Received: 07/08/2015 Accepted: 04/10/2015 Published: 11/10/2015
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Background and objectives: In this hospital-based survey, we aimed to determine the level of hopelessness and the perception of spirituality or spiritual care, and correlation between them in a sample of Turkish nurses. Method: The Beck Hopelessness Scale (BHS) and The Spirituality and Spiritual Care Rating Scale (SSCRS) were used to determine level of hopelessness and perception of spirituality or spiritual care, respectively. Data on sociodemographics and understanding of spirituality were collected with the Study Questionnaire Form. Results: Eighty nurses (77 females, 3 males; mean age, 27.9 ± 4.0 years) participated in the study. Most of the participants (70%) were aware of the importance of spirituality and spiritual care. Total scores were 5.4 ± 4.7 and 52.88 ± 4.79 for BHS and SSCRS scales. There was a weak and negative correlation between total scores of BHS and SSCRS (r=-0.266, p=0.017). Sociodemographic parameters (age, gender, education) and understanding and practice of spiritual care have no or limited effect on the BHS and SSCRS scores. Conclusion: In conclusion, the education, perception, and practice of spiritual care are not sufficient among Turkish nurses. Hopelessness of nurses negatively affects their perception of spirituality and spiritual care.
Nurse, Spiritual care, Hopelessness, Survey
The spirituality plays an important role in people's lives. Spiritual care is a specific care given to patients to meet the needs of the human spirit after a trauma or disease. Spiritual needs vary among individuals, thus it should be specialized to include supporting, connecting, or simply listening .
Providing spiritual care is now considered as an essential part of nursing practice in all clinical areas . However, in clinical practice many nurses are uncertain about what spiritual care involves and lack confidence in this area. They may also incorrectly assume that family, spiritual or mental health professionals should address spiritual needs. Other barriers to spiritual care include lack of time, personal, cultural, or institutional factors, and professional educational needs . Furthermore, health-care professionals' hopelessness contributes to the hopelessness of patients, precluding nurses to provide effective spiritual care . Due to these limitations, nurses in clinical practice usually neglect spiritual care.
The understanding and practice of spiritual care by nurses are also affected by cultural beliefs and values about spirituality . Therefore, national data on the perception of spiritual care by nurses and factors affecting this perception should be obtained to address needs of practicing nurses and to define best approaches to develop educational programs and spiritual awareness across country. Although a few reports on Turkish nurses’ spiritual care practices have been published recently, there is still need for more studies to understand the current perception of spiritual care by nurses [6,7].
In this study, we aimed to determine the level of hopelessness and the perception of spirituality or spiritual care, and correlation between them in a sample of Turkish nurses. Furthermore, we evaluated whether nurses’ sociodemographics and general thoughts, behavior, and trends on spiritual care have any effect on their hopelessness and the perception of spirituality or spiritual care.
Study design and participants
This was a hospital-based survey performed on all nurses working in various clinics of our hospital between April and June 2013. The study was approved by the Institutional Ethics Committee, and conducted in accordance to latest version of Helsinki Declaration. The participation into the study was anonymous and voluntary; all participants gave written informed consent to participate in the study. The study data were collected by the questionnaires completed by participants.
Each participant was asked to complete three questionnaires in the scope of the study. First one is the Study Questionnaire Form that was designed by the study team to collect data on participants’ sociodemographics and general thoughts, behavior, and trends on spiritual care in clinical nursing practice. This questionnaire contains 13 multiple-choice or open-ended questions, and a 10-point visual analog scale, which scores participants’ thoughts on the importance of spiritual care in the scope of nursing practice in which 1 corresponds to “not important at all” and 10, corresponds to “very important” (Figure 1).
The second questionnaire was the Beck Hopelessness Scale (BHS), which is a 20-item self-report inventory developed by Beck et al , to measure three major aspects of hopelessness: feelings and expectations about the future, loss of motivation, and expectations (hopes). It measures the extent of the respondent's negative attitudes, or pessimism, about the future. The BHS contains 20 questions answered as “Yes” or “No”. The scores of BHS range between 0 and 20, with high scores indicating high level of hopelessness. The BHS has been adapted into Turkish and shown to be valid in psychometric studies [9,10].
The third questionnaire used in the study was The Spirituality and Spiritual Care Rating Scale (SSCRS), which is a 17- item, five-point Likert scale to determine and measure the spirituality and spiritual care . It has three factor-based subscales: spirituality and spiritual care, religiosity, and personalized care. The total score ranges between 17 and 85, and higher scores generally indicate a higher level of perception of spirituality or spiritual care. The reliability and validity of Turkish version of SSCRS have been shown by Ergul and Bayik .
We evaluated whether there is a relation between the BHS and SSCRS scores, and sociodemographics and participants’ perception of spiritual care have any effect on these scores.
The study data were summarized with descriptive statistics (frequency, percentage, mean, standard deviation, and range). The quantitative data of subgroups generated by the responses to study questionnaires were compared by Mann-Whitney U test for two groups or Kruskal-Wallis test followed by Mann-Whitney U test as post-hoc test for more than two groups. The correlations between questionnaires were determined by Pearson correlation analysis and expressed as correlation coefficient (r) along with p value.
Statistical analysis was performed using SPSS version 19.01 (SPSS Inc., Chicago, IL, U.S.). Statistical level of significance was set to p<0.05.
Study participants, and perception of spiritual care
The number of nurses working in our hospital was 80 (77 females, 3 males; mean age, 27.9 ± 4.0 years; age range, 20–42 years), and all of them responded to study questionnaires and participated in the study. Of the participants, 3 (3.8%) had college, 8 (10%) undergraduate, 62 (77.5%) graduate and 7 (8.8%) postgraduate degrees. The majority of participant nurses were working in surgery clinic (n=29, 36.2%) or intensive care unit (n=16, 20.0%). Only around 34% had work experience over 5 years (Table 1).
|Age (years)||27.9 ± 4.0 (20–42)|
|Marital status||Married||35 (43.8)|
|Education level||College||3 (3.8)|
|Place of work||Surgery clinic||29 (36.2)|
|Internal medicine clinic||8 (10.0)|
|Intensive care unit||16 (20.0)|
|Operating room||11 (13.8)|
|Nursing services||2 (2.5)|
|Work experience (years)||≤ 5||53 (66.2)|
|Have you chosen your profession voluntarily?||Yes||71 (88.8)|
|Have you heard of the concept of spiritual care?||Yes||50 (62.5)|
|Have you taken courses on spiritual care during your professional education?||Yes||31 (38.8)|
|Do you give spiritual care to your patients?||Yes||56 (70.0)|
|Do you think that holistic care includes spiritual care?||Yes||67 (83.8)|
Table 1: Sociodemographics and basic characteristics of study participants according to responses to study questionnaire.
Thirty participants (37.5%) had not even heard of the concept of spiritual care before, and 49 (61.2%) had not received education on spiritual care during formal professional education (Table 1). Only 18 participants (22.5%) reported that they were informed on spiritual care through other sources such as in-service training, scientific meetings, publications, and mass media. Of the participants, only 24 nurses (30%) give spiritual care to their patients (Table 1). However, majority of nurses (n=56, 70%) marked 7 or higher score in 10-point visual analog scale for the importance of spiritual care, showing that most of the participants were aware of the importance of spirituality and spiritual care.
BHS and SSCRS scores
The total and subscale scores of the BHS and SSCRS questionnaires were summarized in Table 2. Total scores were 5.4 ± 4.7 and 52.88 ± 4.79 for BHS and SSCRS scales. The lowest score was obtained for expectations component of the BHS scale, while highest score was obtained for spirituality and spiritual care component of SSCRS scale.
|Mean ± SD (range)|
|Total||5.4 ± 4.7 (0–20)|
|Feelings about the future||0.9 ± 1.5 (0–5)|
|Loss of motivation||2.7 ± 2.3 (0–8)|
|Expectations||1.8 ± 1.7 (0–7)|
|Total||52.88 ± 4.79 (39–63)|
|Spirituality and spiritual care||23.73 ± 3.19 (14–31)|
|Religiosity||11.19 ± 1.76 (5–14)|
|Personalised care||13.15 ± 1.84 (8–18)|
Table 2: Descriptive statistics of total and subscale scores of the Beck Hopelessness Scale (BHS) and the Spirituality and Spiritual Care Rating Scale (SSCRS) (n=80)
There was a weak and negative correlation between total scores of BHS and SSCRS (r=-0.266, p=0.017) (Table 3). In terms of subscales, expectation score of BHS was found to be negatively correlated with total (r=-0.385, p<0.001), spirituality/spiritual care (r=-0.385, p<0.001), and personalized care (r=-0.226, p=0.043) scores of SSCRS. On the other hand, loss of motivation score of BHS was positively correlated with spirituality/spiritual care score of SSCRS (r=0.273, p=0.014) (Table 3).
|BHS scores||SSCRS scores|
|Total||Spirituality and spiritual care||Religiosity||Personalised care|
|Feelings about the future||r||-0.154||-0.279||0.003||-0.117|
|Loss of motivation||r||0.155||0.273||-0.044||0.202|
Table 3: Correlations between the total and subscale scores of the Beck Hopelessness Scale (BHS) and the Spirituality and Spiritual Care Rating Scale
Effects of sociodemographics and participants’ perception of spiritual care on the scores of questionnaires
We evaluated whether sociodemographics and participants’ perception of spiritual care, which were determined by responses to the Study Questionnaire Form, have any effect on the scores of the BHS and SSCRS. We found that these parameters have no or limited effect on the scale scores (Tables 4 and 5). Expectations subscale score of BHS significantly changes with education level (p=0.013), but there is no linear and consistent increase or decrease in scores with increasing level of education. Participants who think that holistic care includes spiritual care had significantly higher scores of loss of motivation subscale of the BHS than those who do not think so (p=0.046). Furthermore, participants who had chosen their profession voluntarily had higher total (p=0.025) and spirituality/spiritual care subscale (p=0.005) scores of the SSCRS. Participants who heard of the concept of spiritual care before, and those giving spiritual care to their patients had also higher spirituality/spiritual care subscale (p=0.019 and p=0.005, respectively) scores of the SSCRS than those giving “No” to these questions.
|Total score||Feelings about the future||Loss of motivation||Expectations|
|Mean ± SD||p||Mean ± SD||p||Mean ± SD||p||Mean ± SD||p|
|Gender||Female||5.27 ± 4.64||0.222||0.91 ± 1.53||0.211||2.62 ± 2.32||0.194||1.74 ± 1.63||0.442|
|Male||8.67 ± 5.51||2.00 ± 2.00||3.67 ± 0.58||3.00 ± 3.00|
|Education level||College||4.67 ± 4.73||0.455||1.00 ± 1.73||0.738||3.33 ± 3.51||0.814||0.33 ± 0.58||0.013|
|Undergraduate||6.00 ± 5.18||1.00 ± 1.51||2.63 ± 2.83||2.38 ± 1.60|
|Graduate||5.66 ± 4.79||1.00 ± 1.61||2.74 ± 2.28||1.92 ± 1.71|
|Postgraduate||2.71 ± 2.36||0.43 ± 1.13||1.71 ± 1.25||0.57 ± 1.13|
|Marital status||Married||6.14 ± 5.79||0.792||1.26 ± 1.96||0.553||2.69 ± 2.49||0.731||2.20 ± 2.01||0.148|
|Single||4.82 ± 3.54||0.71 ± 1.10||2.64 ± 2.14||1.47 ± 1.33|
|Have you chosen your profession voluntarily?||Yes||5.20 ± 4.66||0.196||0.90 ± 1.54||0.452||2.59 ± 2.31||0.323||1.70 ± 1.67||0.204|
|No||7.00 ± 4.74||1.33 ± 1.66||3.22 ± 2.17||2.44 ± 1.81|
|Have you heard of the concept of spiritual care?||Yes||5.24 ± 4.72||0.539||0.92 ± 1.54||0.811||2.66 ± 2.40||0.785||1.66 ± 1.70||0.199|
|No||5.67 ± 4.67||1.00 ± 1.60||2.67 ± 2.12||2.00 ± 1.68|
|Have you taken courses on spiritual care during your professional education?||Yes||5.81 ± 4.76||0.478||1.16 ± 1.73||0.45||2.87 ± 2.47||0.652||1.77 ± 1.80||0.658|
|No||5.14 ± 4.65||0.82 ± 1.42||2.53 ± 2.18||1.80 ± 1.63|
|Do you think that holistic care includes||Yes||5.03 ± 4.51||0.122||0.85 ± 1.49||0.253||2.46 ± 2.25||0.046||1.72 ± 1.68||0.314|
|spiritual care?||No||7.31 ± 5.25||1.46 ± 1.81||3.69 ± 2.29||2.15 ± 1.77|
|Do you give spiritual care to your patients?||Yes||5.04 ± 4.83||0.159||0.84 ± 1.57||0.121||2.43 ± 2.33||0.085||1.77 ± 1.77||0.574|
|No||6.25 ± 4.28||1.21 ± 1.50||3.21 ± 2.13||1.83 ± 1.52|
Table 4: Effects of sociodemographic parameters and responses to study questionnaire on the total and subscale scores of the Beck Hopelessness Scale.
|Total score||Spirituality and spiritual care||Religiosity||Personalized care|
|Mean ± SD||p||Mean ± SD||p||Mean ± SD||p||Mean ± SD||p|
|Gender||Female||52.92 ± 4.86||0.395||23.78 ± 3.23||0.296||11.21 ± 1.77||0.484||13.13 ± 1.86||0.598|
|Male||51.67 ± 3.06||22.33 ± 1.53||10.67 ± 1.53||13.67 ± 1.15|
|Education level||College||54.00 ± 1.00||0.443||24.00 ± 2.00||0.892||12.00 ± 0.00||0.247||11.67 ± 1.53||0.423|
|Undergraduate||54.00 ± 4.31||23.50 ± 3.16||12.13 ± 1.13||13.00 ± 1.31|
|Graduate||52.47 ± 5.11||23.63 ± 3.32||10.98 ± 1.89||13.18 ± 1.91|
|Postgraduate||54.71 ± 2.69||24.71 ± 2.81||11.57 ± 0.98||13.71 ± 1.70|
|Marital status||Married||52.20 ± 5.57||0.477||23.29 ± 3.25||0.212||10.89 ± 1.95||0.407||12.94 ± 1.81||0.32|
|Single||53.40 ± 4.08||24.07 ± 3.14||11.42 ± 1.57||13.31 ± 1.86|
|Have you chosen your profession voluntarily?||Yes||53.48 ± 4.19||0.025||24.06 ± 3.13||0.005||11.30 ± 1.63||0.311||13.32 ± 1.64||0.124|
|No||48.11 ± 6.66||21.11 ± 2.52||10.33 ± 2.50||11.78 ± 2.73|
|Have you heard of the concept of spiritual care?||Yes||53.00 ± 5.14||0.319||24.24 ± 3.59||0.019||11.02 ± 1.77||0.281||13.22 ± 1.98||0.492|
|No||52.67 ± 4.24||22.87 ± 2.18||11.47 ± 1.74||13.03 ± 1.59|
|Have you taken courses on spiritual care during your professional education?||Yes||52.65 ± 5.50||0.77||23.71 ± 3.45||0.788||11.32 ± 1.82||0.425||12.97 ± 2.07||0.88|
|No||53.02 ± 4.34||23.74 ± 3.05||11.10 ± 1.74||13.27 ± 1.68|
|Do you think that holistic care includes||Yes||53.03 ± 4.90||0.472||23.94 ± 3.18||0.225||11.15 ± 1.79||0.749||13.24 ± 1.90||0.213|
|spiritual care?||No||52.08 ± 4.29||22.62 ± 3.12||11.39 ± 1.61||12.69 ± 1.44|
|Do you give spiritual care to your patients?||Yes||53.20 ± 5.20||0.11||24.27 ± 3.39||0.005||11.11 ± 1.76||0.414||13.23 ± 2.01||0.405|
|No||52.13 ± 3.68||22.46 ± 2.25||11.38 ± 1.79||12.96 ± 1.37|
Table 5: Effects of sociodemographic parameters and responses to study questionnaire on the total and subscale scores of the Spirituality and Spiritual Care Rating Scale.
Participants’ age was not correlated with the total and subscale scores of the BHS and SSCRS (Table 6).
|Feelings about the future||r=-0.130 (p=0.249)|
|Loss of motivation||r=-0.200 (p=0.075)|
|Spirituality and spiritual care||r=0.014 (p=0.899)|
|Personalized care||r=-0.069 (p=0.543)|
Table 6: Correlations between participants’ age and the scores of the Spirituality and Spiritual Care Rating Scale (SSCRS) and the Beck Hopelessness Scale (BHS).
Spiritual care is considered one of the essential responsibilities of nurses who are the key members of health team. Spirituality, which is defined as the relationship with the self and a dimension beyond the self, was found to have strong effect on nurses’ understanding and practice of spiritual care . Over the last few decades, there has been growing interest in the scope of spirituality and spiritual care in nursing education and practice. Many surveillance studies were published on the nurses’ perception of spirituality and spiritual care and role of education and other factors in this perception and practice of spiritual care [2,5,14-16].
Spiritual awareness is spiritual needs of the patient while the patient care can be revealed by considering. A university study conducted among nursing students in the last class of class I in Canada. In the study the students’ spiritual perception / awareness evaluated and the study results showed that the spiritual perception / awareness increased in the last class. Baldacchino also work to increase awareness of the spiritual of last year nursing students, established a working unit in the spiritual dimension, work has been achieved . Nurses are the health professionals which are working 24 hours, attaches great importance to the holistic care of patients. But it ignored most of the time are specified in the study of spirituality in nursing care and apply enough of the spiritual care .
Caring for ill patients negatively affects personal life and beliefs of nurses. Most of the nurses in a study who care particularly for end-stage patients expressed feelings of inadequacy and hopelessness about treatment of patients, and negative effects of caring for dying patients on their personal lives . Therefore in the present study, we hypothesized that level of hopelessness of nurses negatively affects their perception of spirituality or spiritual care. We also assessed the role of sociodemographic parameters on hopelessness and perception of spirituality or spiritual care. We applied validated and commonly used scales to determine level of hopelessness and perception of spirituality or spiritual care, BHS and SSCRS, respectively.
The overall score of SSCRS indicate that our participating nurses had moderate level of perception of spirituality or spiritual care—lowest awareness for religiosity, and highest awareness for spirituality or spiritual care. BHS scores showed that although nurses have positive feelings about the future and expectations, their loss of motivation was high. Overall BHS score shows mild to moderate level of hopelessness among nurses. Total scores of BHS and SSCRS were negatively correlated, showing that while nurses’ hopelessness decreases, their perception of spirituality or spiritual care increases, as suggested by Mok et al . However, most of the participants (70%) were aware of the importance of spirituality and spiritual care.
The role of sociodemographics of nurses (age, gender, education, understanding of spirituality etc.) in predicting perception of spirituality and spiritual care has been reported in many studies. Wu and Lin found that clinical nurses who held a master's degree, received spiritual care lessons during continuing education, have over 10 years of clinical experience, or specialty in palliative nursing had higher levels of spiritual care perception . Ronaldson et al. also found that palliative care nurses' spiritual caring practice was more advanced and their spiritual perspective stronger than acute care nurses .
We found that sociodemographic parameters (age, gender, education) and understanding and practice of spiritual care have no or limited effect on the BHS and SSCRS scores. Participants who had chosen their profession voluntarily, who heard of the concept of spiritual care before, and those giving spiritual care to their patients had higher SSCRS scores. Similarly, Chung et al. found no statistically significant correlation between the demographic variables and understanding and practice of spiritual care . Ozbasaran et al. surveyed 348 staff nurses in Turkey and reported that Turkish nurses' perceptions were indecisive and inconclusive . In contrast to our findings, Ozbasaran et al. found significant correlation between perceptions of spirituality and spiritual care and their ages, marital status, and education levels .
A higher education level and more spiritual care lessons or training courses were reported to increase level perception of spirituality and spiritual care . A recent pilot study showed that student nurses have broad view of spirituality and spiritual care . Another recent online survey on 4054 nurses conducted by the Royal College of Nursing indicated that in spite of some uncertainty on the boundaries between personal belief and professional practice, nurses had generally a broad and inclusive understanding of spirituality and considered spiritual care among fundamental roles of nurse . A survey on student nurses’ also showed that high level of spiritual awareness among students . They also emphasized the need for a formal education of spirituality within nursing programs. However, a number of ethical concerns on education of spirituality to student nurses have also been reported . These concerns may vary according to culture and understanding of religion in a community.
Despite increasing awareness of spiritual care among nurses, the majority still feel that they require more education and guidance to enable them effectively meet their patients' spiritual needs . Nurses who completed education programs including spirituality and spiritual care were reported to incorporate spiritual care into practice more than those who did not receive a formal education . Our results did not support the role of education on the level of hopelessness and perception of spirituality or spiritual care of the nurses. However, this negative finding may be due to limited number of our study population, and we believe that increasing number of participants will prove the importance of spiritual care education during formal nursing training.
In conclusion, in this nurse-based surveillance study, we found that while majority of nurses are aware of the importance of spirituality and spiritual care, the education, perception, and practice of spiritual care are not sufficient among Turkish nurses. Furthermore, hopelessness of nurses negatively affects their perception of spirituality and spiritual care. Education on spiritual care during formal nursing training and in practice should be targeted on increasing hope and expectations of nurses in addition to considering the patients’ beliefs, physical, and mental conditions.
Since cultural approach and religion are important factors for understanding the nurses’ perception of spirituality and spiritual care, experiences were published from various countries including Turkey [6,15,22,23]. However, limited studies has been noted the nurses' perception on applying spiritual care in Turkey with a population of about 76 million and around 125,000 practicing nurses. Our study is thus important in the respect that it provides Turkish nurses’ perception of spirituality and spiritual care in relation with their level of hopelessness, sociodemographics, and understanding and practice of spiritual care. The data obtained for the present and similar studies will be used to develop culture-specific education and practicing programs on spiritual care for nurses.
The major limitation of our study is the small sample size. We can’t generalize the results for the Turkish population.