Competence in providing spiritual care and its relationship with spiritual well-being among Iranian nurses.

BACKGROUND: Competence in providing spiritual care to patients has become an increasingly important aspect of nursing care delivery. However, studies on nurses' competence in spiritual care delivery and the factors affecting it are very limited. The present study was conducted to evaluate Iranian nurses' competence in providing spiritual care and its relationship with their Spiritual Well-Being.
MATERIALS AND METHODS: The present study is descriptive-analytical research conducted in Bam in the south of Iran between 2016 and 2017. All nurses working in the teaching hospitals affiliated with Bam University of Medical Sciences were invited to participate in the study. For data collection, the Spiritual Care Competence Scale (SCCS) and the Spiritual Well-Being Scale (SWBS) were used. Collected data were then analyzed using descriptive statistics (mean and standard deviation), Pearson correlation coefficient, independent t-test, and one-way ANOVA with SPSS software.
RESULTS: In this study, 158 nurses were participated. The result showed that the mean score SCCS and SWBS were 101 ± 12.6, 76.92 ± 13.4, respectively. Pearson correlation test showed a significant and direct relationship between the mean score of SCCS and SWBS (P = 0.001, r = 0.264). The results of this test also showed a significant relationship between all the dimensions of SCCS and SWBS (P < 0.05).
CONCLUSIONS: In this study, the nurses had a relatively appropriate competence in providing spiritual care to patients. There was also a significant relationship between the nurses' spiritual care competency and their spiritual well-being. Given the lack of adequate studies in spiritual care delivery competencies, it is recommended that similar studies are conducted among nurses in other parts of the country and worldwide. Copyright:

Introduction

Efficient and effective nursing care involves the provision of physiological, psychological, cultural, social, developmental, and spiritual needs of patients.[1] However, among these aspects of nursing care, spiritual care has received little attention.[23] The neglect of spiritual care can be traced back to the 18th and 19th centuries when the biomedical model, based on the positivist injury paradigm, was dominant in science and medicine.[2] However, in recent years, more attention has been paid to the spiritual care needs of patients.[4] Spiritual care is defined as activities and procedures that promote the quality of spiritual life, spiritual well-being and spiritual functioning of patients.[2] Several bodies of evidence suggest that spiritual well-being can help improve the recovery of patients.[4] Sabzevari et al. believe that spiritual care results in an increase in patients’ adherence to the care plan and health promotion behaviors, and can also decrease psychological distress and social isolation during illness.[5]

For effective and efficient delivery of patient care, it is essential that nurses be competent in all aspects of healthcare.[5] Even though little attention is paid to the spiritual needs of patients in most healthcare systems, provision of spiritual care to patients has been found to have a positive effect on patients’ recovery. Thus, it essential that nurses be also competent in spiritual care to safely and effectively promote the health of patients.[2] In Iran, the dominant religion is Islam, and from the viewpoint of this religion, paying attention to the spiritual needs of individuals is necessary. Nurses’ competence in providing spiritual care has gained the attention of researchers in Iran and worldwide over the past few years. Previous studies on nurses’ competencies in providing spiritual care in Iran have yielded contradictory results. In one study conducted in Iran, Adib-Hajbaghery reported that Iranian nurses felt unqualified to provide spiritual care to patients.[2] Furthermore, Zakaria reported that Iranian nurses were unable to recognize patients’ spiritual needs due to inadequate training during their education, and were not qualified to provide spiritual care.[6] Contrary to these findings, Sabzevari et al. reported that the Iranian nurses were competent in providing spiritual care to patients.[5]

Achievement of the desired quality of care and patients’ satisfaction are important aspects of healthcare delivery.[7] Moreover, the quality of nursing care plays a major role in healthcare delivery. In recent years, researchers have focused on the role of spiritual wellbeing in nurses and its impact on the quality of nursing care.[8] Two dimensions of spiritual well-being have been defined; religious well-being and existential well-being. In religious wellbeing, an individual perceives a personal satisfaction due to having a relationship with superior power. Existential well-being is achieved when an individual attempts to understand the meaning and purpose in life. Individuals with a holistic approach to life usually have high spiritual well-being and are more flexible. They usually deal with the problems around them with an open mind.[91011] Many studies have suggested that higher spiritual well-being in nurses can improve the quality of nursing care.[8] For instance, Mehdipoorkorani et al. reported that high level of spiritual well-being among nurses working in the oncology ward significantly correlated with increased quality of care provided to their patients.[12]

Based on the results of previous studies that indicated a relationship between nurses’ spiritual wellbeing and the quality of nursing care, it can be hypothesized that nurses’ spiritual well-being may also be related to their competence in providing spiritual care to patients. Therefore, the present study was conducted with the aim of evaluating Iranian nurses’ competence in providing spiritual care and its relationship with their spiritual well-being.

Materials and Methods

Study design and setting

The present study is a descriptive-analytical research project conducted in 2016–2017 on nurses working in teaching hospitals affiliated with Bam University of Medical Sciences.

Study participants and sampling

The study population consisted of all nurses with undergraduate or higher degrees working in these hospitals. Sampling was carried out using the convenience sampling method in the wards where the nurses work.

For sampling, after the necessary coordination with the management of the various hospitals, the list of nurses working in each hospital was obtained.

Nurses who were absent on the days in which sampling was carried out for any reason, including maternity leave, were excluded from the list. After coordinating with the head nurses, questionnaires were distributed among the nurses in the wards. This was done in two morning and evening shifts. The completed questionnaires were collected from the nurses at the end of each shift at the wards by the researchers.

Data collection tool and technique

For data collection, a researcher-made checklist for demographic variables and two standard questionnaires Spiritual Care Competence Scale (SCCS) and Spiritual Well-Being Scale were used. The checklist for demographic variables included items about nurses’ age, gender, hospital ward, working experience, and marital status. To study nurses’ competence in providing spiritual care, the SCCS developed by van Leeuwen and Cusveller in 2004 was used. This scale is comprised 6 dimensions (including assessment and implementation of spiritual care, professional development and improving the quality of spiritual care, personal support and patient counseling, referral to professionals, communication, and attitude toward patients’ spirituality) and 27 items that are answered on a 5-point Likert scale (1–5) ranging from strongly agree to strongly disagree. The overall score of this scale is between 27 and 135.[13] This scale had desirable psychometric properties when used in an Iranian population.[14]

The tool used in this study to examine nurses’ spiritual well-being was the Palutzian and Ellison Spiritual Wellbeing Scale.[15] This scale consists of 20 items, which assesses one's spiritual wellbeing in two distinct dimensions (existential and religious well-being). Each dimension consists of 10 items, and each item is scored on a 6-point Likert scale (1–6) ranging from completely disagree to completely agree. The total score of the items in each dimension (existential and religious well-being dimensions) is between 10 and 60. Thus, the total score of the spiritual well-being scale ranges from 20 to 120. The spiritual well-being score is divided into three categories; low (20–40), moderate (41–99), and high (100–120). The validity and reliability of this tool have been examined in previous studies in Iran. This scale has been demonstrated to have desirable psychometric properties.[16]

Ethical consideration

The present study was a research project conducted under the supervision of the University of Social Welfare and Rehabilitation Sciences (USWR). The study was approved by the Committee for Ethics in Biomedical Research in USWR. Measures were taken to ensure the confidentiality of the participants’ identification and the information obtained. Nurses were informed that participation in the study is voluntary and that refusing to participate would not have any effect on their working conditions or employment status. According to the ethics protocol of USWR, all nurses who participated in the study were asked to sign informed consent forms before completing the questionnaires.

Data analysis

The data were analyzed using SPSS statistical software version 18 (SPSS Inc., Chicago, Illinois, USA);using descriptive statistics (mean, variance, standard deviation) and inferential statistics including Pearson correlation test and independent t-test. To determine the relationship between the mean score of competence in providing spiritual care and emotional intelligence, the Pearson correlation test was performed. P value less than 0.05 was considered statistically significant.

Results

In this study, 158 nurses working in hospitals affiliated with the Bam University of Medical Sciences completed the questionnaires. The majority of participants were female and married. The mean age of the participants was 29.9 ± 5.6, with the age range of 21–46. The number of years of working experience was between 1 and 23 years with a mean of 7.5 ± 5.2 years.

Competence in providing spiritual care

The mean score of the nurses’ spiritual care competency was 101.6 ± 12 (ranging from 72 to 133). The mean scores of the nurses’ spiritual care competencies for the different dimensions of the SCCS were as follows: a mean score of 22.9 for the nurses’ competence in the assessment and implementation of spiritual care, 22.4 for professional development and improving the quality of spiritual care, 22.3 for personal support and patient counseling, 11.1 for referral to professionals, 15.1 for communication, and 7.2 for attitude toward patients’ spirituality. The mean score of spiritual care competency among the male and female nurses was 99.7 ± 16.4 and 101.2 ± 11.9, respectively. The difference between the mean score of spiritual care competency among the male and female nurses was statistically significant (P = 0.007). The Pearson correlation test showed no significant relationship between the mean score of the nurses’ spiritual care competency and their number of years of working experience or age (P > 0.05).

Spiritual well-being

The mean score of spiritual well-being among the nurses who participated in this study was 76.9. The mean scores for the different dimensions of spiritual well-being were 38.3 for existential well-being and 38.6 for religious well-being. Independent t-test analysis showed no significant difference between the mean score of spiritual well-being in the male and female nurses (P = 0.1). Pearson correlation test revealed a significant and direct correlation between the total score of the nurses’ spiritual well-being and their age (P = 0.005, rr = 0.9), but there was no significant correlation between the nurses’ age and the mean spiritual well-being score (P = 0.07).

The relationship between competence in providing spiritual care and Spiritual wellbeing

To examine the relationship between spiritual care competency and spiritual well-being, the Pearson correlation test was performed. The correlation analysis showed a direct and significant relationship between the mean score of the nurses’ spiritual care competency and the mean score of their spiritual well-being (P = 0.001, rr = 0.264). Furthermore, there was a direct and significant relationship between the mean score of the nurses’ spiritual care competency and the mean score of their religious well-being (P = 0.005, rr = 223) and existential wellbeing (P = 0.001, rr = 0.272). Table 1 illustrates this in more detail.

Table 1

Relationship between competence in providing spiritual care and spiritual well-being

Variables	Assessment and implementation of spiritual care	Professional development and improving the quality of spiritual care	Personal support and patient counseling	Referral to professionals	Attitude toward patients’ spirituality dimensions	Communication	Spiritual care competence total score
Religious well-being
rr	0.109	0.213	0.225	0.078	0.157	0.331	0.223
P	0.173	0.007	0.005	0.33	0.049	0.001	0.005
Existential well-being
rr	0.169	0.267	0.225	0.163	0.259	0.214	0.272
P	0.03	0.001	0.005	0.04	0.001	0.007	<0.001
Spiritual well-being
rr	0.147	0.255	0.240	0.127	0.219	0.296	0.264
P	0.06	0.001	0.002	0.11	0.006	<0.001	0.001

Discussion

To provide spiritual care to patients, nurses must have the necessary competencies required for delivering spiritual needs to patients.[17] The results of most previous studies on nurses’ competence in providing spiritual care are similar to the findings of the present study, however, few studies have reported different findings. In one study in Saudi Arabia in 2018, Alshehry examined nurses’ competencies in providing spiritual care to patients. They evaluated the spiritual care competency of 302 nurses using the same tool as in the present study. Similar to the results of the present study, the authors reported that the nurses were competent in providing spiritual care to their patients.[3] In another study, Abell et al. examined the competencies of a group of American nurses in providing spiritual care to patients. In their study, the SCCS was used to evaluate the nurses’ spiritual care competency. Similar to the results of the present study, the nurses reported a desirable level of competence in providing spiritual care.[18] In one study conducted in 2014 in Iran, Adib-Hajbaghery et al. examined the competence of 239 nurses in providing spiritual care to patients. The results of this study, contrary to the results of the present study and those of the above-mentioned studies, indicate that most of the nurses had moderate and sometimes inadequate competence in providing spiritual care.[2] The difference between the results of our study and that of Adib-Hajbaghery et al. can be attributed to two factors. First, different tools were used for the evaluation of spiritual care competency between the two studies. In the present study, SCCS was used to evaluate the nurses’ competencies in providing spiritual care, whereas in Adib-Hajbaghery et al. study, a researcher-made questionnaire was used. Furthermore, over the past few years, there has been increasing attention to holistic nursing care, and it has been recommended by many studies that nursing educators incorporate holistic care to nursing students’ curriculum and training programs for nurses in Iran.

This might have increased the awareness of spiritual care. In the second part of the study, the relationship between the nurses’ spiritual care competency and the level of their spiritual wellbeing was investigated. Nurses who reported a higher level of spiritual wellbeing felt more competent in providing spiritual care compared with the nurses who reported low level of spiritual wellbeing. We performed a literature search to find studies that examined the relationship between spiritual care competency and spiritual wellbeing among nurses in Iran. Three related studies were retrieved, and the results of all three studies are in line with the results of the present study. In one study, Zare and Jahandideh examined the relationship between spiritual care competency and spiritual well-being among 180 nurses working in the intensive care units. The tools used in their study were similar to the tools used in the present study.[9] Similar to the results of our study, they reported that nurses with higher spiritual wellbeing felt more competent in providing spiritual care. In another study, Ebrahimi et al. investigated these two concepts among 555 nurses. The results of their study are also consistent with our study. The authors indicated that nurses who reported a high level of spiritual care competency had higher spiritual well-being.[19] A similar finding was also reported by Azarsa et al.[20]

Being a spiritual person is usually the first step towards developing the competency required for providing spiritual needs for others. It seems that nurses who are aware of spirituality are better able to recognize the need to provide spiritual care for patients. A spiritual nurse brings his/her knowledge and experience of spirituality to the healthcare center and helps meet part of the patient's spiritual needs. In this regard, nurses can use their own life experiences or their experiences with other patients to help promote the health of patients. Those nurses are able to provide spiritual care that values this concept, and are educated about it and have confidence on their ability to provide such care.[7]

Limitations

In the present study, the self-report method was used to investigate the nurses’ Spiritual Well-Being and competence in providing spiritual care. For further participation and accuracy in response, the objectives of the research explained to participants. Furthermore, participants have enough time to response to questionnaires items. In addition, participants ensured that data remained confidential in all stages of the study.

Conclusions

Providing spiritual care to patients is highly important because holistic nursing care would be incomplete without considering the spiritual needs of the patients. In the present study, the Iranian nurses had a relatively desirable competence in providing spiritual care. Moreover, the nurses’ spiritual care competency was directly and significantly related to their spiritual well-being, such that nurses with higher level of spiritual well-being reported a higher level of competence in providing spiritual care. It seems that the spiritual well-being of nurses has a positive effect on the spiritual care they deliver to patients. Given the lack of adequate studies in spiritual care delivery competencies, it is recommended that similar studies be conducted among nurses worldwide. Furthermore, it is recommended that nurses’ spiritual care competencies be evaluated using methods other than self-report studies, and to investigate its relationship with spiritual wellbeing.

Ethics approval and consent to participate

This study was approved by the ethics committee of the University of Social Welfare and Rehabilitation Sciences, Tehran, Iran (REC/P-1395.1101). The written informed consent was obtained from the participants.

Financial support and sponsorship

University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.

Conflicts of interest

There are no conflicts of interest.