Critical Care Nurses’ Spiritual Care Practice and Its Relationship with Their Spiritual Perception and Competency

: Background: Holistic nursing care including spiritual care should be provided to critically ill patients. Critical care nurses should assess the patients’ spiritual needs and provide holistic nursing care accordingly. Nurses’ spiritual perception and competency may be facilitators or barriers to the spiritual practice of critical care nurses. So, the current study was conducted to assess this relationship. Objective: To assess critical care nurses’ spiritual care practice and its relationship with their spiritual perception and competency. Design of the study: A descriptive correlational research design. Settings : Seven intensive care units at the Alexandria Main University Hospital. Subjects: A convenient sample of 150 critical care nurses who provide direct care to patients were enrolled in the study. Tools: Three tools were used in this study. Tool one was the spiritual care practice questionnaire. Tool two was the spirituality and spiritual care rating scale, and tool three was the spiritual care competency scale. Method: Online questionnaire was sent to critical care nurses to report their spiritual care practice, perception, and competency. Results: Critical care nurses’ spiritual care practice was positively and significantly correlated with nurses’ perception of spiritual care (r=0.55, P = 0.04), and awareness of spiritual care competency (r=0.87, P = 0.02). Conclusion: Critical care nurses provide spiritual care when they have a positive attitude toward spiritual care and are aware of spiritual care competency components. Recommendations: Raise critical care nurses’ awareness of spiritual care competency to provide a more positive attitude toward spiritual care and provide satisfactory spiritual care to critically ill patients.


Introduction
Spiritual well-being is a part of individual health.There is no consensus on spirituality definition (Rachel et al., 2019), therefore there is no specific definition for spiritual care.In one piece of literature, it was defined as the care that is connected to the meaning and purpose of life (Willemse et al., 2020).Another reference defined spiritual care as nurses' use of spiritual resources to help the patient to discover the purpose and meaning of life within the nurse-patient relationship (Deng & Liu, 2020).
The significance of spiritual care is enabling nurses to help patients explore their own strengths that increase their ability to cope with the disease in a better way.It increases patients' hope, decreases negative emotions and so improves patients' quality of life (Deng & Liu, 2020;Hvidt et al., 2020).

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Spiritual care is the spiritual support to the patients and their families.It should not be only limited to end-of-life care, but it should be provided to all critically ill patients when needed (Mamier et al., 2019;Rachel et al., 2019).Gordon et al. (2018) proposed that spiritual care has a role in the treatment of critically ill patients and their families.
The Holistic Nurse Association recommended the assessment and provision of spiritual care as a part of holistic nursing care.Also, The National Inpatient Priority Index ranked spiritual care as the highest priority care that should be provided to all patients (Cooper et al., 2020;van Leeuwen et al., 2021).
Specific to critical care nursing, the Synergy Model of the American Association of Critical care Nurses introduced spiritual care as a component of the care that should be provided to critically ill patients.This association stressed also on holistic care for critically ill patients which is mind, body, and spirit care (Cooper et al., 2020;Smith, 2006).
Nurses in many studies reported their willingness to provide spiritual care, but they were not able to determine the spiritual care practice and its competency components (Batstone et al., 2020;Linda et al., 2020).Spiritual care education and training is the basic step in improving nurses' competency to provide spiritual care (Hu et al., 2019).
Nurses in critical care settings rarely include spiritual care in their routine patient care.They perceived many barriers to practicing spiritual care such as lack of training, lack of understanding of the concept of spirituality, and rating of spiritual care as the last priority of care after biological needs (Choi et al., 2019).
In an integrative literature research for Willemse et al. (2020), they suggested that critical care nurses' perception of spirituality was a complementary component to provide effective spiritual care practice.Also, knowledge and training on spiritual competency was expected to improve spiritual care practice of critical care nurses.

Significance of the study:
Patients in critical care units require more spiritual support because they are exposed to more critical situations like fear of death and dependency.Spiritual wellbeing improves both patients' physical and mental well-being (De Diego-Cordero et al., 2022).Critical care nurses should provide high priority to spiritual care practice.Factors that influence nurses' provision of spiritual care should be addressed and modified.So, we conducted the current study to assess critical care nurses' spiritual care practice and its relationship with their spiritual perception and competency.

Aims of the study
The aim of the study is to: Assess critical care nurses' spiritual care practice and its relationship with their spiritual perception and competency.

Research questions:
1. What is the critical care nurses' spiritual care practice?
2. What is the relationship between nurses' practice of spiritual care and their spiritual perception and competency?

Materials:
Research design: Descriptive correlational research design was used in this study.

Settings:
Seven intensive care units (ICUs) at Alexandria Main University Hospital, namely unit I, unit II, unit III, unit IV, unit V, unit VI, and unit VII.These ICUs receive medical and trauma patients in their acute stage directly from the emergency department or transfer from other hospitals.

Subjects:
A convenience sample of 150 critical care nurses were included in the current study.The criteria for inclusion in the research were nurses who provide direct patient care, voluntary agree to take part in the study, and have the electronic skills to respond to electronic questionnaire.
Nurses' sample size was computed using the Epi-info program version 7.1 based on the following parameters: population size is 208, acceptable error 5%, confidence coefficient 98% and expected frequency 30%.

Tools:
Three adopted tools were used to the study.
Tool I: "Spiritual Care Practice Questionnaire".It was adopted from Gallison et al. (2013) to assess nurses' spiritual care practice.It consists of two parts.Part I is "spiritual support" which consists of 3 items, and part II is "barriers to providing spiritual care" which consists of 8 items.The test-retest reliability of the scale was 0.80 with Cronbach's alpha for Part I of the scale equal 0.87 and Part II of the scale equal 0.64.Subscale I is a 5-point Likert-type scale ranging from 1 to 5, with 1 being very seldom and 5 being very often.In subscale II, there are two choices, agree which is scored by 2, or disagree which is scored by 1 with respect to reversed questions score.The total score on the scale ranges from 11 to 31.
Tool II: "Spirituality and Spiritual Care Rating Scale''.It was adopted from McSherry et al. (2002) to assess nurses perception about spiritual care.It consists of 4 subscales: spirituality (5 items), spiritual care (5 items), religiosity (3 items), and personalized care (4 items).The 17-item of the scale have a reasonable level of internal consistency reliability by a Cronbach's alpha of 0.74.The scale is a 5-point Likerttype scale ranging from 1 to 5, with 1 is strongly disagree and 5 is strongly agree.The total score on the scale ranges from 17 to 85.

Tool
III: "Spiritual Care Competency Scale".It was adopted from Van Leeuwen et al. (2009) to assess nurses' spiritual care competency.It consists of 6 subscales: assessment and implementation of spiritual care (6 items) with 0.82 of Cronbach's alpha reliability, professionalization and improving the quality of spiritual care (6 items) with 0.82 of Cronbach's alpha reliability, personal support and patient counseling (6 items) with 0.81 of Cronbach's alpha reliability, referral to professionals (3 items) with 0.79 of Cronbach's alpha reliability, attitude towards patient spirituality (4 items) with 0.76 of Cronbach's alpha reliability, communication (2 items) with 0.71 of Cronbach's alpha reliability.The scale is a 5-point Likert-type scale ranging from 1 to 5, with 1 is completely disagree and 5 fully agree.The total score on the scale ranges from 27 to 135.
In addition to nurses' sociodemographic and work-related variables which includes nurses age, gender, marital status, academic degree, and years of experience.
• Approval of data collection was taken from Alexandria Main University Hospital before data collection.
• The three tools of the study were adopted and designed on an online questionnaire using Microsoft Office electronic form.
• The online questionnaire was shared with nurses on their whats app groups or their personal whats app from 15 October to 12 November 2022.
• The response of the online questionnaire was collected automatically after the nurses' submission, then analysis for nurses' response was conducted.

Statistical analysis
Data from the current study were analyzed by the Statistical Package for Social Science (SPSS) version 28.0.Categorical variables were presented in number and percentage.Continuous variables were presented in mean ± standard deviation after testing the normality of the variable by the shaper wick test.
The percent score for the subscales was calculated by dividing the mean score of the subscale by the total score of the subscale, then multiplying the decimal by 100 to convert it to a percentage.Person correlation coefficient test was used.A twotailed p-value equal or less than 0.05 was statistically significant value.

Ethical considerations:
-Informed consent was the first part of the electronic questionnaire, by clicking agree to participate button at the beginning of the electronic questionnaire, the nurse was considered giving the consent.
-Voluntary participation in the study was emphasized to the critical care nurses at the beginning of the electronic questionnaire.
-Confidentiality of the collected data was maintained during the implementation of the study.
As regards nurses' academic degrees, more than half (52.7%) of nurses had a bachelor degree, 33.3% of them had a technical degree, and 14% of the studied nurse had a master degree.Regarding nurses' years of experience, 39.3% of 68 nurses had experience less than 5 years, 28.0% of nurses had experience ranging from 5 to less than 10 years, and 32.7% of nurses had experience more than 10 years old.
Table II shows the mean and percent scores of nurses' responses to the spiritual care practice questionnaire.The percentage of nurses' response score to provide spiritual support for their patients was only 27.33% with a mean response score of 4.1±1.6.The percentage of nurses' response score to perceived barriers that inhibit providing spiritual care was 77.0% with a mean response score of 12.32±3.87.The total percentage of nurses' response score to the spiritual care practice questionnaire was 52.97% with a mean response score of 16.42±4.89.
Table III shows mean and percent scores of nurses' response to the spirituality and spiritual care rating scale.The percentage of nurses' response score to spirituality meaning and purpose was 77.08% with a mean response score of 19.27 ± 5.82, while the percentage of nurses' response score to perceived spiritual care importance was 81.48% with a mean response score of 20.37 ± 6.29.
The percentage of nurses' response score to religiosity meaning which is not equal to spirituality meaning was 69.06% with a mean response score of 10.36 ± 4.38, while the percentage of nurses' response score to personalized care that is specific to the patient was 41.45% with a mean response score of 8.29 ± 3.47.The total percentage of nurses' response score to the "Spirituality and Spiritual Care Rating Scale" was 68.58% with a mean response score of 58.29 ± 10.72.The percentage of nurses' response score to attitude towards patient spirituality was 61.85% with a mean response score of 12.37 ± 5.43, and the percentage of nurses' response score to communication with patients was 59.8% with a mean response score of 5.98 ± 1.33.The total percentage of nurses' response score to the "Spiritual Care Competency Scale" was 48.79% with a mean response score of 65.86 ± 7.39.

Table V illustrates correlation between
nurses' spiritual care practice, perception, and competencies.There was a significant moderate correlation between nurses' spiritual care practice and their perception about spirituality and spiritual care (r=0.55,P= 0.04), but there is a significant strong correlation between nurses' spiritual care practice and their spiritual care competency (r=0.87,P= 0.02).Also, it can be noted from the table that there is a significant week correlation between nurses' perception about spirituality and spiritual care and their spiritual care competency (r=0.26,P= 0.03).

Discussion
The current study revealed that most of the studied nurses did not provide spiritual support to their critically ill patients because they perceive many barriers to provide spiritual care practice.This result in congruency with Riahi et al. (2018) who found that most of critical care nurses did not provide spiritual care because of nurses' considerations with barriers like heavy workload, lack of staff, and lack of education (De Diego-Cordero et al., 2022).
In the current study, there was a relationship between nurses' spiritual care practice, their perception and competency.Critical care nurses provide spiritual care when they have a positive attitude toward spiritual care.Also, nurses provide spiritual care when they are aware with spiritual care competency components.
Also, there was a relationship between spiritual care perception and competency.Spiritual care competency develops more positive attitude toward spiritual care among critical care nurses.This result in line with Melhem et al. (2016) who found that spiritual care courses improves nurses' competency and increase nurses positive attitude toward spiritual care.Moreover, McSherry et al. (2020) confirmed the relationship between nurses spiritual perception and their competency to provide spiritual care.
The more experienced nurses have more positive attitude and competency in provision of spiritual care practice.This may be related to increase of nurses' experience to manage patients' problems and meet their needs (Noble & Jones, 2010).This is not in congruency with the current study results.More than half of the nurses in the current study had experience that exceeds five years, but they did not have a positive attitude toward spiritual care or aware of the components of the spiritual care competency.
Spiritual care competency influenced by nurses' education (Cooper et al., 2020).In the current study, more than half of nurses had a bachelor degree but they did not aware of all the components of the spiritual care competency due to lack of spiritual courses education or training.Training on spiritual care provision increase nurses' competency, increase positive perception and provision of satisfactory spiritual care (Riahi et al., 2018).
Another study reported that lack of understanding to the concept of spiritual care and lack of training on assessing spiritual need is a barrier to provide spiritual care practice (Rachel et al., 2019).Lack of understanding and training is considered a lack of competency that influences nursing practice of spiritual care (Hu et al., 2019).Moreover, Willemse et al. (2020) concluded that spiritual care practice in ICU is closely linked to nurses' competency in spiritual care.They also suggested that improving knowledge and updated training on provision of spiritual care can greatly improve nurses' competency to effective spiritual care practice.

Conclusion:
Based on the findings it can be concluded that critical care nurses provide spiritual care when they have a positive attitude toward spiritual care.Also, nurses provide spiritual care when they are aware with spiritual care competency components.Also, spiritual care competency develops more positive attitude toward spiritual care among critical care nurses.

Recommendations: 70
The following are recommended.The scale is a 5-point Likert-type scale ranging from 1 to 5, with 1 is strongly disagree and 5 is strongly agree.The scale is a 5-point Likert-type scale ranging from 1 to 5, with 1 is completely disagree and 5 fully agree.

Table II : Mean and percent scores of nurses' responses to the spiritual care practice questionnaire (n = 150) Subscales of Spiritual Care Practice The score range for the subscale
Subscale (I) is a 5-point Likert-type scale ranging from 1 to 5, with 1 being very seldom and 5 being very often.In subscale (II), there are two choices, agree (2) or disagree (1).

Table V : Correlation between nurses' spiritual care practice, perception, and competencies (n = 150) Nurses' spiritual care practice, perception, and competencies Spiritual care practice Perception of spirituality and spiritual care Spiritual care competence Spiritual care practice
is person correlation, P is significance value, * is statistically significance value ≤ 0.05. r