Nurses' perceptions of spirituality and spiritual care giving: A comparison study among all health care sectors in Jordan
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0973-1075.173949
Source of Support: None, Conflict of Interest: None
Aims: This study aimed to describe nurses' perceptions of spirituality and spiritual care in Jordan, and to investigate the relationship between their perceptions and their demographic variables.
Keywords: Jordan, Nurses, Spiritual care, Spirituality
Today, spiritual care is considered an essential part of the overall care provided to improve the quality of life for patients and their families., The World Health Organization (WHO) has stressed the importance of patients' physical, psychological, social, and spiritual well-being rather than just focusing on the disease.
The meaning of spirituality and spiritual care among nurses is culturally constituted and influenced by many factors, such as the nurse's ethnic background, religious affiliation, level of education, and clinical experience.,, Moreover, different nursing specialists have different perceptions of spirituality and spiritual care. Many studies have argued that hospice and palliative care nurses have a better perception of spirituality and spiritual care and are more competent at providing spiritual care than other nursing specialists., In addition, nurses who were employed in Midwifery, Pediatric or Psychiatric Departments demonstrated more perception of spirituality and spiritual care than other nurses (Chan, 2009; Ozbasaran et al., 2011).
Nurses' perceptions of spirituality and spiritual care affect their ability to provide spiritual care.,,, Many authors have, however, suggested that current nurse perceptions of spirituality and spiritual care are mostly based on the Western “Judeo-Christian” culture; this is not necessarily consistent with the perception of spirituality and spiritual care of nurses from other cultures.,,,,,
Although nurses consider spiritual care to be at the heart of the care they provide, their perceptions and levels of understanding of spirituality and spiritual care vary, which may affect their ability to provide a consistent quality of care.,, In addition, the readiness of nurses to provide spiritual care to their patients is influenced by their perception and understanding of spirituality and spiritual care. Studies conducted to explore nurses' perceptions of spirituality and spiritual care showed that nurses who were more knowledgeable on the meaning of spirituality were more able to provide spiritual care.,,,
Nurses' demographic characteristics can influence their individual perceptions of spirituality and spiritual care. Previous studies have reported the influence of some of these characteristics, such as a nurse's age, marital status, education level, and years of experience.,,
Globally, several studies have provided valuable insight into the range of nurse perceptions of spirituality and spiritual care. However, there is a lack of research investigating nurses' perceptions of spirituality and spiritual care in Jordan. This study provides some initial research into Jordanian nurses' understanding of spirituality and spiritual care to inform these nurses, other stakeholders, and nurse educators of the current situation, any potential for improvements, and the impact on patient and family care.
Spirituality is an abstract, subjective, and complex term, whose definition varies between individuals, philosophies, and cultures, and which has abstract components associated with many subjective meanings., These characteristics lead many authors to argue that there is no agreement on the definition of spirituality as a concept.,, On the other hand, many studies have revealed a clear definition of spirituality in the nursing literature (Tanyi, 2002; Vachon, Fillion, and Achille, 2009)., Studies have tended to explore the understanding of spirituality from the perspective of a predominantly Western culture, with the majority being either Christians or without religion. These studies found spirituality to be highly related to the way people searched for the meaning of life, and that it was generally perceived as being separate from religion., It has been demonstrated, however, that Muslims perceive their spirituality as being inseparable from their religion and as being derived from the Holy Qur'an and the Hadiths (Sunnah).,,, This view of the inseparability of spirituality and religion was revealed in nursing studies that were conducted among other cultures, such as Taiwanese and Maltese.,
Spiritual care is defined as “actions to meet the spiritual needs of the patient and family.” Nurses provide spiritual care to meet the spiritual needs of the patients and their family in an attempt to improve the quality of life during the patient's disease trajectory.,
The responsibility to provide spiritual care is an emerging subject in nursing literature. Several studies' findings have confirmed that nurses consider this aspect to be a vital part of nursing care.,, Although spiritual care is a vital and basic requirement of the nursing role, many nurses reported that they need further support when providing spiritual care to their patients, and most of them asked for help from multi-faith centers within the hospital.,,
Studies suggest that providing spiritual care could help patients improve their physical comfort, decrease levels of anxiety, and increase their hope for the future.,, Furthermore, spiritual practices serve as coping resources, improve pain management, enhance surgical outcomes, safeguard against depression, and minimize the chance of patients engaging in substance misuse and suicidal behaviors. In addition, people reporting a greater awareness of their spirituality co-reported that they are healthier.
Studies conducted among different nursing specialists and in different cultures and aiming to discover what types of nursing spiritual care can be provided to satisfy patients' and families' spiritual needs reported many different interventions. The spiritual care interventions most often reported by nurses were a compassionate presence with patients, accepting and respecting patients' feelings, consulting chaplains about patients' concerns, sharing in patients' religious practices, educating patients, maintaining patient confidentiality, being nonjudgmental, advocating and facilitating patient and family needs, assisting patients in accomplishing uncompleted tasks, facilitating patient communication with family and relatives, and reassuring patients.,,,
A cross-sectional descriptive design was used to describe current nurses' perceptions of spirituality and spiritual care and to investigate the relationship between their perceptions and demographic variables within eight hospitals in Jordan. A survey was used as the data collection method. This method was considered appropriate because the research purposes required obtaining baseline information from subjects, rather than deducing cause-and-effects relationship between variables, and because it helped the researcher to gather extensive data from a large group of nurses within a short period of time.
This study was conducted in Jordan. In Jordan, the health care system is divided into four main sectors; University Affiliated Hospitals (n = 2), private hospitals (n = 61), governmental hospitals affiliated to the Ministry of Health (MOH) (n = 31), and military hospitals affiliated to the Royal Medical Services (n = 12) (MOH statistics, 2011). [Table 1] displays the total number of hospitals in Jordan, the number of hospitals in each sector, the total number of beds, and the number of registered nurses. This study included all health care sectors in Jordan that provide health care services and took place in eight different hospitals: Two hospitals from each health care sector.
A convenience sample of 560 registered nurses was invited to participate in this study. Registered nurses who were Arabs, who were employed in one of the hospitals involved in the study, and who had agreed to participate were eligible to take part in the study; there were no specific criteria for eligible participants regarding their personal characteristics (i.e., age, gender, etc.).
The data were collected from study participants between 20th June and 15th September 2013. Registered nurses from the eight selected hospitals in Jordan were invited to voluntarily participate in the study. Approval for the study was given by the institutional review committee in each hospital. The researcher directly contacted the majority of registered nurses who were available in various departments at the proposed hospitals during the data collection period and invited them to participate in the study. All registered nurses who met the inclusion criteria and agreed to participate received an information sheet about the study's purpose and procedures, together with the study questionnaire. Confidentiality and anonymity in data handling were assured. A stamped addressed envelope was also provided to facilitate the collection of the questionnaires. The return of the questionnaire was considered as an agreement to participate.
Spiritual care-giving scale
The spiritual care-giving scale (SCGS) was adopted, after obtaining the authors' permission, to determine the nurses' perception of spirituality and provision of spiritual care. The SCGS was used in this study because it was developed in multicultural society to measure perceptions of spirituality and spiritual care in practice, and it has satisfactory reliability and validity with Cronbach's alpha 0.86.
The tool consists of 35 statements that are categorized under five factors, as follows. The first factor, “attributes for spiritual care,” is an eight-item factor that explores participants' views on the importance of having certain attributes to enable a nurse to engage in spiritual care-giving. The second factor, “spirituality perspectives,” has eight items exploring the definition of spirituality from the participant's perspective. The third factor, “defining spiritual care,” contains seven items which explain the meaning of spiritual care from a nurse's perspective. The fourth factor is “spiritual care attitudes.” This factor has seven items which are used to evaluate individuals' attitudes toward perspectives. The fifth factor, “spiritual care values,” includes five items that explore nurses' beliefs and understanding about spirituality and spiritual care values.
Each statement in the SCGS is rated on a six-point Likert scale ranging from one “strongly agree” to six “strongly disagree.” The SCGS is scored by calculating the arithmetic mean across all items for the average score, which ranges from 1 to 6. In general, ratings of four and higher indicate agreement with scale items.
Descriptive statistics were used to describe and summarize study participants' demographic characteristics. An independent sample two-tailed t-test, One-way analysis of variance and a Pearson's product-moment correlation test were used to infer group differences in participants' perception of spirituality and spiritual care and their demographic characteristics. The level of significance was set at 0.05.
The total number of participants who completed and returned the questionnaires was 408, representing an overall response rate of 72.8% (408 out of 560) from all health care sectors in Jordan. In this study, more than the half of the participants were females (n = 208, 51%) and 49% (n = 200) were males. The means of the participating nurses' age and length of clinical experience were 28.2 years (standard deviation [SD] 4.90 years), 5.5 years (SD 4.86 years), respectively. Of the 408 participating nurses, 374 (91.7%) reported that they held a bachelor's degree in nursing. More than one-third of the participants (39.5%) were working in adult medical or surgical wards, whereas about one-third 32.2% (n = 131) were working in Intensive Care Units. 379 (92.9%) participants reported that they had not previously taken spiritual care courses. [Table 2] shows the demographic data of the participants who were involved in the study.
Results of spiritual care-giving rating scale
The mean value of the average item on the SCGS was 4.56 (SD = 0.65) with a median of 4.00 (max–min: 5.64–1.64) indicating a high level of agreement with scale items. A full set of results is presented in [Table 3].
Item-by-item analysis revealed that Item 2 (”spirituality is an important aspect of human existence”) and Item 35 (”spiritual care is important because it gives the patient hope”) had the highest average score of all the SCGS items (M = 5.15 ± 0.96; M = 4.90 ± 1.01, respectively). Item 1 (”everyone has spirituality”) and Item 12 (”spiritual care is more than religious care”) obtained the lowest average score (M = 2.83 ± 1.10; M = 2.99 ± 1.53, respectively).
Relationship between spiritual care-giving scale and sample characteristics
The results showed no statistically significant relationship between average total SCGS score and nurses' age and length of clinical experience (P = 0.945, 0.587, respectively). In addition, marital status was not linked to any statistical difference in average total SCGS score (t = 0.112, df = 406, P = 0.911), and neither was area of work (F = 0.379, df = 404; P = 0.685), nor their marital status (t = 0.112, df = 406, P = 0.911). On the other hand, there was a significant link between participants' gender and their average total SCGS score (t = −2.97, df = 406, P = 0.003); the average total SCGS score for male nurses was 4.54 (SD = 0.71), which was lower than the average total SCGS score obtained by female nurses (M = 4.71, SD = 0.58). Furthermore, there was a significant link (t = 3.20, df = 406, P = 0.001) between the average total SCGS scores and previous attendance of previous spiritual care courses; the average total SCGS score for nurses who had previously attended spiritual care courses was (M = 5.00; SD = 49), which was higher than the average total SCGS score indicated by nurses who had not previously had such courses (M = 4.60, SD = 66). In addition, there was a significant difference in the average total SCGS score between different health care sectors; a post-hoc test revealed a significant difference between the private and the governmental sectors in relation to the average SCGS score (P = 0.049). Looking at the means to describe the results, it seems that nurses working in the private sector had an average SCGS score (M = 4.71; SD = 0.7) which was significantly higher than nurses working in the governmental sector.
The findings of this study revealed a high level of spirituality and spiritual care perceptions of spirituality and spiritual care among participating nurses in all health care sectors in Jordan. Although the majority of participating nurses had not taken any previous spiritual educational courses, the majority was oriented toward spirituality, and they appreciated the importance of spiritual care being given to their patients. This result is consistent with a number of studies conducted in many Western and Eastern cultures which explored nurses' perceptions of spirituality and spiritual care; these studies found that nurses had an acceptable understanding of spirituality and a willingness to provide spiritual care to their patients.,, In a study conducted by Wong et al., Chinese nurses reported a high level of understanding and awareness of spirituality as a concept, and reported enthusiasm and great interest in giving spiritual care to their patients. Conversely, our results are inconsistent with the study of Ozbasaran et al. which reported confused perceptions of spirituality and spiritual care among Turkish nurses. This difference might be related to the variation in both study tools.
Participating nurses' perceptions of “attributes for spiritual care” indicated that 87% of nurses believe that spiritual care has some characteristics which are considered as basic prerequisites to providing this type of care. This finding possibly suggests that study participants acknowledge that establishing a rapport and building trust relationship with patients would help the nurse to engage in providing spiritual care and would facilitate addressing patient's spiritual needs. The results resonate with the study conducted by Tiew et al. who found that nursing students in Singapore viewed the nurse-patient relationship as crucial in facilitating appropriate spiritual nursing care. Leeuwen et al. found that nurses considered the spiritual dimension sensitive; a topic they were not able to discuss with patients unless they had established a resilient trust relationship with them. Furthermore, Baldacchino  suggested that because of the sensitive nature of a patient's spirituality, nurses need to establish a trust relationship with patients before addressing their spiritual needs.
The results of this study suggest that although most nurses showed agreement with a number of “spirituality perspectives,” they did not agree that “everyone has spirituality.” The findings indicated that the participating nurses believe that spirituality does not exist in all human beings. This could be due to lack of knowledge of the definition of spirituality and spiritual care. In addition, Islamic culture may contribute to these findings as the majority of participants were Muslims.
In this study, responses to items regarding “defining spiritual care” suggested that most nurses perceive that good spiritual care means focusing on respecting patients' beliefs and dignity as well as respecting their needs to share their feelings and concerns with others. This finding is consistent with the study by Leeuwen et al. in which nurses reported that spiritual care helps them to respect the patients' emotions and beliefs and to pay attention to their feelings and concerns. In addition, Abu-El-Noor  found that Muslim patients in Gaza need nurses to appreciate their humanity, confidentiality, traditions, and belief system.
Although most nurses considered spiritual care as a nursing competency, they also considered Item 40 “A team approach is important for spiritual care” is essential for the provision of spiritual care. This result could be related to the complexity of the spiritual dimension; it is difficult for the nursing profession alone to satisfy patients' spiritual needs. This hypothesis is supported by Baldacchino, who found that despite nurses' acknowledgment of their professional role in providing spiritual care they viewed themselves as lacking some skills to deliver this care appropriately. Therefore, they suggested that applying a multidisciplinary team approach for the provision of spiritual care may support nurses in their role.
Regarding “spiritual care attitudes,” the majority of participating nurses acknowledged that the significance of spiritual care is in giving hope to patients. This finding is consistent with McSherry and Jamieson, who found that about 77% of British nurses considered hope to be essential part of human spirituality, and that 95% of them viewed hope as one of the most important spiritual needs that the nurse has to address in caring for their patients.
Another remarkable finding, which is indicated by the high score on Item 31, (”spiritual care should be instilled throughout a nursing educational program”), is nurses' need to have spiritual care integrated into nursing education and training in Jordan. Incorporating spirituality into nursing educational programs is recommended to enhance nurses' knowledge and skill in handling spiritual issues and to increase their awareness of patients' spiritual needs, which would facilitate the provision of appropriate holistic care.,, Since Muslim's spirituality is interlinked with religion and influenced by cultural beliefs and attitudes, many researchers who conducted their research in Muslim countries suggested developing spiritual care training courses based on Islamic religious values to increase understanding of spiritual aspects.
In terms of “spiritual care values,” most nurses considered that optimal care for patients required integration of spiritual care; however, they disagreed that spiritual care is more than religious care. One might query whether this finding suggests a narrow perception of spirituality and confounds the definition for the term with religious beliefs. This might be related to a view of the inseparability of religion and spirituality.
The current study reveals another worthy finding on the issue of “spirituality and spiritual care education or training.” The majority of participants had not attended spiritual courses or lectures (92.9%, n = 379), either in nursing schools or continuing education at hospitals. Similarly, in a British nursing survey about 79% of surveyed nurses reported that they had not received an adequate education on spiritual care. Such a result might be related to the absence of a formal establishment of spirituality and spiritual care training or courses either in Jordanian nursing schools' curricula or in in-service continuing educational programs at hospitals; a state of affairs that reflects a low interest in the spiritual domain. McSherry and Jamieson  suggest that the deficit in spiritual training among nurses is due to the fact that governmental and educational institutions do not consider issues related to spirituality to be an important part of nurses' education.
Relationship between spiritual care-giving scale and sample characteristics
The study revealed some existing correlations between nurses' demographic variables and their perceptions of spirituality and spiritual care. In a similar way to Tuck et al.'s  study, this study revealed significant differences in perceptions of spirituality and spiritual care between males and females; female nurses reported a much more level of spirituality and spiritual care perception than male nurses. This might be related to the fact that female nurses have a better ability to share emotions and feelings with patients than male nurses. This explanation is supported by Milligan (2001), who found that nurses considered that female nurses tend to focus on patients' emotions and feeling while male nurses focus on the physical aspects of nursing care. Contrary to the findings of previous studies,, in this study, there is no correlation between nurses' “perceptions of spirituality and spiritual care” and their age. Such result could suggest that nurses do not become “more” spiritual with age.
Further analysis showed that receiving spiritual care education appeared to have a positive impact on perceptions of spirituality and spiritual care. The findings might suggest that spiritual care education increases nurses' awareness of the importance of this aspect of care. This positive correlation has been previously reported in the nursing literature.,, For example, Wu and Lin  surveyed 350 clinical nurses to explore their perceptions of spirituality and spiritual care. They found that nurses who received spiritual care lectures reported higher levels of spirituality and spiritual care perception.
Finally, with regards to differences among health care sectors, our findings revealed one variance between the health care sectors. This variance was between participants from private and governmental health care sectors. Nurses working in the private sector reported higher levels of spirituality and spiritual care perception than nurses working in the governmental sector. This difference could be related to other factors which have not been examined in this study such as factors related to clinical settings context, factors related to institutional care policies or factors related to in-service continuing educational programs. This difference warrants further examination in future studies.
There are some limitations associated with the study: (1) Regarding the sampling technique, although the study encompassed all health care sectors in Jordan, the selection of study participants was done conveniently. The findings may not, therefore, represent the views of all nurses in Jordan. It could be that nurses who did not participate have different perceptions of spirituality and spiritual care from the participants in the study. However, the sample size was large enough to enhance the results' generalizability. Similar studies could be undertaken to investigate the views of different population that have not been explored previously such as nurse managers, or clinical nursing instructors. (2) As the nature of spirituality is complex and multidimensional, exploring the nurses' understanding and perceptions of spirituality and spiritual care using a questionnaire may not reflect all views. Findings from a qualitative research study to examine nurses' spiritual perspectives may help to explore the nurses' understanding of spirituality. (3) The study results revealed one variance among two health care sectors (private and governmental) and this difference could be related to other factors that were not examined in this study. This difference warrants examination in future studies.
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Conflicts of interest
There are no conflicts of interest.
[Table 1], [Table 2], [Table 3]