The impact of Islamic-based spiritual self-care training on stress reduction and improved spiritual well-being in mothers of preterm newborns: a quasi-experimental study

Abstract

Background

Caring for preterm newborns imposes substantial psychological stress on mothers, often affecting their mental health and overall quality of life. Strengthening spiritual well-being, a key dimension of holistic health, may offer an effective coping resource. Addressing this need, the present study uniquely developed and evaluated an Islamic-based spiritual self-care training specifically tailored for mothers of preterm newborns, integrating structured spiritual practices (Adhkar, recitations, and guided reflection) rooted in Islamic teachings with psychological coping principles. This study aimed to investigate the effects of an Islamic-based spiritual self-care training program on stress and spiritual well-being among mothers of preterm newborns in Iran. The intervention was designed to incorporate Islamic spiritual principles and practices relevant to the maternal experience in this cultural context.

Methods

This quasi-experimental pretest–posttest study with sequential sampling included 95 mothers of preterm infants admitted to neonatal intensive care units. Participants were assigned to either an intervention group receiving Islamic-based spiritual self-care training or a control group receiving standard care. The program, conducted over six sessions, combined spiritual recitation, reflection, and self-regulation practices inspired by Islamic spirituality. Data were collected using the Miles and Funk Parental Stress Scale and the Ellison and Paloutzian Spiritual Well-being Scale and analysed using descriptive statistics and MANCOVA (SPSS v.20).

Results

The mean scores of post-tests spiritual well-being in the intervention and control groups were 108.00 ± 8.87 and 74.17 ± 13.00, respectively. The mean score of post-test maternal stress in the intervention and control groups was 46.74 ± 14.57 and 140.38 ± 10.00, respectively.

The MANCOVA results demonstrated the impact of the intervention on both outcome variables: spiritual well-being and maternal stress (F = 110.547, p < 0.001, partial η² = 0.720). Pairwise comparison analysis revealed that the intervention group had a higher mean post-test score for spiritual well-being (partial η² = 0.515) and a lower mean post-test score for maternal stress (partial η² = 0.679) after controlling for covariates (P < 0.001).

Conclusions

The study demonstrates that Islamic-based spiritual self-care training significantly enhances mothers’ spiritual well-being and reduces stress, underscoring the value of culturally grounded, faith-integrated interventions in maternal mental health care. The unique contribution of this study lies in operationalizing Islamic spiritual practices into a reproducible, session-based intervention model. However, results should be interpreted with consideration of the quasi-experimental design and sequential sampling. Future randomized controlled trials in diverse Islamic settings are recommended to substantiate these findings and refine the integration of spiritual self-care into maternal support programs.

Trial registration

This study has been registered with the Iranian Registry of Clinical Trials (IRCT) under the registration code ‘IRCT20250530065981N1’ on 18/07/2025.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-026-04742-9.

Introduction

The birth of a preterm newborn represents a profound global health challenge, with approximately 15 million such births occurring annually [1]. Caring for a preterm newborn imposes significant psychological strain on mothers, exacerbating feelings of anxiety, guilt, and inadequacy, thereby jeopardizing their capacity for caregiving [2].

Spiritual well-being is recognized as a critical component of holistic health, offering comfort, strength, and meaning-making during adversity [3–5]. Despite literature showing that parents of preterm infants use personal spiritual resources for coping in the high-stress NICU, the explicit integration of spiritual support into formal parental care remains underdeveloped [6, 7]. Research in this area is largely observational, showing a clear lack of interventional studies that use structured programs to cultivate spiritual well-being for mothers in the NICU [8].

This gap in knowledge and practice is especially salient in cultural contexts where spirituality and religion are deeply interwoven with daily life and coping mechanisms, such as in Islamic societies. Although the value of spiritual care is recognized, there is a significant lack of faith-based, culturally congruent interventions specifically developed and evaluated for Muslim mothers in the NICU. Existing general support studies confirm the need for approaches that align with specific religious identities and practices [9, 10]. The lack of such tailored interventions represents a significant missed opportunity to provide holistic, person-centred care.

To address this identified gap, the present study developed and evaluated a culturally congruent, Islamic-based spiritual self-care training program for mothers of preterm newborns in Iran. Grounded in the Richards and Bergin framework and explicitly incorporating Islamic spiritual practices, such as Quranic recitation (Surah Al-Fatiha), prescribed prayers (du’a’), and dhikr (remembrance, e.g., “Ya Shafi”), this intervention was designed to address both the religious and existential dimensions of spiritual well-being.

While numerous studies have quantified the effects of spiritual and religious interventions on stress reduction in clinical populations, including parents [11, 12], this investigation addresses a significant gap in the literature through a focused approach. The core novelty of this research extends beyond the mere application of religious elements; rather, it lies in the structured, contextually embedded operationalization of Islamic-Based Spiritual Care (IBSC), specifically tailored to the highly challenging environment of the Neonatal Intensive Care Unit (NICU). Although some prior literature has focused on general concepts of spirituality (such as spiritual enrichment frameworks) [13], the present intervention uniquely integrates established Western theoretical frameworks, such as the Richards and Bergin model, with specific Islamic principles and devotional practices [e.g., “Du’a” (supplication), “Tawakkul” (trust in God), and “Sabr” (patience) rooted in Quranic and narrative teachings]. This integration adds a key conceptual level, practically ensuring that the psycho-spiritual training directly resonates with the worldview and innate resources of Muslim participants. Consequently, the contribution of this study lies in elucidating the efficacy of a religion-specific spiritual care model within a vulnerable population facing unique environmental demands (NICU), an area that has not been comprehensively explored to date. This quasi-experimental study, therefore, aimed to assess the efficacy of a tailored program in reducing perceived stress and enhancing spiritual well-being among mothers during their infants’ NICU hospitalizations.

Methods

Study design and population

This study was a quasi-experimental design with an experimental and a control group. The study population consisted of all mothers of preterm newborns admitted to the Neonatal Intensive Care Unit of Persian Gulf Martyrs Hospital Bushehr, southwestern Iran. The study was conducted over a period of 5 months, from February to July 2024.

Sampling method and inclusion criteria

Due to the practical and ethical limitations inherent to the nature of the population under study, namely mothers of preterm infants in the NICU, the implementation of randomization and a parallel-group design were not feasible. For example, accommodating mothers of preterm infants in a “mother’s hotel” could have led to contamination between the intervention and control groups through the exchange of information about the intervention. In addition, the lack of two comparable hospitals from which to recruit separate intervention and control groups made a parallel study design impractical. Furthermore, the Maternal Stress Questionnaire is intended to be completed during the infant’s hospitalization. Consequently, even with a sequential design, it was not possible to recruit all eligible participants at baseline for random allocation. Many infants whose mothers would have been assigned to the intervention group might have been discharged before the completion of the control phase. Consequently, a sequential design with convenience sampling was employed in this study. Initially, the control group participated in the study, and subsequently, the intervention group was enrolled following the completion of the questionnaires at pre- and post-test times by the control group. Given the potential for this sampling method to introduce bias due to secular trends, a series of measures were implemented to mitigate this risk. Bias due to secular trends refers to changes over time that may affect study outcomes independently of the intervention. Because the control and intervention groups were recruited at different time periods, external factors such as changes in clinical practice, staff experience, hospital policies, or improvements in neonatal care may have influenced maternal stress levels or related outcomes. Therefore, these temporal changes may have introduced bias when comparing the two groups. The control group was recruited and completed first, followed immediately by the intervention group. No alterations were observed in hospital policies, care protocols, or NICU procedures during the study period. Staffing levels remained constant, with no alterations in nursing personnel during the study period. The physical environment of the NICU remained unaltered. The enrolment of participants occurred over a relatively brief and stable time frame. These observations suggest that the influence of major time-related changes on the study outcomes was likely minimal. Nonetheless, the sequential nature of the design remains susceptible to residual temporal bias, which should be considered when interpreting the results.

Inclusion criteria for the study comprised: maternal willingness to participate, being at least 18 years of age, literacy (ability to read and write), having attended at least one neonatal visit within the NICU environment, having a neonate with a gestational age between 24 weeks and 36 weeks and 6 days, and a minimum of 3 days having elapsed since the neonate’s admission to the NICU. The selection of the 3-day criterion allowed researchers to assess maternal stress under more stable conditions and with reduced influence from transient stressors. This time frame is consistent with a review of prior studies and assists researchers in presenting a more accurate depiction of mothers’ actual stress levels [14–16]. The exclusion criteria included the following: a history of preterm birth in the mother, prior neonatal death, significant congenital anomalies in the neonate (as documented in medical records), maternal history of mental health disorders such as schizophrenia, bipolar disorder, or depression (based on self-report), maternal history of severe physical illnesses such as severe cardiac conditions, advanced or metastatic cancers, advanced renal disease, and other conditions that could substantially impact the mother’s overall health and potentially hinder her effective participation in the educational program or engagement in spiritual self-care activities (based on self-report), maternal history of psychoactive substance or narcotic use, complicated or high-risk maternal delivery (e.g., instrumental delivery, severe postpartum haemorrhage, eclampsia, and severe pre-eclampsia) as documented in medical records, maternal employment in healthcare facilities or current enrolment in medical or paramedical studies, maternal exposure to stressful life events (e.g., divorce, bereavement) within the past three months, and unwillingness to continue participation in the research.

Sample size

Based on the mean and standard deviation of stress in the intervention and control groups, respectively, 32.1 ± 17.4 and 43.6 ± 19.9 in the study by Zafarian Moghaddam et al. [17], with a type I error rate of 0.05 and a power of 80%, the sample size was calculated using G*Power software (version 3.1.9.2) to be 43 individuals per group. Considering a 10% dropout rate, 48 individuals per group were required, resulting in a total sample size of 96.

Procedure

After obtaining the necessary permissions and a written referral letter from the Research and Technology Deputy of Bushehr University of Medical Sciences, the researcher visited the research site (Persian Gulf Martyrs Hospital, Bushehr). Upon coordination with hospital officials, the researcher entered the mothers’ room or hotel and selected participants based on the inclusion and exclusion criteria. To control for potential communication between the control and intervention groups, sampling in the control group was conducted first. Participants were provided with information about the study’s objectives and procedures, and written informed consent was obtained from those who agreed to participate. Maternal and neonatal demographic information form, spiritual well-being, and parental stress questionnaires were administered to the participants in the presence of the researcher. Participants were assured of the confidentiality of their responses and were asked to carefully answer the questionnaire items. Information such as gestational age at birth, birth weight, and Apgar score was recorded from the medical records. The newborn’s exclusion criteria were also considered based on the medical records. After the initial data collection from the control group, the same two questionnaires (spiritual well-being and parental stress) were completed again two weeks later.

Following the completion of sampling in the control group, sampling for the intervention group commenced. The objectives and procedures of the study were explained to the participants, and written informed consent was obtained from those who agreed to participate. After explaining the study objectives and procedures, information about the educational intervention was provided to the mothers in the intervention group. Subsequently, the demographic information of the mother and newborn, along with the two questionnaires (spiritual well-being and parental stress), were completed for the intervention group. The spiritual self-care intervention then commenced. Spiritual self-care training was delivered to each mother over one week, consisting of six one-hour sessions conducted continuously. In the subsequent week, if an in-person meeting was not feasible, the researcher kept contact with the mothers every other day, either in person or via telephone, to monitor their engagement in the prescribed spiritual practices and tasks. At the conclusion of the second week, the questionnaires were re-administered in person.

Intervention method

The spiritual self-care training was explicitly designed and implemented as an Islamic-based intervention. Its core content was derived from Islamic spiritual principles and structured around specific devotional practices to ensure cultural and religious congruence with the participant population. Key elements included the recitation of Quranic chapters (Surah Al-Fatiha), prescribed prayers (du’a), dhikr (remembrance of God, e.g., “Ya Shafi” [O Healer]), and seeking forgiveness (istighfar). The number 70 is often associated with the concept of completeness and is mentioned in noteworthy hadiths, suggesting a profound level of spiritual engagement and dedication. Empirical studies have also shown that repetition can enhance neural pathways related to spirituality and mindfulness. Engaging in repetitive prayer or chant can lead to a meditative state, promoting relaxation, reducing anxiety, and improving emotional well-being. The selected repetitions aim to anchor participants in a focused mental state conducive to spiritual realization and emotional regulation. Additionally, the gradual increase in repetitions serves to allow participants to build their concentration and commitment over time. Starting with a lower count, such as 70, can serve as an accessible entry point, while transitioning to higher counts, like 391, encourages deeper levels of engagement and transformation through sustained practice. These practices were integrated within the adapted Richards and Bergin framework for spiritual self-care [18, 19], under the supervision of an Islamic studies scholar. The intervention aimed to address both the religious and existential dimensions of spiritual well-being inherent in an Islamic worldview.

The guidelines and educational content for this study were adapted from the model of Richards and Bergin [20], as outlined in the thesis by Sakhamanesh et al., and customized based on Islamic teachings and cultural norms [21]. This educational content was developed under the supervision of a religious scholar as a scientific advisor to the project, who was also a faculty member at Bushehr University of Medical Sciences.

The intervention was delivered to each mother in six one-hour sessions over a week in classrooms located at Persian Gulf Martyrs Hospital, Bushehr. The timing of the sessions was adjusted to accommodate the mothers’ schedules and ensure their readiness. The classrooms were selected based on several factors, including minimal foot traffic, adequate lighting, appropriate educational tools, and a suitable ventilation system. The intervention (spiritual self-care training) was conducted in small groups of 4–6 mothers. The intervention was delivered by the researcher, a master’s student in paediatric nursing, and a spiritual intervener who was a religious scholar. Each therapy session included: (1) checking the participants’ homework assigned in the previous session; (2) providing feedback to participants; (3) providing a summary of the previous sessions to create continuity and prepare participants for new topics; (4) conducting new discussions and exercises; (5) assigning homework for the current session; and (6) providing explanations and summarizing the session topics (Table 1). The criterion for evaluating the completion of homework by participants was self-report. However, to ensure that the homework was completed correctly and thoroughly, the researcher discussed and asked questions about how the homework was completed in each session. To encourage and motivate participants and improve their homework completion, the researcher provided feedback in each session and made frequent contact to provide appropriate feedback. It is worth noting that the intervention steps of Richards and Bergin were considered a theoretical framework for spiritual self-care intervention, which is a practical framework. Further details about the intervention are available in the ‘Supplementary Material’ section.

Table 1.

Content of the Islamic-based spiritual self-care training for mothers of preterm newborns

Training session	Training content
First session	The researchers introduced themselves and the spiritual intervener to the mothers, providing necessary explanations about the study and its objectives. Subsequently, the researcher explained the roles of the group members. Next, the researcher completed the demographic form, spiritual well-being questionnaire, and parental stress questionnaire in the presence of the mothers. Then, the spiritual intervener proceeded to deliver the training content based on the mentioned concepts, the six steps of the Richards and Bergin model, and tailored to the needs of each participant. The spiritual intervener taught the mothers specific tasks, including reciting the chapter of praise (Al-Fatiha) (70 times), blessings and the remembrance of ‘Ya Shafi’ (O Healer) (391 times), and remembrance of seeking forgiveness (100 times), emphasizing their completion until the next session. In various Islamic spiritual texts, specific numbers for repeated invocations carry significant weight. Overall, these numbers are crafted to harmonize spiritual tradition with modern understanding of the psychological benefits of repetitive practices, thus validating their inclusion in the study as vital components of the intervention. The gradual increase in repetitions serves to allow participants to build their concentration and commitment over time. Starting with a lower count, such as 70, can serve as an accessible entry point, while transitioning to higher counts, like 391, encourages deeper levels of engagement and transformation through sustained practice [22]. Furthermore, the researcher maintained regular contact with the mothers, providing recommendations on the consistent performance of the recitations, ensuring their correct and frequent repetition, and offering additional advice tailored to the participants’ needs. Additionally, the researcher patiently listened to and responded to the mothers’ concerns regarding complications related to preterm birth or similar issues.
Sessions Second to Fifth	The researcher was responsible for checking the homework assigned to the participants in the previous session and providing the necessary information to the spiritual intervener. Subsequently, the spiritual intervener provided feedback to the mothers. If the mothers encountered any difficulties with the previous session’s homework, the researcher and the spiritual intervener addressed their concerns. Moreover, the spiritual intervener provided a summarized list of the previous session’s topics to create continuity and prepare the participants for new discussions. New discussions and exercises were conducted, and homework for the following session was assigned. The session was then concluded with a summary of the topics covered.
Sixth session	At the end of the session, the spiritual intervener summarized the key points. In the following week (the second week), the parental stress and spiritual well-being questionnaires were completed again by the researcher in the presence of the mothers.

Table 2.

Checklist for an Islamic-based spiritual care intervention protocol for mothers of premature newborns

Stage / Session	Main activities	Key training content/tasks
First	Introduction, completion of pre-test forms (demographics, spiritual well-being, parental stress), presentation of main content.	Main content: Introduction to the concepts and six stages of the Richards and Bergin model. Assignments: Recitation of Surah Hamd (Al-Fatiha): 70 times. Recitation of Salawat and “Ya Shafi” 391 times and Istighfar: 100 times. Emphasis on continuous implementation and regular contact of the researcher to follow up and provide necessary recommendations.
Second to fifth	Reviewing assignments from the previous session, providing feedback from the spiritual coach, fixing problems, presenting new topics, and assigning assignments for the next session.	Continuity and Feedback: Checking progress in the adhkar (Recitations), responding to concerns, and maintaining continuity in the training by summarizing past discussions.
sixth	Summary of key points by the spiritual coach and re-completion of the parental stress and spiritual well-being questionnaires.	End of intervention: Final evaluation of the results of the intervention (Table 2).

Data collection instruments

The data collection instruments in this study included a demographic form for the mother and newborn, Miles and Funk’s Parental Stress Scale, and the Ellison and Paloutzian Spiritual Well-being Scale, which were completed through face-to-face interviews with the mothers.

Demographic form for mother and newborn

The demographic form for mothers included items such as mother’s age, education level, occupation, family economic status, gestational age, type of pregnancy, mode of delivery, birth order of the child, the number of hospitalization days of the neonate at the time of enrolment in the study, and type of residence. The demographic form for newborns included seven questions regarding the newborn’s age, birth weight (grams), sex, mechanical ventilation, Apgar score, multiple birth status, and type of newborn feeding.

Spiritual Well-Being Scale (SWBS)

The 20-item Spiritual Well-being Scale developed by Ellison and Paloutzian was used [23]. This questionnaire comprises two primary dimensions: Religious Well-being and Existential Well-being. The Religious Well-being dimension pertains to an individual’s relationship with a transcendent power or God, indicating the extent of their belief, connection, and sense of closeness to the divine and religious aspects of life. In essence, this dimension reflects spirituality rooted in religion and spiritual experiences within the framework of religious beliefs. Conversely, the Existential Well-being dimension addresses the meaning of life, purposefulness, feelings of inner satisfaction, and harmony with oneself, others, and the surrounding world. Independent of religious beliefs, it encompasses the philosophical and psychological facets of spirituality. The fundamental distinction between these two dimensions lies in the fact that Religious Well-being focuses on the relationship with God and religiosity, whereas Existential Well-being primarily emphasizes the individual’s comprehension of life’s meaning and sense of personal purpose, without necessarily depending on a specific religion. This scale consists of 10 items with odd numbers measuring religious well-being and 10 items with even numbers measuring existential well-being. Each subscale has a possible score ranging from 10 to 60. The total spiritual well-being score is the sum of the two subscales, with a range of 20 to 120. Based on the instrument’s common interpretive guidelines, total scores can be qualitatively categorized: scores of 20–40 indicate low spiritual well-being, 41–99 indicate moderate spiritual well-being, and 100–120 indicate high spiritual well-being [23, 24].

The validity and reliability of this instrument in Iran have been established by Fatemi et al., with content validity confirmed and Cronbach’s alpha reliability coefficient of 0.82 [18]. The present study assesses internal consistency for reliability. The Cronbach’s alpha for religious well-being, existential well-being, and the total instrument was 0.78, 0.86, and 0.90, respectively.

Parental Stress Scale (PSS)

This questionnaire was developed by Miles et al. [19]. It was designed to assess the stress experienced by parents in neonatal intensive care units and was used in this study to measure the stress experienced by mothers of preterm newborns. The scale consists of 34 items rated on a 5-point Likert scale. Initially, mothers indicated whether they had experienced the stressors presented in the questionnaire. If they had not experienced a particular stressor, they were given a score of 0. If they had experienced a stressor, they were asked to rate the level of stress they experienced on a 5-point Likert scale ranging from ‘no stress’ (score 1) to ‘extreme stress’ (score 5). The total score range is 0 to 170, with 0 indicating no stress and 170 indicating the highest level of stress. While no universally established clinical cutoffs exist for this specific scale in maternal populations, scores can be contextualized within the possible range. For interpretive reference in this study, higher scores represent greater perceived stress, and changes in scores were evaluated for statistical and practical significance within the study’s design.

In Iran, the content validity of this instrument was confirmed by Mianaei et al., with a mean content validity index of 0.93. Additionally, these authors reported a Cronbach’s alpha reliability coefficient of 0.81 [25]. The present study assessed the internal consistency of the data set, with a resultant Cronbach’s alpha of 0.92.

Ethical considerations

This study was reviewed and approved by the Ethics Committee of Bushehr University of Medical Sciences, with the ethical code ‘IR.BPUMS.REC.1402.106’. The research was conducted in accordance with ethical guidelines set forth by the Helsinki Declaration. Furthermore, the present study has been registered with the Iranian Registry of Clinical Trials (IRCT) under the registration code ‘IRCT20250530065981N1’ on 18/07/2025. All participants provided written informed consent after receiving comprehensive information regarding the study’s purpose and methodology. The collected data were recorded anonymously using a unique code for each participant. Data were stored in encrypted files accessible only to the principal investigator. Throughout all stages of the research, the principles of data confidentiality and participant anonymity were strictly adhered to. Furthermore, participants were informed of their right to withdraw from the study at any time.

Data analysis

The collected data were then subjected to analysis using the Statistical Package for the Social Sciences (SPSS), version 20. All statistical tests were conducted at a significance level of p < 0.05. The intention-to-treat (ITT) approach was employed in this study. Subsequent to this, the participants were subjected to a subsequent analysis in their respective groups. One participant from the intervention group was lost to follow-up, resulting in a final sample size of 95 (47 intervention, 48 control).

First, the data were examined for outliers and missing values. No outliers were identified, but as indicated in the demographic characteristics table, certain demographic variables were found to be incomplete. In order to assess the potential impact of missing demographic data on the outcomes of the intervention, an exploratory comparison was performed between participants with missing demographic variables and those with complete demographic profiles. Participants with missing data were then coded and grouped accordingly. Subsequently, a comparative analysis was conducted between the pre-test and post-test scores of the aforementioned subjects and those of the remaining members of the intervention group. The objective of this comparison was to assess whether the participants with incomplete demographic data demonstrated analogous patterns of change across the intervention as those with complete data. The analysis revealed that there were no statistically significant differences between the two groups in terms of pre-post intervention changes, suggesting that the missing data are unlikely to have introduced systematic bias. Therefore, the missingness is considered to be either Missing Completely at Random (MCAR) or Missing at Random (MAR). Consequently, the results can be interpreted with reasonable confidence. In the main variables, the missing data were at the level of 2%, which was replaced by the mean.

Descriptive statistics, including the mean, standard deviation, frequency, median, and interquartile range, were employed to characterize the data. The normality of the data distribution was assessed using the Shapiro-Wilk test. A variety of statistical tests were employed to compare demographic variables between the intervention and control groups, including independent t-tests, Mann-Whitney U tests, chi-square tests, and Fisher’s exact test. Given the normal distribution of pre- and post-test scores for spiritual well-being and stress, paired t-tests were used for within-group comparisons.

A Multivariate Analysis of Covariance (MANCOVA) was conducted to evaluate the effect of the intervention on the two dependent variables, maternal stress and spiritual well-being, while controlling for potential covariates. The selection of covariates was based on statistical significance between groups at baseline and their relationship to dependent variables, as well as their theoretical and empirical relationships with the outcome variables. Accordingly, baseline variables that showed significant between-group differences but did not demonstrate a meaningful association with the outcome variables were not included as covariates in the final models. In order to ascertain the existence of an association between the dependent variable and the potential quantitative covariate, the researchers implemented a Spearman or Pearson correlation test. A correlation of 0.3 or greater was considered eligible as a covariate. The selection of qualitative demographic variables as covariates was predicated on the measurement of the mean score of maternal stress and spiritual well-being between the levels of qualitative variables using either an independent t-test or analysis of variance (Or the nonparametric equivalent of these tests). Cohen’s d of 0.2 and above was established as the selection criterion for the covariate. Pursuant to these conditions, four variables were selected as covariates: maternal age, gestational age, number of children, and infant feeding type. Following a rigorous examination for collinearity, maternal age, as well as the pre-test scores of maternal stress and spiritual well-being, were incorporated as covariates in the final model. Due to the presence of collinearity between the two variables of gestational age and infant feeding, the infant feeding type was considered a covariate; however, due to its nominal nature, this variable was entered into the model along with the group variable (intervention vs. control) as fixed factors.

Before performing the between-group comparisons, the relevant assumptions for the multivariate analysis were assessed. Linearity between each covariate and dependent variable was checked using scatterplots. The correlation between the two dependent variables was examined, as well as the correlation between the covariates, to assess multicollinearity. We assessed the homogeneity of variance-covariance matrices using Box’s M test and confirmed the homogeneity of regression slopes by testing for non-significant interactions between covariates and the independent variable.

Despite the normality of the dependent variables across groups, SPSS does not provide direct multivariate normality tests. Given the slight deviations from normality observed in the residuals, based on histograms and Q-Q plots, the possibility of deviations from multivariate normality was suggested. Therefore, a bootstrapping procedure with 1,000 resamples was employed to enhance the robustness of the estimates.

Blinding

Given the nature of the educational intervention, it was not possible to blind participants (mothers) to their involvement in the study, as they were fully aware that they were receiving a structured educational programme. Similarly, the individual delivering the intervention could not be blinded to group allocation, as they were actively involved in administering the training sessions. Therefore, blinding of both participants and the implementer was not feasible in this context.

Moreover, unlike pharmaceutical trials where a placebo can be ethically and practically administered, creating a placebo equivalent for spiritual education poses significant challenges. Providing an intentionally incomplete or ineffective version of spiritual content to the control group would not only be methodologically flawed but also ethically problematic. Such an approach could undermine participants’ trust and compromise the integrity of the informed consent process. Ensuring transparency about the nature and purpose of the educational content is essential, and withholding meaningful information from participants could jeopardise both ethical standards and the credibility of the research.

Results

The initial sample size included 48 mothers in each of the control and intervention groups, for a total of 96 participants. Ultimately, data from 48 mothers in the control group and 47 mothers in the intervention group (95 participants in total) were analysed, yielding a 99% response rate. The study flow chart is provided in the Supplementary Material section (Fig. 1).

Demographic characteristics

The study findings revealed significant differences (p < 0.05) between the intervention and control groups in terms of maternal age, gestational age, birth weight, days of hospitalization, and number of children (Table 3). Additionally, comparisons of the two groups regarding qualitative demographic characteristics of the participating mothers showed statistically significant differences (p < 0.05) in variables such as place of residence, planned pregnancy, education level, income status, and newborn feeding type (Table 4).

Table 3.

Comparison of the quantitative variables between the intervention and control groups

Variable	Control group	Intervention group	t or Z*	p-Value
	Mean ± SD orMedian (IQR)	Mean ± SD orMedian (IQR)
Mother's age	28.31±6.02	33.29±6.41	-3.798	0.006
Gestational age/weeks	34.90±1.77	33.60±2.29	-2.808*	0.005
Birth weight of the baby/kg	2.44±0.63	2.07±0.59	2.839	0.006
Days of hospitalization study when entering the study	5.85±3.04	4.26±0.93	-3.144*	0.002
Number of children	1(1-2)	2 (1-3)	-3.595*	<0.001

In other cases, the reported statistic is t, and the test conducted is the independent t-test

SD Standard deviation, IQR Interquartile range, kg Kilograms

*The reported statistic is Z, and the test conducted is the Mann-Whitney test

Table 4.

Comparison of the qualitative variables between the intervention and control groups

Variable	Subgroups	Group		Test statistic	p-Value
		Control group	Intervention group
		Number (%)	Number (%)
Employment status	Employed	16 (34.0)	7 (15.6)	4.190	0.054
	Housewife	31 (66.0)	38 (84.4)
	Missing data	1 (2.1)	2 (4.3)
Place of residence	City	40 (85.1)	31 (66.0)	4.663	0.031
	Village	7 (14.9)	16 (34.0)
	Missing data	1 (2.1)	0 (0)
Planned pregnancy	Yes	42 (93.3)	28 (71.8)	6.978	0.008
	No	3 (6.7)	11 (28.2)
	Missing data	3 (6.3)	8 (17.0)
Type of childbirth	Natural vaginal delivery	12 (25.5)	10 (21.7)	0.185	0.667
	Caesarean section	35 (74.5)	36 (78.3)
	Missing data	1 (2.1)	1 (2.1)
History of previous infant death	Yes	3 (6.7)	7 (15.6)	1.800	0.180
	No	42 (93.3)	38 (84.4)
	Missing data	3 (6.3)	2 (4.3)
Education level	Diploma or less	13 (32.5)	27 (58.7)	11.897*	0.008
	Postgraduate diploma	8 (20.0)	2 (4.3)
	Bachelor’s degree and above	19 (47.5)	17 (37.00)
	Missing data	8 (16.7)	1 (2.1)
Income status	More than or equal to living expenses	38 (79.2)	23 (52.3)	7.432*	0.006
	Less than living expenses	10 (20.8)	21 (47.7)
	Missing data	0 (0)	3 (6.4)
Baby’s gender	Girl	24 (52.2)	19 (40.4)	1.291*	0.256
	Boy	22 (47.8)	28 (59.6)
	Missing data	2 (4.2)	0 (0)
Apgar score at the fifth minute of birth	Seven or more	44 (91.5)	44 (100)	2.153*	0.118
	Less than seven	4 (8.5)	0 (0)
	Missing data	1 (2.1)	3 (6.3)
Need for artificial respiration	Yes	12 (25.0)	16 (34.0)	0.934	0.334
	No	36 (75.0)	31 (66.0)
Single or multiple twins	No	39 (88.6)	33 (75.0)	2.750	0.97
	Yes	5 (11.4)	11 (25.0)
	Missing data	4 (8.3)	3 (6.4)
Child’s nutritional status	Feeding by a method other than breastfeeding	26 (54.2)	12 (26.1)	7.690*	0.006
	Breastfeeding by the mother	22 (45.8)	34 (73.9)
	Missing data	0 (0)	1 (2.1)

In other cases, the Chi-square test was conducted

*The test performed is Fisher's exact test

Within-group comparisons

The findings indicated that the mean ± SD scores in the control group were 79.42 ± 6.61 and 74.17 ± 13.00 at pre-test and post-test, respectively. In the intervention group, the corresponding scores were 90.02 ± 13.39 and 108.00 ± 8.87. Within-group comparisons in the intervention group revealed that post-test scores for total spiritual well-being, existential well-being, and religious well-being were significantly higher than pre-test scores (p < 0.05). In contrast, in the control group, the post-test score for existential well-being was significantly lower than the pre-test score (p < 0.05), while no statistically significant differences were observed for total spiritual well-being or religious well-being (p > 0.05).

Regarding maternal stress, the mean ± SD scores in the control group were 131.16 ± 22.50 and 140.38 ± 10.92 at pre-test and post-test, respectively. In the intervention group, the corresponding scores were 103.03 ± 29.66 and 46.74 ± 14.75. Within-group comparisons indicated that the post-test maternal stress score in the intervention group was significantly lower than the pre-test score (p < 0.05), whereas in the control group, the post-test score was significantly higher than the pre-test score (p < 0.05) (Table 5).

Table 5.

Within-group comparisons of spiritual well-being and maternal stress

Variable	Group	Pre-test	Post-test	t (p-Value)	df	95% CI for mean differences	ES (Cohen’s d)
		Mean ± SD	Mean ± SD
Existential well-being	Intervention	53.46 ± 8.30	54.62 ± 5.75	-8.566(< 0.001)	46	-13.56; -8.39	1.29
	Control	40.37 ± 4.70	36.00 ± 7.26	2.526(0.016)	47	0.77; 6.978	0.40
Religious well-being	Intervention	46.73 ± 6.32	53.36 ± 3.88	-5.538(< 0.001)	46	-9.09; -4.23	0.86
	Control	39.77 ± 3.34	38.42 ± 7.15	1.203(0.237)	47	-1.063; 4.168	0.20
Total spiritual well-being	Intervention	90.02 ± 13.39	108.00 ± 8.87	-7.031(< 0.001)	46	-21.90; -12.10	1.13
	Control	79.42 ± 6.61	74.17 ± 13.00	1.907(0.067)	47	-0.32; 9.97	0.33
Maternal stress	Intervention	103.03 ± 29.66	46.74 ± 14.75	9.224(< 0.001)	46	41.35; 65.01	1.74
	Control	131.16 ± 22.50	140.38 ± 10.92	-2.923(0.006)	47	-15.85; -3.74	0.50

SD Standard deviation, ES Effect size

Between-groups comparisons (multivariate analysis of covariance)

A multivariate analysis of covariance (MANCOVA) with 1,000 resamples using the bootstrap method was performed. Initially, the covariates were identified. Preliminary statistical analyses were conducted to ascertain which covariates should be incorporated, as delineated in the analysis section. All relevant assumptions were assessed before conducting MANCOVA. The study design ensured the independence of observations; participants were sampled independently. Although SPSS does not provide direct multivariate normality tests, the analysis revealed slight deviation from normality, as indicated by histograms and Q-Q plots of the residuals. To address this issue, the bootstrapping method was employed with 1000 resamples used for all F-tests and confidence intervals. Scatterplots and correlation matrices revealed linear relationships between each covariate and dependent variable. The homogeneity of the regression slopes was tested by checking the interaction terms between each of the covariates and the independent variables in separate generalized linear models (GLMs). No significant interactions were found, indicating that homogeneity of regression slopes was met (Table 6). The Box-M test for homogeneity of variance-covariance matrices yielded a significant result (F [9, 18123.605] = 2.038, p < 0.031). Thus, the relatively conservative Pillai’s trace was used to estimate the F-statistics in the analysis.

Table 6.

Results of MANCOVA examining the interaction effects of independent variables and covariates on post-test maternal stress and spiritual well-being scores (multivariate and univariate tests)

Interaction effect	Both dependent variables		Spiritual well-being post-test score		Maternal stress post-test score
	F	p-value	F	p-value	F	p-Value
Group × spiritual pre-test score	2.679	0.075	0.079	0.779	1.760	0.190
Group × maternal stress pretest score	0.002	0.998	0.002	0.966	0.001	0.976
Group × mother age	0.986	0.378	0.603	0.440	1.766	0.188
Baby nutrition × spiritual pretest score	1.223	0.338	0.001	0.998	0.401	0.529
Baby nutrition × spiritual pretest score	0.209	0.812	0.059	0.809	2.773	0.100
Baby nutrition × mother age	1.578	0.213	1.028	0.314	1.146	0.215

The results of the MANCOVA showed a significant main effect of the intervention on the combined dependent variables (F (2, 86) = 110.547, p < 0.001, partial η²=0.720, 95%CI [0.568;0.817]). However, the main effects of neonate nutrition type (F (2, 86) = 0.982, p < 0.379, partial η² = 0.022, 95%CI [0.006;0.245]) and intervention × neonate nutrition type interaction (F (2, 86) = 2.692, p < 0.074, partial η² = 0.059, 95%CI [0.010;0.233]) on the combined dependent variables were not significant. Follow-up univariate analyses showed the effect of the intervention on spiritual well-being and maternal stress, with partial η² values of 0.515 and 0.679, respectively (Table 7). Pairwise comparison analysis revealed that the intervention group had a higher mean post-test score for spiritual well-being and a lower mean post-test score for maternal stress after controlling for covariates (Table 8). Bootstrapped parameter estimates indicated a significant effect of the intervention on both outcomes: spiritual well-being (B = 26.559, BCa 95% CI [19.616, 33.267]) and maternal stress (B = -78.800, BCa 95% CI [-89.994, -69.189]).

Table 7.

Univariate between-subjects effects from MANCOVA on post-test maternal stress and spiritual well-being after controlling for covariates

Source	Dependent Variable	df	F	p-Value	partial η²	95%CI for partial η²
Group	Post-test of maternal stress	1	184.226	< 0.001	0.679	0.568; 0.777
	Post-test of spiritual well-being	1	92.301	< 0.001	0.515	0.338; 0.650
Baby nutrition type	Post-test of maternal stress	1	1.711	0.194	0.019	0.003; 0.040
	Post-test of spiritual well-being	1	0.722	0.398	0.008	0.001; 0.041
Group * baby nutrition	Post-test of maternal stress	1	2.704	0.104	0.030	0.000; 0.058
	Post-test of spiritual well-being	1	1.366	0.246	0.015	0.001; 0.044

Covariates in the model were mother age, pre-test of spiritual well-being, and pre-test of maternal stress

CI Confidence interval

Table 8.

Between groups comparison of two dependent variables

Dependent Variable	Intervention group	Control group	Mean differences	p-Value	95% CI for mean differences
	Mean (SE)	Mean (SE)
Post-test of maternal stress	61.17 (3.67)	132.34(3.21)	-71.18	< 0.001	-81.60; -60.75
Post-test of spiritual well-being	106.74(2.17)	77.02 (1.89)	29.72	< 0.001	23.57; 35.86

Covariates appearing in the model are evaluated at the following values: mother age= 30.4574, pre-test of spiritual well-being= 85.1882, Pre-test of maternal stress= 117.1766. CI Confidence interval, SE Standard error

Discussion

This study investigated the impact of Islamic-Based spiritual self-care education on stress and spiritual well-being among mothers of preterm infants admitted to the Neonatal Intensive Care Unit (NICU) at Persian Gulf Martyrs Hospital in Bushehr, Iran. The novelty of this research lies in three key aspects. First, unlike prior studies that generally examined the effects of faith or spirituality on stress [26], this intervention systematically incorporated structured Islamic practices, including Dhikr (remembrance), contemplation on the Asma ul Husna (The Beautiful Names of God), and principles such as Sabr Jameel (beautiful patience). Second, these Islamic elements were integrated within the Richards and Bergin spiritual care framework, providing a culturally adapted and replicable template for acute medical care settings. Third, the intervention specifically addressed the unique stressors faced by parents of premature infants in the NICU, including fears related to infant survival, developmental concerns, and feelings of helplessness [27]. This structured and context-specific operationalization represents the innovation of the study, offering a formalized approach to religion-specific spiritual care that goes beyond generalized religiosity.

The findings revealed that the mean age of mothers in the control and intervention groups was 28 and 33 years, respectively. Additionally, the average length of infant hospitalization upon entry into the intervention was approximately 5 days. The majority of mothers were housewives, urban residents, and had planned pregnancies, with breastfeeding being the predominant feeding method for the newborns. Also, this study showed that Islamic-based spiritual education led to meaningful improvements in mothers’ spiritual well-being, particularly within the existential domain, and significantly reduced maternal stress compared with the control group. Mothers who received the intervention reported stronger meaning-making, emotional grounding, and coping capacity, whereas the control group experienced declining existential well-being and rising stress levels.

The two groups were not homogeneous in terms of certain demographic and infant-related characteristics, which can likely be attributed to convenience sampling, its sequential nature, and the lack of random assignment. This heterogeneity could potentially influence the results of the primary variable, and to mitigate this impact and ensure more accurate results, it was considered in the statistical analyses, and MANCOVA analysis was performed for control. The MANCOVA demonstrated that, despite the accounting of confounding variables, the intervention exerted a positive effect on spiritual well-being. The results demonstrated a significant increase in the mean spiritual well-being and its two domains (religious well-being and existential well-being) in the intervention group. MANCOVA results confirmed the positive effect of the intervention on spiritual well-being.

Spiritual well-being, as defined by Paloutzian and Ellison, encompasses two interrelated dimensions: a vertical or religious component that reflects one’s relationship with God, and a horizontal or existential component that pertains to meaning, purpose, and interpersonal connectedness [28]. The existential dimension is particularly concerned with one’s relationships with others and the surrounding world, promoting a deeper sense of connectedness and more adaptive social interactions [29]. Overall, spiritual well-being represents a harmonious integration of the individual’s relationship with God, self, others, and nature, supporting the pursuit of meaning and coherence in life [28]. Within this conceptual framework, the findings of the present study indicate that Islamic-based spiritual education, including Quran recitation, supplications, prayer, and invocation of the Imams (AS), enhanced mothers’ awareness of spirituality as a coping resource and strengthened their orientation toward meaning-making. These changes contributed to the observed improvement in spiritual well-being, particularly in the existential domain, among mothers of hospitalized preterm infants [30]. The structured and supportive presence of a spiritual educator likely reinforced this effect by fostering empathy, emotional reassurance, and a sense of being understood during a highly stressful period. This supportive interaction appeared to bolster mothers perceived spiritual and social support, thereby enhancing their coping capacity in the face of uncertainty and emotional strain associated with preterm birth.

The MANCOVA results indicated a statistically significant reduction in maternal stress in the intervention group compared with the control group.

These findings are consistent with the results of Khalifi et al., which showed that spirituality education enhances spiritual well-being in nursing students [31]. Similarly, the study by Zafarian Moghaddam et al., conducted on caregivers of children with leukaemia, demonstrated a comparable effect on the caregivers’ spiritual well-being [17]. The findings of Nosratabadi’s study also indicated that religious education can increase mothers’ self-confidence and enhance their awareness [32].

Previous studies have shown that parents of premature infants may experience significant psychological stress as well as spiritual challenges, including spiritual alienation and the need for spiritual support [33].

These findings align with previous evidence suggesting that individuals with stronger spiritual orientations tend to exhibit more adaptive responses to adversity and higher psychological well-being [34]. Furthermore, the improvement in existential well-being may have facilitated more constructive relationships with healthcare providers, including nurses. This interpretation is consistent with the findings of Jamali et al., who reported that higher levels of maternal existential well-being were positively associated with better perceived connection and communication with nurses, ultimately contributing to more effective care processes [16].

Similar to the present study, several national studies have reported significant stress reductions following spiritual self-care education, highlighting the potential effectiveness of such interventions [35–38]. Additionally, Mohagheghi et al. investigated the impact of multifaceted support, which included spiritual support for parents, on the stress of mothers of preterm infants. The results showed that the mothers’ stress scores in the intervention group were significantly lower than those in the control group [39]. Yazarloo et al. reported that 25% of the changes in reducing stress in mothers of preterm infants hospitalized in the hospital were related to spiritual self-care education [40]. These findings indicate that spiritual care can improve individuals’ conditions in stressful situations.

However, not all studies have reported similar results. Mann et al. found that religion and spirituality did not reduce stress in Latin American women during pregnancy and postpartum [41]. Kadivar et al., found no significant relationship between spiritual well-being and stress in mothers of preterm infants [28]. Differences in findings may be due to variations in stress sources, cultural and linguistic factors, measurement tools, study design, or the severity of stressful conditions. For example, mothers in Kadivar’s study may have faced additional financial, social, or familial stressors that were not mitigated by spiritual well-being alone. In contrast, in the present study, spiritual well-being may have acted as a stronger supportive resource. Spirituality can strengthen an individual’s ability to evaluate negative events and foster a sense of control when facing challenges [38, 42]. Individuals’ reactions to stressors are influenced by genetics, personality traits, living environment, and social support [43, 44]. Moreover, the cross-sectional design of Kadivar’s study does not allow causal inferences, whereas the present study employed a quasi-experimental design.

Although several national studies have reported substantial reductions in maternal stress following interventions, ranging from approximately 30 to 70 points [36, 45], the pronounced decrease observed in the present study should not be attributed solely to the intervention. Part of the observed change may be influenced by the quasi-experimental sequential design, baseline differences between groups, the Hawthorne effect, and reliance on self-reported measures. In addition, because a Minimal Clinically Important Difference (MCID) has not yet been established for the Parental Stress Scale in mothers of preterm infants, the clinical meaningfulness of the reduction remains uncertain. Therefore, while the findings are promising, they should be interpreted with caution, and further randomized studies are needed to confirm the clinical significance of these effects.

It is important to consider the study setting when interpreting these results. The participants were mothers of infants admitted to the neonatal intensive care unit (NICU), a controlled environment with limited parental access, mostly for breastfeeding purposes. In typical hospital-based care models, parents of preterm infants often do not receive structured educational or supportive interventions. Therefore, any educational or spiritual intervention may have a substantial impact on maternal stress levels. Part of the observed reduction may also be influenced by mothers’ awareness of receiving the intervention, potentially leading to response bias. Comparing spiritually-based education with other types of educational interventions could provide additional insights, and explanatory mixed-methods studies may offer a deeper understanding of the mechanisms behind stress reduction.

The control group showed a significant increase in post-test stress levels compared to pretest scores, likely due to mothers’ concerns about the appearance and health of their preterm infants. These concerns, compounded by a lack of information and communication with NICU staff, led to heightened stress. In contrast, mothers in the intervention group, supported by the spiritual educator and researcher, reported greater confidence, motivation, and hope, contributing to improved existential well-being and better communication with NICU nurses. The absence of such support in the control group may explain their reduced ability to cope. These findings highlight the importance of incorporating spiritual and educational interventions into NICU care. Furthermore, nursing managers can facilitate the provision of specialized spiritual self-care education by experts to target groups, including mothers of preterm infants, by creating favorable conditions in hospitals, such as organizing skilled human resources [46]. Creating supportive hospital environments can enhance maternal spiritual skills, strengthen emotional bonds, and improve the overall well-being of both mothers and infants. Observed significant stress reduction in the intervention group should be interpreted cautiously, as it may be influenced by factors such as the Hawthorne effect or response bias, rather than solely by the intervention itself.

Limitations and suggestions for future studies

A major limitation of this study is its sequential quasi-experimental design and the absence of randomization, both of which increase the likelihood of temporal bias and the influence of underlying secular trends. Although the environmental conditions, staffing levels, and NICU care protocols were reported to remain stable throughout the study period, the lack of parallel comparison groups limits the ability to fully control for time-dependent factors. In addition, the use of convenience sampling may have restricted the representativeness of the sample, thereby reducing the generalizability of the findings. Therefore, despite the improvements observed in spiritual well-being, the results should be interpreted with caution. Future randomized controlled trials are recommended to confirm the robustness and clinical applicability of these findings.

Some demographic characteristics also differed between the control and intervention groups, which may be attributable to the sequential recruitment process, convenience sampling and nonrandom allocation. Although statistical adjustment was performed using MANCOVA and covariates were selected based on predefined statistical and theoretical criteria, not all baseline variables were included in the final model. Variables such as maternal education and household income were excluded because they did not demonstrate sufficient statistical association with the outcome variables according to the predefined selection thresholds. Additionally, although gestational age was initially considered as a potential covariate, collinearity with infant feeding type led to the inclusion of infant feeding in the final model instead. While these decisions were made to ensure model stability and methodological rigor, it remains possible that some variables may have exerted subtle or indirect effects that were not fully captured. Therefore, residual confounding cannot be entirely excluded, and the findings should be interpreted with appropriate caution.

Another limitation is that study outcomes was assessed solely through self-report measures. While self-report is a common method in behavioral and psychological intervention studies, it is inherently susceptible to reporting bias, such as social desirability bias, which may lead to an overestimation of the actual level of engagement or compliance with the prescribed training modules. This reliance on subjective reporting, in the absence of objective verification methods (e.g., daily logs verified by an independent party or use of specific tracking technologies), represents a potential constraint on the true fidelity of the intervention delivery. Future studies should seek to incorporate objective measures or triangulation of data sources to provide a more robust assessment of participant adherence. The substantial improvements observed in both maternal stress and spiritual well-being should be interpreted cautiously, as they may have been influenced not only by the intervention itself but also by potential Hawthorne effects and response bias. Although the magnitude of stress reduction suggests a potentially meaningful clinical benefit, the minimal clinically important difference (MCID) for maternal stress in mothers of preterm infants has not been clearly established. Therefore, the clinical significance of the observed changes in stress remains uncertain. Future research should aim to establish and validate the MCID for maternal stress and further explore the practical significance of changes in spiritual well-being within populations of mothers of preterm newborns.

Furthermore, the study was conducted in an Islamic/Middle Eastern setting, which may limit the generalizability of the findings to populations with different cultural or religious backgrounds. Future studies, if feasible, employing random sampling and random allocation within a controlled trial using a parallel-group design, or the assignment of two comparable hospitals to intervention and control groups, may yield more robust and generalizable findings. In addition, examining the effects of similar interventions in diverse cultural and social contexts may provide more robust and generalizable findings.

Conclusions

The findings of this study demonstrated that Islamic-Based spiritual self-care education was associated with increased spiritual well-being and reduced maternal stress among mothers of hospitalized preterm newborns. These results suggest that spiritual self-care interventions may represent a promising and potentially cost-conscious supportive strategy in this population. The findings also highlight practical implications for nursing care, including the integration of Islamic-Based spiritual education into supportive programs for mothers. However, given the non-randomized sequential design, baseline differences between groups, and the cultural context of the study, the results should be interpreted with caution and should not be considered definitive evidence for routine clinical decision-making. Further randomized parallel-group trials conducted in diverse settings are needed to confirm the robustness and generalizability of these findings.

From a theoretical standpoint, spiritual self-care engages existential capacities and moral virtues to strengthen coping and psychological well-being. In this study, structured Islamic practices, such as prayer, Quran recitation, and supplication, were incorporated into the Richards and Bergin spiritual care framework, representing a culturally adapted innovation within the NICU context. Through their behavioural, cognitive, emotional, and ethical dimensions, these practices may foster greater meaning, a sense of belonging, and more effective coping with stressful experiences. Spirituality has been shown to enhance individuals’ ability to interpret negative events and sustain a sense of control when facing challenges, while responses to stress are shaped by genetics, personality, environment, and social support. In line with Orem’s perspective, self-care is a fundamental determinant of health maintenance and promotion, and spiritual self-care appears to reduce stress by strengthening coping skills and resilience.

Abbreviations

NICU

Neonatal Intensive Care Units

SWBS

Spiritual Well-Being Scale

PSS

Parental Stress Scale

SPSS

Statistical Package for the Social Sciences

ITT

Intention-to-Treat

MCAR

Missing Completely at Random

MAR

Missing at Random

MANCOVA

Multivariate Analysis of Covariance

AS

Alayhim al-Salaam

MCID

Minimal Clinically Important Difference

IRCT

Iranian Registry of Clinical Trials

Authors’ contributions

Study concept and design (RG, MS, MK); Data collection (MK); acquisition of subjects and/or data analysis and interpretation (RB); preparation of manuscript (SP, RG, MK). All authors have read and approved the manuscript.

Funding

This study was funded by Research Deputy of Bushehr University of Medical sciences in the framework of the grant number: ‘1465, 2/07/2023’. The funder had no role in the study implementation, data collection, data analyses or interpretation of study results.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was reviewed and approved by the Ethics Committee of Bushehr University of Medical Sciences, with the ethical code ‘IR.BPUMS.REC.1402.106’. Furthermore, the present study has been registered with the Iranian Registry of Clinical Trials (IRCT) under the registration code ‘IRCT20250530065981N1’ on 18/07/2025. The research was conducted in accordance with ethical guidelines set forth by the Helsinki Declaration. Informed consent was obtained from all participants, who were made aware that participation in the study was voluntary, and that their names would not be included in the questionnaire due to confidentiality. Additionally, participants were informed that they could withdraw from the study at any time.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.