Health Care Providers' Perception of Their Competence in Providing Spiritual Care for Patients

INTRODUCTION

The spiritual dimension of humans has a multidimensional and complex nature with cognitive, emotional, and behavioral aspects. The cognitive or philosophical dimension includes meaning and having a purpose in life. The emotional dimension of spirituality mixes with individual hope, love and dependence, internal peace, comfort, support, and experiences. Behavioral aspects include inner spirituality and personal beliefs that are spliced with the outside world. In fact, spiritual care manifests in caring and nurturing in the spirit of individual such that attention to physical, intellectual, emotional, and spiritual dimensions is highly important to keep health and promote spiritual care.[1]

The terms spirituality and religion are used interchangeably, but they have different meanings for most individuals. While religion is considered as a particular set of beliefs in an organized group, spirituality is considered a personal feeling of peace, purpose, relation with others, and beliefs about life.[2] Spirituality is beyond colors, features, and geographical borders, and unifies the person with other people around the world and with God.[3] Religion is a bridge for spirituality such that religion contributes to a meaningful feeling of spirituality by encouraging people to use thought methods, feelings, and behaviors.[4] Spirituality is the nature of humans that gives meaning to life and accompanies people in their life journey. Developing spiritual relationships with the infinite power gives individuals the confidence that a strong power always supports them. These individuals deal with accidents calmly by relying on their faith and belief and suffer less from stress and anxiety. Therefore, their expectation of the future is more optimistic.

Spirituality increases the coping ability of an individual against diseases and improves the speed of recovery.[5] Nurses should think about providing spiritual care to patients. Although spiritual dimensions have considerable effects on different aspects of human life and providing spiritual care is one of the duties of nurses, it is not fully considered.[6]

Understanding this dimension of patients is very important for nurses since nursing is a profession which looks at all dimensions of the patient,[7] and spiritual care is an indispensable part and the core of holistic care. The holistic view requires that nurses consider individuals as biological, psychological, and social creatures with a core (of spirituality). Therefore, nurses are expected to accept the spiritual care of patients and establish appropriate relationships with patients.[8]

Competence is defined as a set of traits and characteristics which form the basis for optimal performance.[9] The dimensions of competence relate to knowledge, skill, attitude, communication, management, motivation, education, culture, ethics, spirituality, research and information technology, and working with devices.[10] The competence of a nurse is effective in guaranteeing the quality of care services provided for patients and their satisfaction, and a key factor in the competition intense world for the survival of hospitals.[11] Spiritual care is a set of skills used in the professional field or nursing process which include therapeutic relationships between the nurse and patients, being accessible for patients, active listening, showing empathy, providing religious facilities for patients with certain religious beliefs, helping patients, etc.[12] Spiritual competence in spiritual care refers to a set of skills which are used in the clinical nursing processes.[13] If nurses become aware of their spiritual condition, they will be aware of the spiritual state of their patients.[14] This awareness and spirituality in nurses is a prerequisite for creating commitment in the spiritual care process.[15] In fact, for communicating patients with tension, nurses should become aware of their spiritual life. According to the standards, nurses should have the required skills for meeting the spiritual needs of patients.[16]

Although nurses are aware of the importance of spiritual care, studies show that it is not adequately provided.[171819] Based on different studies, there is a close relationship between nurses' internal spirituality and attention and the tendency for providing spiritual care. This means that the higher the internal spirituality of a nurse, the more spiritual care he or she will provide for patients.[7]

Because spiritual care needs understanding the spiritual ideas of patients and recognizing their intellectual needs, it is expected that nurses develop their knowledge and understanding in this regard.[19] To provide complete and suitable services for patients by preserving human and ethical virtues, it is necessary to consider spiritual dimension as an important dimension which has a significant influence on individual health.[2021] The nurses' perception of spirituality can directly influence how they behave, deal with their patients, and communicate with them in providing spiritual care. The importance of nurses' abilities to understand their own perception of spirituality before assessing the spiritual needs of others has to be stressed.[22]

Literature reviews and other studies revealed some common backgrounds about spiritual care. First, nurses believe that spiritual care is a part of their role, but most of them are confused about how to include it in clinical practice. Second, nurses in all levels of clinical work feel that they are not ready for spiritual care. Third, spiritual care may be defined in different ways and nurses should have their specific definition for providing acceptable care.[23] Studies have shown that spiritual care-a central element of holistic and multidisciplinary care-is not often included in practice.[24] Since we live in a country in which we believe in a supreme being and worship God, our nurses should have a higher understanding of their competence for presenting spiritual care, as spiritual care needs competence in nursing.

SUBJECTS AND METHODS

A cross-sectional descriptive design was utilized. The study population was all nurses who were working as a nurse or a nursing manager in one of the medical-educational centers of Tabriz University of Medical Sciences (head nurse, supervisor, and director of nursing care) and had study criteria (at least 1 year work experience and university degree). To determine sample size, Morgan table was used (considering 95% and error 5%). Sample consisted of 555 nurses in hospitals related of Tabriz University of Medical Sciences. Multistage random sampling was used, and the suitable assignment was used for allocation to wards. Therefore, after selecting hospital, samples were chosen randomly considering number of nursing staff in different wards of hospitals. To gather data, first, researcher submitted her request from research deputy to related hospitals. Then, researcher referred to selected wards and after explaining the purpose and delivered questionnaires to nurses in there different shifts to complete. Researcher returned 1 week later to take back questionnaires. Data were entered into SPSS software version 13 (SPSS Inc., Chicago, IL, USA) and were analyzed. To gather data from demographic questionnaire and spiritual care competence scale (SCCS) were used which designed by van Leeuwen et al.[14] Back translation to Persian was performed by two English language experts. Then Persian version was retranslated into English. Content validity of Persian version was done by experts' opinion such that the scale was delivered to ten faculty members of nursing to study questions regarding ease, being clear and relevant. Cronbach alpha was used for reliability of scale, and its coefficient was 0.93. Reliability and validity were measured by Khalaj et al. in 2013, and Cronbach alpha of questionnaire was 0.77 and for subscales was 0.65–0.85.[3] This scale has 27 questions with 5 point Likert scale (1 – strongly disagree, 2 – disagree, 3 – neutral, 4 – agree, 5 – strongly agree) which is divided to 6 categories individual support and consultation with patient (6 questions 1–6), being professional and improving quality of spiritual care (6 questions, 7–12), attitude toward religious states (4 questions, 13–16), communication (2 questions, 17–18), evaluating and implementing spiritual care (6 questions, 19–24) and referral to experts (3 questions, 25–27). The statistical analysis was performed using SPSS software version 13. The data were analyzed using descriptive statistics (frequency, percent, mean, and standard deviation [SD]) and inferential statistics (independent t-test, one-way ANOVA test, Pearson, and Spearman correlation tests). In all statistical tests, the significance level (P < 0.05) was considered.[25] Before implementing the study, proposal was approved by the ethics committee of Tabriz University of Medical Sciences. Required information and rights of participants were given to research units and confidentiality of responses was emphasized.

RESULTS

Demographic characteristics of participants are expressed. Furthermore, results showed that there was significant difference score of nurses' understanding from their competence in spiritual care in hiring and workshop (P < 0.05) and in other cases (gender, marital status, shift, income, and position), there was no significant difference (P > 0.05).

Based on the findings, mean ± SD conception of nurses from their competence in provision spiritual care was 95.2 ± 14.5. Questionnaire has minimum 27 score and maximum 135 score such that below 64 is low spiritual competence, 64–98 indicates average spiritual care, and above 98 shows high spiritual competence [Table 1].

Table 1 Comparing mean scores of nurses' perception from their competence in providing spiritual care in term of demographic characteristics

Results of the study for each category in competence questionnaire for spiritual care was significantly higher than average. Individual support, professionalism, evaluating, and implementing spiritual care categories includes 6 questions in 5 point Likert scale from 1 to 5; therefore, their score range was between 6 and 30 with mean 18. Attitude toward religious states category has 4 questions ranging 4–20 with mean 12. Communication field category with score 2–10 has mean 6. Referral to expert ranges was 3–15 with mean 9 [Table 2].

Table 2 Responses of nurses to different spiritual care competence (one sample t-test)

DISCUSSION

Providing spiritual care for patients is influenced by personal, cultural, and educational factors.[26] Moreover, those who provide spiritual care should have spiritual and ethical competence. The findings of this study showed that the scores for nurses' spiritual care competence were between 38 and 135, with a mean of 95.2 ± 14.5, which indicates that the perception of nurses of providing spiritual care for patients is average. Most nurses who participated in this study gained an average score. In another study, the mean spiritual care competence of nurses was 97.5 ± 13.6 which is consistent with our study.[8] Of course, these results are expected for our society which has religious and spiritual values. However, there is a need for promoting spirituality in nurses. On the other hand, religious attitudes in Iran may be effective on responses to the questions of the scale, and individuals might be evaluated themselves in higher level. The results of the present study showed that the mean score for each category of the SCCS was higher than average. The highest score was related to religious state of the patient which indicated that nurses respect the beliefs of patients even if their beliefs were different from theirs. The lowest score was observed for the referral category, and most nurses stated that they did not have the required knowledge. The communication score was 7.8 (1.4), and most nurses stated that their shifts were busy and they did not have enough time for establishing relationships with patients. A study conducted by Pesut on freshman and senior nursing students showed that communication has the most important role in providing spiritual care.[15] Most nurses state that they focus on physical care. Narayanasamy and Wen (2001) considered the causes of this inattention to be the vague role of spirituality in nursing, the nonscientific nature of spirituality, environmental factors, and lack of suitable relationships between patients and nurses.[27] Although studies on the perception of nurses of their competence in providing spiritual care for patients are very limited, several studies have been conducted on other aspects of spiritual care. Sabsevari et al. showed that the students' competence of spiritual care was higher than that of nurses, which may be caused by the higher knowledge of students compared to nurses regarding spiritual care. On the other hand, nursing students did not have to deal with issues such as work pressure, lack of time, and routine programs.[8] Wong et al. studied the perception of 429 Chinese nurses in relation with spiritual care for patients and reported that nurses have a positive perception of spiritual care. They concluded that religious beliefs and education of nurses promote their perception of spirituality and spiritual care.[28] Azarsa et al. stated that there is a relationship between nurses' spirituality and their performance in providing spiritual care.[29] It seems that there is a relationship between spiritual care and performance and competence, and further research is recommended in this regard. In studying the relation between scores of spiritual care competence and individual characteristics of nurses, a significant difference was observed in hiring type and participation in ethics workshops which are consistent with the results of Sabzevari et al.[7] Participating in ethics workshops and receiving education on the concept of spirituality and becoming aware of others' views about spirituality helps nurses to achieve a higher level of spiritual perception, improve their attitude toward spirituality and spiritual care, develop their skills in recognizing patients' spiritual needs, and providing spiritual care.[8] In addition, in Iran's health system, nurses with the employment status of plan are newly graduated nurses with little work experience. Sufficient work experience seems to increase maturity both for critically evaluating one's own nursing philosophy and providing expert care.[30]

Although differences were observed in the scores of spiritual care competence regarding the level of education and work shifts of nurses, they were not significant based on the t-test. Regarding the relation between participation in ethics workshops and spiritual care competence, it is suggested that nursing management provides conditions for the participation of nurses in educational courses including continuous education, workshops, and conferences for spiritual care.

CONCLUSION

According to the findings, although the spiritual care competence of nurses is average, promoting and increasing the spiritual capacity and spiritual care competence in education and training of nurses are useful tactics which must be considered by nursing curriculum designers.