INTRODUCTION:

Spirituality and spiritual care are well known to be essential aspects of patient care. Therefore, the different interpretations of spirituality may influence the quality of care for patients [1]. In the provision of holistic nursing care, spirituality is an essential part of an individual's health and well-being [2]. As defined by Narayanasamy [3] spirituality is the essence of being and provides meaning and purpose to one's existence; it is the intangible dimension that connects humans to one another and their surroundings [3]. While spirituality and religion have historically been inextricably associated with each other and the terms have often been used interchangeably, for many people they have become distinct and independent constructs that separate religious observance and ritual from spiritual experience [4].

The definition of spirituality may vary in different cultural context. In the Iranian context, according to Quran and the teachings of Muhammad that forms the essence of religious and cultural lives of Muslims, religious belief and practices is the core of spirituality. The Islamic religion plays an integral role in Muslim cultural perspectives concerning illness. Diseases in Islamic tradition are of four types: spiritual, functional, structural, and superficial. Most of Muslim patients believed that the disease is a religious fate, something selected by God for them, for which there is no way out but surrender. They views disease as an examination by God [5].

Spiritual care seeks to affirm the value of each and every person based on non judgmental love [6]. In other words, it is about supporting and helping people maintain their personal and spiritual identities [7]. Govier [8] defined the concept of spiritual care in 5Rs: Reason, Reﬂection, Religion, Relationship and Restoration. Undoubtedly, spiritual care is a part of holistic care, so it is essential for nurses to give such care during their clinical practice [6]. According to Kociszewski [9] spiritual care is a prominent concern for critically ill patients. He goes on that critical care nurses have demonstrated that it is difficult to differentiate between patient’s spiritual and psychosocial needs.

Reviewing literature revealed that nursing critical care is highly limited to “technological caring” and spiritual care was clearly neglected [9]. Providing spiritual care is distinctly separate from the health care professionals' usual focus of identifying and resolving specific problems [2]. Chan et al. [6] assessed Hong Kong nurses’ perceptions of spiritual care and practices. They reported that nurses’ different levels of spiritual care perceptions and practices affect patients’ healing process. Lundmark [10] also assessed nurses’ attitudes towards spiritual care in a Swedish oncology unit. They found that 98% of nurses indicated that holistic care was of great importance. 76% of nurses thought that holistic care included spirituality. The nurses’ opinion showed that they should engage in spiritual care. Strang et al. [11] found that the majority (87%) of Swedish nurses indicated a positive attitude towards patients’ spiritual needs. In the literature review two Iranian studies, were found that showed nurses’ perspective about spirituality and spiritual care [12, 13]. In cross-sectional study, Mazaheri et al., [12] reported that majority of psychiatric nurses had a positive attitude towards spirituality and spiritual care . Abbasi et al., [13] examined first and forth year Iranian nursing students’ spiritual well –being and their perspectives about spiritual care. They found that 98.8% of the first year and 100% of the fourth year students were in the group of moderate spiritual well-being. They had a moderately positive perspective towards spiritual care. No significant difference was found between first and fourth year nursing students’ perspective towards spiritual care. Since nurses are continuously are in contact with critically ill patients, they should considered the wholeness and integrity of patients in order to provide their spiritual well-being [14, 4]. In many instances, spiritual assessment is not conducted and, when it is, the resultant diagnosis and planned interventions are frequently not adequate to meet the spiritual needs of patients [15]. In Iran, spiritual care is a new concept and studies on the subject are rare. As most research exploring nurses’ perception on this topic was conducted in western countries, these findings may not be applicable in the Iranian context because of the cultural differences. So, further studies need to be conducted to gain more insights into spiritual care by use of new tools as data collection instruments, especially suitable to Iranian Culture [13]. This knowledge is necessary, not only to be able to evaluate the present situation of spiritual care, but also to make projections about the situation in foreseeable future, point out realistic goals for tomorrow. This can also make a basic context for improving the holistic care. Therefore, this quantitative study was done to examine the Iranian critical care nurses’ perception about spiritual care.

METHOD:

Design

This study is a descriptive, cross-sectional study. The research ethics committee in Kerman Medical University approved the study. A census sample consisted of 152 critical care nurses working in critical care units supervised by Kerman Medical University participated in this study. There was an approval from the heads of critical care units prior to the collection of data.

Instruments

Demographic information

First, a questionnaire was developed to obtain demographic information which was assumed to influence spiritual care perception. It included questions about gender, age, marital status, and religiosity (belief in god, attendance to religious services, effect of religious advocates on their recovery, effect of their belief to the God on their recovery from the disease, religious advocates).

Iranian spiritual care perception scale

To examine critical care nurses' perception of spiritual care, Iranian Spiritual Care Questionnaire was used. Development and validation of this scale was done by Iranmanesh et al [16]. This is a self administered questionnaire consist of 33 items categorized in four components. These components were identifies as: (1) meeting patient as a being in meaning and hope, (2) meeting patient as a being in relationship , (3) meeting patient as a religious being, and (4) meeting patients as a being with autonomy. The items’ responses were graded from 0–5 (0= strongly disagree, 5= strongly agree). The scale scores ranged from 0 to 165 and greater score indicate a high level of spiritual care perception. This means neutral to positive perception [16]. The original version of questionnaire was developed in English and, after initial validation, translated to Farsi for further validation. For translation of questionnaires from English into Farsi, the standard forward-backward procedure was applied.

The validity of scale has been assessed through a content validity discussion. Scholars of statistics and nursing care have reviewed the content of the scales from religious and cultural aspects of spiritual care and agreed upon a reasonable content validity. The alpha coefficient of the scale was 0.89. The three weeks test-retest coefficient of stability was 0.80. To examine the construct validity of the scale a factor analysis (Rotated Component Matrix) was done. The KMO measure of sampling adequacy was computed to determine the adequacy of the items for analysis within this sample. The KMO was 0.57. Four components with an eigenvalue >1 were identified [16].

Data collection and analysis

Accompanied by a letter including some information about the aim of the study, the questionnaires were handed out by the author to 152 nurses who were introduced by the head of each ward at work during winter 2011. Some oral information about the study was also given as well by the author. Participation in the study was voluntary and anonymous. All questionnaires filled in by respondents. In all collected data, 98 % of all questions were answered. Data from the questionnaires were analyzed using the Statistical Package for Social Scientists (SPSS). A Kolmogorov-Smirnov test indicated that the data were sampled from a population with normal distribution. Descriptive statistics of the sample and measures that were computed included frequencies, means and reliability. Checking the effect of categorical variables on spiritual care perception, Independent t-test and One-Way ANOVA was performed. T-test was used to identify the relationship between gender (male, female), Education (Diploma, Bachelor), Job experience (≤10, >10), Marriage status (Single, Married), Attendance to religious services (always, sometimes), Religious advocates (Yes, No) and spiritual care perception score. ANOVA-test was used to identify the relationship between age group (20-29, 30-39,40-50)/ Effect of their belief to the God on their recovery from the disease (totally effective, relatively effective, no effective) and spiritual care perception score. The significance level was set to P < 0.05.

RESULTS AND DISCUSSION:

Background information

A descriptive analysis of the background information revealed that the mean age of the participants was found to be 32.22± 6.74. Participants’ demographic characteristics are listed in table 1. 69% of participants belonged to the age group of 30 to 39 years. The mean age of them was 32.56 years. About 91% were married. Considering religiosity, all of participants were Muslim. 77% reported that religious advocates positively affect their recovery. 78.9% claimed that they attended to the religious services. 75.7% reported that their belief to the God positively affect their recovery from the disease. According to T-test, a positive correlation was found between spiritual care perception and religious advocates (p=0.002). Critical care nurses belief to the God also positively affects their spiritual care perception (p= 0.03).

Spiritual care perception

The critical care nurses, mean score of spiritual care perception was 98.89 ± 16.50. Frequencies in each item showed in table 2. According to the results, the mean score of spiritual care perception among a sample of critical care nurses in South-East of Iran was high (m= 98.89). This is similar to the results of Mazaheri et al. [12] study. They reported that majority of psychiatric nurses had a positive attitude towards spirituality and spiritual care. Strang et al. [12] also found that the majority (87%) of Swedish nurses indicated a positive attitude to the patients’ spiritual needs. Chan et al. [6] asserted that nurses’ different levels of spiritual care perceptions and practices affect patients’ healing process. They continued that understanding nurses’ spiritual care perceptions and practices related to such care is important for future professional development.

In the first category (meeting patient as a being in meaning and hope) 48% of critical care nurses perceived that being aware of patients’ source of meaning and hope in life is spiritual care. Based on the findings of earlier studies [1, 17, 18, 19] assisting patients to find meaning in life was one of the meaning nurses give to the spiritual care. Wright [20] concluded that spiritual care is related to the acknowledgment of a person’s sense of meaning and purpose in life, which may, or may not, be expressed through formal religious beliefs and practices. 46% percent of participants believed that spiritual care is assisting patient to have positive view on life. In addition 44% of them perceived spiritual care as being aware of things that patient is unable to do them in life.

Table 1 Background information of critical nurses
Characteristics	N	%
Gender
Male [%]	35	23
Female [%]	117	77
Marriage status
Single	61	40.1
Married	91	59.9
Age [years]
20-29	50	32.9
30-39	69	45.4
40-50	33	21.7
Education
Diploma	36	23.7
Bachelor	6	76.3
Job experience
≤10	92	60.5
>10	60	39.5
Attendance to religious services
Always	32	21.06
Sometimes	120	78.94
Religious advocates
Yes	51	33.6
No	101	66.4
Effect of their belief to the God on their recovery from the disease
Totally effective	115	75.5
Relatively effective	37	24.4
Not effective	4	2.6

In the second category (meeting patient as a being in relationship), 34% of participants strongly agreed that spiritual care is giving support to patient and express empathy with him \her. Participants (32.7%) reported that being available to listen to patient s feeling is spiritual care. Chan et al., in 2006 examined Hong Kong nurses’ perceptions of spiritual care. Based on their findings, most of nurses (nearly 50%) agreed/strongly agreed that nurses can provide spiritual care by listening to the patient’s concerns, discussing and exploring their fears, anxieties and troubles [6]. Iranmanesh et al. [21] 23 also interpreted the meaning of a caring relationship as getting involved in a mutual/demanding close relationship. Edwards et al. [22] asserted that spirituality principally focused on relationships, rather than just meaning making, and was given as a relationship. Relationships formed an integral part of spirituality as they were a spiritual need, caused spiritual distress when broken and were the way spiritual care was given.

Table 2 Frequencies in each item

Question	SA%	A%	MA%	MD%	D%	SD%
Component1: meeting patient as a being in meaning and hope
1.1: Being aware of patients’ source of meaning and hope in life.	48	36.7	14	1.3	0	0
1.2: Providing spiritual care by enabling a patient to find meaning in the good and bad events of life.	30.7	39.3	24.7	4	1.3	0
1.3: Knowing what is truly important to the patient.	30	47.3	20.7	2	0	0
1.4: Being aware of patient’s perception of meaning and purpose in life.	28	45.3	24.7	1.3	0.7	0
1.5: Assisting patient to have positive view on life.	46	40	11.3	2.7	0	0
1.6: Being aware of things that patient is unable to do them in life.	44	42.7	10	2	1.3
Component 2: meeting patient as a being in relationship
2.1: Being available to listen to patient s feeling.	32.7	50.7	12.7	2.7	1.3	0
2.2: Talking with patient to relive the sense of guilt.	29.3	44	24.7	1.3	0.7	0
2.3: Giving support to patient and express empathy with him \her.	34	38.7	18	7.3	2	0
2.4: Encouraging participation in interact with family members, friend and others.	30	42.7	23.3	3.3	0.7	0
2.5: delivery of flower by visitors (family – friends,… ).	20	31.3	42	4	2.7	0
2.6: Staying with patient and being alongside him /her.	24	41.3	27.3	6.7	0.7	0
2.7: Providing meeting with similar patients.	17.3	39.3	31.3	8.7	3.3	0
2.8: Calling long-lost friend.	19.3	25.3	33.3	18.7	3.3	0
Component 3: meeting patient as a religious person
3.1: Jointing with patient in prayer and reciting the Quran, if desired.	24.8	27.5	30.2	14.1	3.4	0
3.2: Reassuring the patient that god is listening, loving and caring.	38.3	35.6	22.1	3.4	0.7	0
3.3: Blessing for patient if desired.	36	24	26	2	3	9
3.4: Assisting patient who is unable to perform his religious worship.	38.3	38.3	18.1	4	1.3	0
3.5: Providing radio or TV religious programs to the patient.	31.5	44.3	21.5	2.7	0	0
3.6: Encouraging patient to do religious ritual.	33	46	9	10	2	0
3.7: Encouraging patient to use religious worship and cultural tradition.	22.1	43.6	24.8	6.7	2.7	0
3.8: putting a prayer book within reach.	24.2	39.6	29.5	3.4	3.4	0
3.9: Facilitating cultural practice that patients and their family find comforting.	22.1	40.9	28.9	4.7	3.4	0
3.10: Giving information to the patient about how to do some worship at the time of disease.	32.9	40.9	20.8	3.4	2	0
Component 4: meeting patients as a being with autonomy
4.1: Being not allowed to judge about patient’s religious views.	26.8	43.6	23.5	4.7	1.3	0
4.2: Providing peace of mind for patient.	25.5	49.7	18.8	4.7	1.3	0
4.3: Accepting patients who are stick on their beliefs about spirituality.	36.5	37.8	20.3	4.7	0.7	0
4.4: Respect for patients who have different religious views.	42.3	36.9	18.1	1.3	1.3	0
4.5: Allowing patient to eat his/her favorite food.	35.2	40	20.8	1.6	2.4	0
4.6: Providing opportunity for patient to meet his/her family to relief his/her spiritual pains.	42.4	40	15.2	2.4	0	0
4.7: Respect for patient’s willing to stay weather at home or at hospital.	24.8	31.2	28	10.4	5.6	0
4.8: Being attention to patient’s spiritual views.	29.6	41.6	19.2	6.4	3.2	0
4.9: Talking about spiritual care if patient desired.	31.2	40.8	21.6	5.6	0.8	0

Values are given as (%).

SA, strongly agree; A, agree; MA: moderately agree; MD: moderately disagree; D: disagree; SD: strongly disagree.

In the third category (meeting patient as a religious person) 38.3% of participants thought that reassuring the patient that god is listening, loving and caring is spiritual care. Spiritual care also perceived by critical care nurses as assisting patient who is unable to perform his religious worship as well as encouraging patient to do religious ritual. According to Edwards et al. [22] spirituality is about transcendence, a relationship or connection with God or a higher being. Prayer is used to connect to God, and there is a sense of a power connecting with them. Callister et al. [23] also asserted that religious practices such as prayer, rituals, and worship may serve as a means for the expression of spirituality.

According to the findings, in the forth category (meeting patients as a being with autonomy) 42.4% of respondents strongly agreed that spiritual care is providing opportunity for patient to meet his/her family to relief his/her spiritual pains. Spiritual care also perceived by 42.3% of critical care nurses as respect for patients who have different religious views. Milligan [24] also explored nurses’ perception of spiritual care and found valuing and supporting autonomy as one of the meaning nurses gave to their care of spirit. According to Murata [25] spiritual pain of the person as a being with autonomy develops from the experience of heteronomy and dependence on others, that is, “becoming unable to do anything”. He goes on that if the patient becomes aware that he/she still has enough freedom of self-determination in each dimensions of perceiving, thinking, speaking, and doing, that is, the perception, thoughts, expression, and activities through his/her talks with spiritual care workers, he/she is certain to recover the sense of value as a being with autonomy.

CONCLUSION:

The results of this study indicate that Iranian critical care nurses perceived spiritual care as meeting patient as a being in meaning and hope, a being in relationship and a being with autonomy. Spiritual care raises a demand that calls nurses to create a close relationship with patients. Since the relationship is one of the most important issues in spiritual care perceived by Iranian nurses, it should be more highlighted in nursing curriculum/ or nursing guidelines. It should also be regarded by health care managers to be supportive and enable nurses to stand up to the demands of close. Professional caregivers must be sensitive and pay attention to the preferences of each unique person’s perceptions through her or his senses. Nurses should be offered opportunities to reflect on their experiences, feelings, actions and reactions to spiritual care in their families in order to enhance the possibilities to utilise personal experiences as a part of positive and constructive learning.

ACKNOWLEDGEMENTS:

We wish to thank the participants who completed the questionnaires and the hospital management who facilitated this study.

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Received on 13.08.2013 Modified on 28.08.2013

Asian J. Nur. Edu. and Research 3(4): Oct.- Dec., 2013; Page 262-266

Spiritual Care: Iranian Critical Care Nurses’ Perception