Spirituality and spiritual care are very important for patient care.1–4 Murray and Zentner defined spirituality as “a quality that goes beyond religious affiliation, that strives for inspirations, reverence, awe, meaning and purpose, even in those who do not believe in any god.”5 Spiritual care is considered as actions such as embraces, respect, offering comfort, listening to the patient, instilling hope, prayer, and holding the patient’s hand.6

Spiritual needs are less tangible than physical needs as they are multifaceted and hard to measure. Frequently, these indefinable needs have been given less importance than more obvious needs. Outside of a religious context, spiritual needs are very likelyto go unobserved. Thus, to recognize spiritual needs and provide spiritual care, it is necessary to understand the nature of spirituality and how different individuals may express it. The International Council of Nurses’ Code (1973) identifies the spiritual aspect of nursing care and recognizes the provision of spiritual care as an essential responsibility for nurses.6–9Every nurse has the responsibility to be vigilant about patients’ spiritual needs as an aspect of holistic patient care.6,8,9

The World Health Organization health definition not only focuses on disease but also includes spiritual health to maximize mental and social wellness.10 The North American Nursing Diagnosis Association and the Joint Commission on Accreditation for Healthcare Organizations also identifies the significance of spiritual care and dictates that spiritual beliefs and support must be evaluated and support offered to all patients as deemed necessary.11

Perception of spirituality among nurses can influence how they act and communicate with patients regarding the delivery of spiritual care. Moreover, spirituality and spiritual care are culturally interrelated and affected by nurse’s ethnicity, religious, educational level, and clinical experience.12,13

Despite the major emphasis placed on spirituality in healthcare, spirituality often remains neglected and poorly understood. Spiritual care is at the core of the holistic care provided by nurses. However, the literature regarding spiritual care among nurses is mainly focused only on belief systems and religious context. Previous studies have revealed that there is a dearth of knowledge concerning nurses’ perceptions and interventions towards spiritual care.6,13,14 Additionally, spirituality and spiritual care in the healthcare delivery system are not formally integrated within programs of nursing education.15 Lack of spiritual care training often makes nurses feel inadequate regarding the provision of spiritual care to their patients.16

Lately, the need for nurses to deliver spiritual care has been emphasized in the literature.6,13,17 However, little is known about spirituality and the provision of spiritual care among nurses in Saudi Arabia. Given the paucity of research, there is a need to investigate the views of nurses about spirituality and spiritual care. Thus, this study aimed to assess nurses’ perception towards spirituality and spiritual care at tertiary care hospitals.

Methods

A cross-sectional survey was carried out at five tertiary care hospitals in Riyadh, Saudi Arabia, in February 2016.

Nurses with ≥ 1-year clinical experience were randomly approached and asked to participate in the survey by an invitation letter attached to the questionnaire and cover page explaining the study aim.

Data were collected using the Spirituality and Spiritual Care Rating Scale (SSCRS) to assess nurses’ perceptions on the subject of spiritual care. The scale was developed by McSherry et al,18 in 2002. It includes 17 items and three subdivisions: (i) spirituality and spiritual healing; (ii) religiosity; and (iii) personal care. The SSCRS is a 5-point Likert scale with 1 indicating ‘definitely do not agree’ and 5 ‘totally agree’. There are four items conversely scored in the scale. When the total points average is close to 5, this indicates that there is a high perception of spirituality and spiritual healing.18,19 The internal reliability of the SSCRS was established with a Cronbach’s alpha of 0.76.

Additionally, demographic characteristics including gender, age, marital status, family members living in Saudi Arabia, having children, education level, current nursing position, and years of clinical experience were collected.

The study was approved by the King Fahad Medical City Institutional Review Board (IRB#: 15-466). Subjects who met the inclusion criteria and voluntarily agreed to take part in the survey provided written informed consent.

Data were described as percentages and averages (mean). The SSCRS score did not demonstrate a normal distribution (The Shapiro-Wilk statistics = 0.930, p < 0.001). Consequently, Mann-Whitney U and Kruskal-Wallis tests were performed to identify the associations between scores and categorical variables. Statistical analyses were accomplished using SPSS Statistics (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp).

Results

A total of 1180 questionnaires were disseminated, and 978 (82.9%) were completed. Consequently, the final analyses were performed with the results from 978 participants. A total of 896/978 (91.6%) respondents were female. Six-hundred and thirty-one (65.0%) respondents were aged 27–35 years old, 871/973 (89.5%) had a bachelor/master degree, and 854/963 (88.7%) had ≤ 10 years nursing experience.

The mean scores for the SSCRS are presented in Table 1. The mean score for SSCRS scale was 3.8±0.5, which fell within the ‘agree’ category to the spirituality and spiritual care statements. The highest mean scores for SSCRS related to spiritual care were achieved by item 2: “I believe nurses can provide spiritual care by showing kindness, concern, and cheerfulness when giving care” (4.4±0.7), and item 14: “I believe nurses can provide spiritual care by having respect for privacy, dignity and religious and cultural beliefs of a patient” (4.3±0.7). The highest mean scores related to the perception of ‘spirituality’ was obtained by item 9: “I believe spirituality is about having a sense of hope in life” (4.3±0.7). The item that attained the lowermost mean scores was item 16: “I believe spirituality does not apply to all religions” (2.4±1.3).

The associations between sociodemographic variables and the total mean perceptions scores are given in Table 2. A statistical significant difference was shown only between participants’ perceptions of spirituality and spiritual care and their length of nursing experience (p = 0.034). Participants with >10 years nursing experience had higher scale scores compared to participants with < 10 years experience.

Discussion

The results of this study reveal several valuable understandings regarding nurses’ perception towards spirituality and spiritual care in Saudi Arabia. It indicated that the participating nurses were oriented towards spirituality, and valued the importance of spiritual care being given to their patients, as the mean SSCRS score was 3.8±0.5. The score falls within the ‘agree’ category of the SSCRS statements. However, effective strategies to enhance spirituality and reinforce nurses’ commitment to the significance of spiritual care are needed. Similarly, previous studies that explored nurses’ perceptions of spirituality and spiritual care in different cultures revealed that nurses appear to have acceptable understanding of spirituality, and were willing to provide spiritual care to their patients.1,20,21 A study conducted by Çetinkaya et al,20 included 289 nurses from three hospitals in a province in the west of Turkey. The authors reported a raised perception of spiritual care among nurses. A study of Chinese nurses revealed similar findings. These nurses were highly aware of spirituality and had a keen interest in giving spiritual care to their patients.1 A study from Iran indicated a moderate level of perception of spirituality and spiritual care among 259 nurses.21 Conversely, our results are inconsistent with the study of Ozbasaran et al,13 which reported a general confusion regarding nurses’ perceptions and interventions related to spirituality and spiritual care among nurses in Turkey. This may be due to the different data acquisition tools to assess the nurses’ perceptions on the subject of spirituality and spiritual care.

In this study, responses to statements regarding the understanding of the term ‘spiritual care’ indicated that most nurses perceive this as showing kindness, concern, and cheerfulness when providing care and focusing on respecting patients’ privacy, dignity, and religious and cultural beliefs. This finding is consistent with a study carried out by van Leeuwen et al,22 in which nurses stated that spiritual care helps them to respect patients’ beliefs and feelings. Nurses participating in the study considered spirituality as having a sense of hope in life and the belief that spirituality exists in all religions. This might be related to the view of the ‘inseparability of religion and spirituality’. Previous studies also revealed that nurses tend to associate spirituality with religion.23–25 Likewise, Wong and Yau26 reported spirituality as mostly related to religion. Yılmaz and Okyay16 reflected similar results. Therefore, we need to disseminate that spirituality may not always be expressed within a religious framework and to make a distinction between them as many scholars see spirituality as a personal search for meaning and purpose in life, which may or may not be related to religion.6,27,28

Previous studies in Western countries identified that the most frequent spiritual care interventions implemented by nurses included listening, affirming the value of belonging to a religious community, touch, prayer, and health education.29,30 However, in the Middle-East, spirituality and religion coexist to the extent that a religious ritual of listening to the holy text is involved in invoking spirituality. Thus, nurses need to be informed of the sociocultural context and beliefs of predominant religions and traditions within Middle-East, which will reduce embarrassing situations arising as a result of misunderstandings of basic knowledge of main traditions and cultural beliefs in the region and ignorance of the religious sensitivities of the patients.

Earlier studies have stated that nurses who were older,31 married,32 of a higher educational level,1,16,24 and with longer work experience,20 had higher spirituality and spiritual care scores. We identified that as the length of work experience increased, so did the spirituality and spiritual care mean scores.

The findings derived from this study will enable nurses to appreciate the importance of spirituality and spiritual care and to become more comfortable with their spirituality, which is the initial step in developing awareness and sensitivity to patients’ spiritual issues. This study will help nurses recognize that patients are not only physical beings but spiritual beings as well. Understanding these concepts is beneficial in efforts to improve patient care. Moreover, the findings of this study could be employed by nursing managers to identify and plan effective strategies to improve spirituality and strengthen nurses’ commitment to spiritual care. This may be achieved through programs and workshops/activities that broadly address the spiritual dimension of nursing care and periodic evaluations of nurses' integrations of spiritual care. Similar studies could be undertaken to explore the views of different populations, not previously explored.

The limitation associated with this study relates to the complex and multifaceted, nature of spirituality, hence determining the nurses’ perceptions of spirituality and spiritual care using a self-administered questionnaire may not accurately reflect all insights.

Conclusions

Our study revealed that nurses are oriented to spirituality, and valued the importance of spiritual care provided to their patients. However, effective strategies and programs to strengthen their commitment to the value of spirituality and spiritual care are needed. The results showed that the participants believed that spirituality exists in all religions and spiritual care means showing concern while serving the patients and focusing on respecting patients’ religious beliefs. Length of work experience is an important determinant of their perceptions towards spirituality and spiritual care.

Disclosure

The authors declared no conflicts of interest.

Acknowledgements

We would like to express our gratitude and appreciation to Research Center, King Fahad Medical City, Riyadh, Saudi Arabia for providing the research grant. We would like to thank Ms. Jenny Gray for her technical support.

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