spiritual care is a part of the holistic nursing care. This type of care should be provided by the nurses and the nursing students to the patients. In the nursing college curriculum, the nursing students need to be thought biological, psychological, social, and spiritual nursing, but the content of spiritual care allocates the least amount of teaching to itself.[4] Having the higher moral intelligence can play an important role in providing holistic care, especially spirituality and spiritual care in nursing students. Studies have shown that the nursing students have a high degree of the moral intelligence.[1925]

According to the results of this study, the male gender, accommodation, and adherence to religion were among the predictors of the student's competency in providing spiritual care. Male students had more competencies to provide spiritual care than the female students.

On the other hand, according to the results of this study, the scores were more in the general self-concept of the nurses, in this regard the results of the study by Parandavar et al. which examined the relationship between professional self-concept of the nurses and the professional moral in the hospitals affiliated to Jahrom University of Medical Sciences showed that there is a significant relationship between the professional moral and the professional self-concept.[20] Rafati et al. also showed that the status of the moral intelligence of the medical students of medical universities of Tehran is not favorable and there is also a positive and significant relationship between the ages, the education level with the moral intelligence.[15]

The results of the study by Golestan et al. which evaluated the level of the professional self-concept among the nurses working in the intensive care unit showed that although the nurses working in the intensive care unit received a relatively high score of professional self-concept, it seems that the obtained mean is far away from the optimum level. The nurses also obtained the lowest score from the general nursing self-concept (self-esteem) dimension, which indicates the weakness of nurses in this field. Therefore, the need for training and preparation of the nurses to have higher professional self-concept and increase self-esteem is felt.[8]

Since the sample of this study was 7th and 8th semester students, one of the limitations of this study was the difficulty access to these students due to their presence in the clinic, which prolonged the time of the study. It is suggested that a similar study be conducted with the participation of students at different semesters. Considering that the moral intelligence, male gender, accommodation, and religious adherence are important predictors of competency in providing spiritual care for students, it is suggested that the comprehensive curricula be designed to enhance these components and these components are considered in nursing education curriculums.

Conclusion

Moral intelligence is an important component in creating the competency and the quality for providing spiritual care by the students. Regarding the relationship between the moral intelligence and the competence of nurses in providing spiritual care, holding classrooms, and workshops with the aim of enhancing the students' ethical intelligence and increasing the competence of nurses in providing the best spiritual care is essential. Furthermore, addressing the religious issues and strengthening religiosity can enhance the competency of the students in providing the spiritual care to patients.

Financial support and sponsorship

Funding of this investigation was provided by Qom University of Medical Sciences, Qom, Iran.

Conflicts of interest

There are no conflicts of interest.