Abstract
Background:
Daily spiritual experiences and spiritual care competence have positive health effects on patients and form an integral part of the nursing profession. This study was conducted to determine the relationship between daily spiritual experiences and the dimensions of spiritual care competence in nursing students.
Materials and Methods:
This cross-sectional study was conducted on 401 nursing students in their last year of the program. The participants were selected from nursing schools in Tehran Province, Iran, in the academic year 2019–2020. The required data were extracted using a demographic information questionnaire, the Daily Spiritual Experiences Scale (DSES), and the Spiritual Care Competence Scale (SCCS). The collected data were analyzed in SPSS software at the significance level of 0.05.
Results:
The mean (SD) of daily spiritual experiences and total spiritual care competence was 67.15 (16.33) and 101.77 (16.26), respectively. The personal support and patient counseling dimensions had the highest mean (SD) [22.10) 4.80)]. Among all these dimensions of spiritual care competence, only professionalization and improvement of the quality of spiritual care were predictors of the students’ daily spiritual experiences (p < 0.05).
Conclusions:
The professionalization dimension of spiritual care competence was identified as a predictor of daily spiritual experience in nursing students. Therefore, the researchers recommend the highlighting of this dimension in nursing programs to promote the students’ spiritual care competence.
Keywords: Clinical competency, nursing students, spirituality
Introduction
Health has generally been studied and analyzed within physical, psychological, and social dimensions over the last decades, but the care delivery systems in place have only emphasized its physical dimension. Spiritual health has recently been proposed as a new dimension of health that is as important as its other dimensions.[1] Spiritual health can be defined as a coherent dimension in the well-being and health of every individual.[2] Spirituality is a key concept that can offer coping and problem-solving strategies.[3]
Daily spiritual experiences are among the dimensions of the concept of spirituality that have been the focus of much research.[4] These experiences include finding meaning in life and understanding this meaning, acquiring positive experiences, feeling happy and content, and being satisfied with life.[5] Spiritual experiences can play a prominent role in people’s health and might have positive psychological outcomes and lead to spiritual well-being.[6] They can make people feel calm, have love and affection for themselves and other human beings, and continue to live in full harmony with their surroundings.[7]
Spiritual experiences have recently become part of the healthcare system as a tribute to the spiritual dimension of patients[8] and to ensure the provision of holistic care to patients, which should include spiritual care.[9] Spiritual care consists of activities needed to overcome doubt, anxiety, crisis, and loss in patients, and thus, improve coping with any health crisis.[10] It is a unique part of nursing care that cannot be replaced by any type of psychological, social, or religious care. Therefore, it is of paramount importance in professional nursing.[11] Spiritual care involves paying attention to the patients’ beliefs, respecting their privacy and confidentiality, and expressing enthusiasm, empathy, and kindness when communicating and interacting with the patients,[12] facilitating and providing religious support to the patients, and talking to the patients about God, and encouraging them to express their emotions.[13,14]
Given the importance of spirituality in holistic nursing care,[15] nurses are morally and professionally obliged to provide spiritual care to their patients.[16] In this respect, they should be competent enough before they can begin to provide this type of care. Professional competence is essential for the members of healthcare teams, especially nurses, to provide effective care. Providing spiritual care, which entails paying attention to the patients’ spiritual needs, can lower anxiety, increase hopefulness and peace,[17] accelerate the recovery process and progression to health, and decrease the duration of hospitalization and treatment.[18] Therefore, care providers need competence in this area. Competence consists of basic features that can lead to optimal performance and is a key factor in nursing areas such as education, clinical practice, and management.[19] Spiritual care competence refers to a set of skills used in a profession or process, such as clinical nursing. This type of care includes nurses’ knowledge, attitude, skills, and capabilities for evaluating and implementing interventions to care for patients’ spiritual needs.[20]
Nurses’ lack of spiritual care competence could result in incorrect assessments of patients’ real needs,[21] and this competence is a prerequisite for spiritual care provision.[22] Research has shown that nurses’ spiritual care competencies are poorly developed and poorly prepared for this role.[14,23] Nursing students are expected to enter a real clinical setting after their graduation and communicate directly with the patients as nursing specialists. One of their expected tasks is to provide spiritual care to patients.[24] The achievement of this competence requires developing various skills and gathering experience.[25] Although spirituality, especially spiritual care, has been the subject of intense research in recent years, nursing students’ daily spiritual experiences and spiritual care competence in Iran are less-explored topics. Thus, the present study was conducted with the aim to determine the relationship between daily spiritual experiences and the dimensions of spiritual care competence in nursing students: The dimension of professionalization and improvement of the quality of spiritual care given the particular religious context of Iran, the results might prove helpful to some other societies.
Materials and Methods
This cross-sectional research was conducted using regression analysis. The research setting consisted of nursing schools, and the statistical population included all the nursing students in some medical universities in Tehran Province (Iran) in 2019–2020.
With a Confidence Interval (CI) of 95% and test power of 80%, and considering the results of a similar study, the sample size was estimated to be 405 individuals. In the mentioned study, the correlation between the variables in Iran was found to be r = 0.19.[26] In this study, the data from four electronic questionnaire submissions were irretrievable, and the analysis was finally performed on 401 samples. Senior undergraduate nursing students undergoing field training (seventh and eighth semesters of the program) at the nursing schools of three medical universities in Tehran Province completed the uploaded electronic questionnaires.
Due to the ongoing COVID-19 pandemic at the time of conducting this research and the impossibility of in-person sampling, a link to the questionnaire (in Google Forms) was provided to the students through a student representative. Convenience sampling was used to select the samples in this study. First, the research objectives were explained to the candidates. The informed consent form designed for this research was attached to the electronic questionnaire, and the candidates could access the questionnaire items once they approved the content of this form. The questionnaire items were designed so that access to each item was enabled once the participant had responded to the former item.
The inclusion criteria consisted of being a seventh or eighth semester nursing student and undergoing field training. The exclusion criteria were being a guest or a transfer student from other universities. This requirement was ensured by the first item of the questionnaire to prevent guest students from filling out the questionnaire. Data were extracted using a demographic information questionnaire, the Daily Spiritual Experience Scale (DSES), and the Spiritual Care Competence Scale (SCCS).
The demographic information questionnaire contained questions regarding age, gender, marital status, self-reported religious adherence (based on a five-point Likert scale), and religion.
Underwood (2002) designed the DSES to measure students’ spiritual experiences. The DSES is designed to examine the individual’s perceptions of a superior power (i.e., God) in their daily lives and their perceived interactions with this power as spiritual experiences and as a key part of their daily lives. This scale evaluates concepts such as presence, connection, joy when connecting, strength in religiousness/spirituality, comfort in religiousness/spirituality, deep inner peace, God’s help, guided by God, love through others, direct love, touched by beauty, thankful for blessings, selfless caring, acceptance of others, and desire to be in union and close.[27] The questionnaire items are scored based on a Likert scale ranging from 6 to 1 [most of the time during the day (6), every day (5), most days (4), some days (3), occasionally (2), and almost never or never (1)]. The DSES has 16 items, with the higher scores indicating more spiritual experiences. The validity and reliability of the DSES were confirmed in several studies in the USA with a Cronbach’s alpha of 0.9[27] and in Iran with the Cronbach’s alpha of 0.90.[27] Moreover, the Kaiser–Meyer–Olkin (KMO) measure was 0.89, indicating sample adequacy. In this study, the identity covariance matrix was rejected based on the result of Bartlett’s test (approx. Chi-square = 2807.2; p < 0.001), which approved the evidence of the factorability of the scale. Findings of the Exploratory Factor Analysis (EFA) revealed a single factor that explained 59% of the total scale variance.[28] In the present study, the reliability of the questionnaire was evaluated through internal consistency, and Cronbach’s alpha for the entire questionnaire was reported to be 0.89, suggesting its good reliability.
The SCCS was developed in 2009. With 27 items and six dimensions to assess nurses’ competence in providing spiritual care. The dimensions of “assessment and implementation of spiritual care” (items 1–6) and “professionalization and improvement of the quality of spiritual care” (items 7–12) examine nurses’ activities for ensuring the quality of care and the development of spiritual care policies. The dimensions of “personal support and patient counseling” (items 13–18) and “referral to professionals” (items 19–21) examine cooperation with other healthcare providers. These dimensions mainly focus on religious counseling with a religious counselor. The dimension of “attitude toward the patient’s spirituality” (items 22–25) classifies personal factors related to spiritual care provision. The “communication” dimension (items 26–27) is related to nurse–patient communication. These items are scored based on a five-point Likert scale ranging from 1 to 5 [completely disagree (1), disagree (2), neither agree nor disagree (3), agree (4), and fully agree (5)]. The total SCCS score ranges between 27 and 135. Higher scores on the scale indicate higher competence in providing spiritual care as a nurse.
The validity and reliability of the SCCS have been confirmed in a study in South Korea with a Cronbach’s alpha of 0.95. Furthermore, the construct validity of the K-SCCS was verified through confirmatory factor analysis (CFA; RMSEA = 0.08, CFI = 0.90, NFI = 0.85).[29] Moreover, in Iran, Cronbach’s alpha of the tool was 0.77. The EFA with varimax rotation yielded six factors with eigenvalues of more than 1, which explained 63.18% of the variance. The subscales showed good homogeneity with average inter-item correlations of more than 0.35 and a good test–retest reliability. The CFA of the six-factor model based on the EFA represented a good fit.[30] In the present study, the reliability of the questionnaire was assessed through internal consistency. In addition, the Cronbach’s alpha values reported for the subscales of assessment and implementation of spiritual care, professionalization and improvement of the quality of spiritual care, personal support and patient counseling, referral to professionals, attitude toward the patient’s spirituality, and communication were 0.79, 0.84, 0.85, 0.86, 0.75, and 0.83, respectively. Cronbach’s alpha of the whole questionnaire was 0.89, indicating its good reliability.
Data were analyzed in SPSS software) version 18; SPSS Inc., Chicago, IL, USA (using descriptive statistics (including frequency, mean, and standard deviation) and analytical statistics (including correlation test and linear regression analysis). Moreover, the data normality was evaluated using the Kolmogorov–Smirnov test. The significance level considered for these analyses was 0.05.
Ethical considerations
This study was approved by the ethics committee of Shahid Beheshti University of Medical Sciences, Iran, with the code IR.SBMU.PHARMACY.REC.1399.113. The participants were assured of the confidentiality of their data, their exclusive use for research purposes, and the publication of the results in a general form.
Results
From among the 405 participants, 401 responded (response rate: 98.80%) to the questionnaire. Of these students, 61.10% were women, and 92.30% were single. Table 1 presents further details about the participants. Based on the findings of this study, the mean (SD) of the DSES and SCCS scores of the nursing students were 67.15 (16.33) and 101.77 (16.26), respectively. The dimension of personal support and patient counseling had the highest 22.10 (4.80), and the communication dimension had the lowest 7.63 (1.56) mean (SD) [Table 2].
Table 1.
Demographic characteristics of nursing students participating in the study (n=401)
| Variable | n (%) |
|---|---|
| Gender | |
| Male | 156 (38.90) |
| Female | 245 (61.10) |
| Marital status | |
| Single | 370 (92.30) |
| Married | 31 (7.70) |
| Semester | |
| 7 | 197 (49.10) |
| 8 | 204 (50.90) |
| Adherence to religious rites | |
| Strongly believe | 108 (26.90) |
| Some belief | 233 (58.10) |
| Lack of belief | 60 (15) |
Table 2.
Mean and standard deviation (SD) of the dimensions of spiritual care competence in the participating nursing students
| Dimensions of nursing students’ spiritual care competence | Mean (SD) | Minimum | Maximum |
|---|---|---|---|
| Assessment and implementation of spiritual care | 21.34 (4.54) | 6 | 30 |
| Professionalization and improvement of the quality of spiritual care | 22.07 (4.89) | 6 | 30 |
| Personal support and patient counseling | 22.10 (4.80) | 6 | 30 |
| Referral to professionals | 10.47 (2.57) | 3 | 15 |
| Attitude toward the patient’s spirituality | 17.07 (2.88) | 4 | 20 |
| Communication | 7.63 (1.56) | 3 | 10 |
| Spiritual care competence | 101.77 (16.26) | 49 | 135 |
The correlation test showed that there was no significant relationship between daily spiritual experiences and dimensions of spiritual care competence. There was significant correlation between daily spiritual experiences and the assessment and implementation of spiritual care dimension (r = 0.30; p < 0.001), professionalization and improvement of the quality of spiritual care dimension (r = 0.33; p < 0.001), personal support and patient counseling dimension (r = 0.31; p < 0.001), referral to professionals dimension (r = 0.31; p < 0.001), attitude toward the patient’s spirituality dimension (r = 0.18; p < 0.001), and communication dimension (r = 0.17; p < 0.001) [Table 3].
Table 3.
Correlation between daily spiritual experiences and the dimensions of spiritual care competence in nursing students
| Variable | 1 | 2 | 3 | 4 | 5 | 6 | 7 | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
| |||||||||||||
| r | p | r | p | r | p | r | p | r | p | r | p | ||
| 1. Daily spiritual experiences | 1 | 0.30 | <0.001 | 0.33 | <0.001 | 0.31 | <0.001 | 0.31 | <0.001 | 0.18 | <0.001 | 0.17 | <0.001 |
| 2. Assessment and implementation of spiritual care | 1 | 0.81 | <0.001 | 0.75 | <0.001 | 0.70 | <0.001 | 0.45 | <0.001 | 0.46 | <0.001 | ||
| 3. Professionalization and improvement of the quality of spiritual care | 1 | 0.81 | <0.001 | 0.77 | <0.001 | 0.475 | <0.001 | 0.41 | <0.001 | ||||
| 4. Personal support and patient counseling | 1 | 0.80 | <0.001 | 0.50 | <0.001 | 0.53 | <0.001 | ||||||
| 5. Referral to professionals | 1 | 0.42 | <0.001 | 0.46 | <0.001 | ||||||||
| 6. Attitude toward the patient’s spirituality | 1 | 0.46 | <0.001 | ||||||||||
| 7. Communication | 1 | ||||||||||||
The results showed that only the professionalization dimension of spiritual care competence was a significant predictor of daily spiritual experiences. In other words, professionalization can affect daily spiritual experiences, while the other dimensions of spiritual care competence have no such effect [Table 4].
Table 4.
Predictors of daily spiritual experiences based on the dimensions of spiritual care competence in nursing students
| Variable | B | SD | Beta | t | p |
|---|---|---|---|---|---|
| Constant | 35.03 | 5.72 | 6.12 | <0.001 | |
| Assessment and implementation of spiritual care | 0.14 | 0.30 | 0.03 | 0.48 | 0.630 |
| Professionalization and improvement of the quality of spiritual care | 0.64 | 0.33 | 0.18 | 1.93 | 0.050 |
| Personal support and patient counseling | 0.34 | 0.33 | 0.09 | 1.03 | 0.302 |
| Referral to professionals | 0.47 | 0.53 | 0.07 | 0.89 | 0.373 |
| Attitude toward the patient’s spirituality | 0.18 | 0.35 | 0.35 | 0.52 | 0.601 |
| Communication | -0.15 | 0.61 | -0.01 | -0.25 | 0.802 |
SD=Standard deviation
Discussion
This study was conducted with the aim to determine the relationship between daily spiritual experiences based on the dimensions of spiritual care competence in nursing students. Based on the findings of the present study, the student’s personal support and patient counseling dimension had a higher average than other dimensions of spiritual care competence.
According to previous studies, individuals’ daily spiritual experiences play a major role in their spirituality and spiritual health.[31] Spiritual experiences have positive effects and are associated with better mental health in general.[13] These experiences, which include worship, praying, connecting to God, trusting in His presence, and feeling good about one’s relationship with God, promote the mental health of nursing students.[32] By having a spiritual relationship with God, nursing students feel more relaxed. Furthermore, their worries and anxieties of their workload are alleviated as they develop self-confidence, enabling them to manage the patients. In religious communities such as Iran, the general religiousness of the society and the prevalence of spiritual beliefs increase students’ daily spiritual experiences.
The mean spiritual care competence of all the students participating in the present study was 101.77, suggesting their ability to provide spiritual care. Likewise, other studies in Iran[9,13] have reported desirable levels of spiritual care competence, which is not unexpected considering the religious context of Iran. These results might be attributed to the rather extensive focus of nursing curricula on spirituality and spiritual care, which increased students’ awareness of this concept. Another reason for these findings could be the tendency of nursing students to maintain their humanistic approach toward patients during their academic years, as they are not greatly preoccupied with time restrictions, heavy workloads, and other nursing routines in the way that working nurses are. Nevertheless, some other studies have reported consistent or inconsistent results on this subject depending on their setting and study population.[13,19] For instance, in a study by Kalkim et al.,[2] nursing students’ perceived spiritual care competence was not desirable. Personal, cultural, and educational factors affect the suitable provision of spiritual care to patients, and those providing this care must have sufficient spiritual and moral competence. In a study by Ross et al.,[12] understanding the concept of spiritual care and one’s personal spirituality were two individual factors related to the students that affected their perceived spiritual care competence. Overall, the more skilled and knowledgeable nurses are in providing spiritual care, the more they will seek to provide this type of care.
This study showed that among the multiple dimensions of spiritual care competence, nursing students had a high competence in the dimension of personal support and patient counseling and the lowest competence in the communication dimension of spiritual care provision. This result is consistent with those of Yazdan Parast et al.[9] in Iran and Ross et al.[12] Workload, limited time, and other nursing routines might have led to the disparate findings.
In general, considering that the present study was performed on nursing students, the present study’s findings cannot be compared with those of studies on nurses and generalized to them.
The findings showed that only the dimension of professionalization and improvement of the quality of spiritual care was a significant predictor of daily spiritual experiences. In other words, professionalization can affect daily spiritual experiences, while the other dimensions of spiritual care competence have no such effect. Despite the lack of similar studies to compare the results, several studies have reported the significance of the professionalization dimension of spiritual care competence.[13] Given that the participants in this study were nursing students, their views on nursing, assumptions about the real work environment, issues related to communication with the patients, and the lack of firsthand experience with the patients’ real spiritual beliefs might have played a role in the prediction of daily spiritual experiences. In this regard, the only available and tangible factor has been the knowledge and expertise acquired during nursing education. Nursing is a patient-centered profession that aims to restore the patients’ physical, mental, social, economic, and spiritual peace, and nurses have to establish a close interaction with their patients. Therefore, the more competent nursing students are in providing spiritual care, the better the care interventions they provide their patients will be in the future. One of the strengths of the present study was examining students from three of the highest-ranking medical universities in Tehran that admit a large number of students from the entire country. This measure makes the sample a good representative of various Iranian cultures. A major limitation of the study was assessing nursing students who had not yet experienced close interaction with patients or built any clinical experience. Therefore, it is recommended that a similar study be conducted on nurses with practical work experience.
Conclusion
This study showed that the professionalization dimension of spiritual care competence is a predictor of daily spiritual experiences in nursing students. Given nurses’ close interactions with patients, if nursing students become more competent in providing spiritual care, they will provide higher-quality care interventions in the future. Policymakers in the health sector, especially nursing policymakers, should promote this dimension as part of nursing training programs by improving nursing students’ spiritual care competence.
Financial support and sponsorship
Shahid Beheshti University of Medical Sciences
Conflicts of interest
Nothing to declare.
Acknowledgements
We express sincere gratitude to the Student Union Council, the representatives of the nursing students, and the WhatsApp group admins who contributed to this project.
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