Spiritual Care Competence among Malaysian Staff Nurses

Corresponding Author: Ali H. Abusafia Nursing Program, School of Health Sciences, Universiti Sains Malaysia, Malaysia Email: ali.abusafia@student.usm.my Background: Perceptions and levels of understanding of spiritual care vary among nurses, which may affect their competency to meet the patient’s spiritual needs. Therefore, determining nurses' perception of spiritual care is the first important step in addressing the spiritual needs of patients, and may also help nursing management in developing spiritual care education and training programs. Purpose: This study aimed to assess the competence of Malaysian nurses toward providing spiritual care and identify the relationship between nurses’ spiritual care competence and their sociodemographic factors. Methods: This study employed a cross-sectional design to assess nurses' competence in spiritual care by using a simple random sampling method which involved 271 staff nurses from a public hospital in Northeast of Peninsular Malaysia. Spiritual care competence scale in Bahasa Malaysia version was used for data collection. Data analysis was performed using descriptive (frequency, percent, mean, standard deviation) and inferential (Chi-square and Pearson’s correlation test) statistics. Results: This study showed that 69.7% of staff nurses had an average level of competence toward providing spiritual care for the patients (M=95.44, SD=4.34). The highest mean difference among the domains was personal support and patients counseling (MD=5.789), while the lowest mean difference was assessment and implementation of spiritual care (MD=1.258). Furthermore, there was no significant relationship between spiritual care competence and sociodemographic factors (gender, age, marital status, educational level, nurses' experience, race, religion, and previous participation in training spiritual care programs). Conclusion: The majority of nurses have an average level of competence toward providing spiritual care. There is no significant relationship between nurses’ spiritual care competence and sociodemographic factors.


Introduction
Based on World Health Organization (WHO), spiritual care can be deemed as an essential part of the definition of health since 1998 (Alliance & Organization, 2014;Nagase, 2012), and it is one of the important elements in the holistic nursing care provided by nurses (Caldeira et al., 2013). However, many nurses still have an inadequate understanding of the significance of spirituality and spiritual care (Lalani, 2020;Wu et al., 2016). The term spirituality can be labeled as "an umbrella term" (McSherry & Jamieson, 2011) due to the variety of individual meanings, associates, and descriptions that people often use to describe and make clear of their understanding of this term. Therefore, spiritual care is recognized as an important part of nursing care towards patients, and understanding patients' spiritual needs must be held significant among nurses because every part of health care dimensions of the patients falls under nursing responsibility (Jafari et al., 2016).
The term 'competence' describes a set of features and characteristics that create the best performance (Schneider, 2019). These features and elements are related to knowledge, skill, attitude, management, communication, and other features (Sharifi et al., 2019). However, a competent nurse would be able to effectively provide quality service to patients and cover all of their needs (Lee et al., 2020). Nurses must not be afraid to discuss spiritual issues with their patients (Gore, 2013). Despite numerous indications that spiritual care is part of nursing duty, it is apparent that there is an inadequate understanding of their responsibility (Zehtab & Adib-Hajbaghery, 2014).
Many studies have mentioned various reasons for the lack of spiritual care provided by the nurses toward patients, which include the lack of skills and knowledge, belief that patient's spirituality is private, time pressure, the difference of culture and religion between patients and nurses, and the difficulty to differentiate proselytizing from spiritual care (Caldeira et al., 2013;Gallison et al., 2012;McSherry & Jamieson, 2011;O'brien et al., 2019;Paal et al., 2015;Rushton, 2014). Therefore, nurses' knowledge, awareness and comprehension on spiritual care are significant to meet patients' spiritual needs (Veloza et al., 2016). When these nurses are more mindful and aware of their spiritual status, they will be more aware of their patients' spiritual needs (Yousefi & Abedi, 2011).
Many previous studies have emphasized the importance of individual and contextual factors when addressing spiritual care competence. Individual factors include age, gender, marital status, education level, working experience, religion, and race. On the other hand, contextual factors include interest in spirituality and spiritual care as well as previous attendance at spirituality/spiritual care courses or training courses (Hsieh et al., 2020;Timmins & McSherry, 2012; van Leeuwen & Schep-Akkerman, 2015). According to van Leeuwen (2009), personal factors such as age, gender, and level of education were assumed to have an essential role in some of the concerns the nurses had in spiritual care. In contrast, Wu et al. (2016) highlighted that age, gender, clinical experience, level of education, and nurses' religiosity did not have an effect on providing spiritual care. The same study, however, noted that the nurses who received sufficient education and training programs in providing spiritual care felt more competent to meet patients' spiritual needs (Wu et al., 2016).
Based on the literature that has been reviewed, it seems that most of the studies regarding spiritual care were applied in Western countries. They were largely from the Christianity perspective, and this included a study conducted in the United States by White and Hand (2017), in Netherland by Vogel and Schep-Akkerman (2018), as well as in Canada by Petersen et al. (2017). As a multi-racial country, the number of populations and different cultures practiced in Malaysia are the factors in providing a different perspective of spiritual care among nurses. However, this topic is not widely discussed in Malaysia (Atarhim et al., 2019). Therefore, this study expects to help nursing management identify the competence of nurses toward providing spiritual care among patients, especially during this critical period as the world is battling a pandemic like COVID-19, including Malaysia. Accordingly, this study aimed to assess nurses' competence toward providing spiritual care in Malaysia and identify the relationship between nurses' spiritual care competence and their sociodemographic factors.

Research design
A cross-sectional study was used to assess nurses' competence toward spiritual care in a single hospital in Malaysia.

Setting and samples
This study was conducted in a public hospital in Northeast of Peninsular Malaysia in July 2019. The population was staff nurses at the specified hospital with a total number of 1,530 at the time of the study. The sample size was determined by using a margin error of 5%, a confidence interval (CI) of 95%, and an expected response rate of 70% (Raosoft, 2004). In lieu of that, the recommended sample size was 267 participants. An additional 15% was added after considering the factor of drop-out from the study, which resulted in 267/(1-0.15) = 314 participants. A simple random sampling method was applied to this study, as all staff nurses had the same ability to participate in this study. This study had included staff nurses with at least one year of working experience to ensure they had valid experience in communicating with patients (Herlianita et al., 2018), and possessed diploma certificates. Staff nurses who had no direct contact with patients prior to this study were excluded.

Measurement and data collection
The researchers used a set of self-administered questionnaires in Bahasa Malaysia that would take an average of 10-15 minutes to complete. The instrument consisted of two parts. The first part included eight questions on participants' sociodemographic factors such as age, gender, marital status, race, religion, experience, and previous experience in attending a spiritual care workshop. The second part consisted of 27 items adopted from the survey of the Spiritual Care Competence Scale developed by van Leeuwen et al. (2009) to measure nurses' competence in providing spiritual care to the patients. It consisted of six domains: first domain included six questions to measure the assessment and implementation of spiritual care (6 items with Mean=18); the second domain consisted of six questions to measure the professionalization and to improve the quality of spiritual care (6 items with Mean=18); the third domain consisted of six questions to measure the personal support and patient counseling (6 items with Mean=18); the fourth domain included three questions to measure the referral to professionals (3 items with Mean=9); the fifth domain consisted of four questions to measure the attitude towards patient spirituality (4 items with Mean=12), and the last domain consisted of two questions to measure the communication (2 Item with Mean=6). All 27 items were rated using a Likert scale ranging from 1 to 5 (1=strongly disagree, 5=strongly agree). The questionnaire had a minimum of 27 scores and a maximum of 135 scores in which the score lower than 64 was categorized as low spiritual competence, the score of 64-98 suggested average spiritual care, and the score of 99 and above demonstrated high spiritual competence.
After obtaining the authors' permission, two Malaysian experts working at a Language Centre in a public university in Northeast of Peninsular Malaysia, who were proficient in English and Bahasa Malaysia (BM), performed the Forward-Backward translation procedure from English to Bahasa Malaysia to the original survey. In order to ensure each translated item reached the required consensus, the questionnaire was then sent to a native BM-speaking Malay lecturer and worked in the English Literature program in Universiti Kebangsaan Malaysia (UKM) and a lecturer in the Nursing program in Universiti Sains Malaysia (USM). Both experts reported that all questionnaire items were appropriate, acceptable, and understandable.
The validity and reliability of the Bahasa Malaysia version of the questionnaire were already tested in a previous study (Abusafia et al., 2020). A total of 320 participants were involved in validation of the questionnaire. The confirmatory factor analysis (CFA) measurement was used to validate the questionnaire. The result showed acceptable fit indices for the 6-factor model: root mean square error of approximation (RMSEA) = 0.050, comparative fit index (CFI) = 0.900, Tucker-Lewis index (TLI) = 0.885, and standardized root mean square residual (SRMR) = 0.065. The total Cronbach alpha of the questionnaire was 0.926, while for the subdomains was 0.685-0.851 (Abusafia et al., 2020).

Data analysis
Apart from descriptive statistics, the Pearson Chi-square test was also used to determine the relationship between sociodemographic factors (gender, marital status, race, religion, and previous experience of attending spiritual care workshop/training) and spiritual care competence among staff nurses. Pearson's correlation coefficient (r) test was used to measure the association between age, nurses' experience, and spiritual care competence score. The statistical significance level was set at 0.05. Data were analysed using SPSS version 24.0 for Windows.

Ethical considerations
The study protocol was reviewed and granted approval for implementation by the Research Ethics Committee (Jawatankuasa Etika Penyelidikan Manusia) Universiti Sains Malaysia (JEPeM-USM). The study had been assigned a study protocol with a code of USM/JEPeM/18080366. The permission to complete the survey at the hospital was obtained from the director of the hospital. The researchers provided a briefing about the aim, risk, and benefit of the study. The researchers also informed the participants that all data would be kept confidential, anonymous, and they were only used for the purpose of the study. Participation in this study was voluntary. The researchers ensured that the participants' working progress would not be affected. Lastly, formal written consent was obtained from every participant who agreed to participate in this study.

Characteristics of respondents
A total of 271 out of the initial 314 staff nurses (86%) had participated and completed the questionnaire. Table 1 shows that 92.6% of the participants were female, and 96.3% were married. On top of that, 96.7% of the participants had diplomas, 87.8% were Muslims, and 79.3% were Malays. More than half of the nurses had not participated in any spiritual care workshop or training prior to the study. The mean (M) age of the nurses was 34.75, the standard deviation (SD) was 8.359, and the experience years were M=12.09 and SD=8.359.  Table 2 shows that the mean score of SCCS was 95.44 with a standard deviation of 4.34 and most of the nurses were in the average level (69.7%) of competence toward spiritual care.  Table 3 shows that the mean score of each domain of the questionnaire on the perception of spiritual care competence was significantly above the average mean. Comparing between domains, the domain of personal support and patient counseling had a high mean difference. At the same time, the assessment and implementation of the spiritual care domains had a lower mean difference.

The relationship between the sociodemographic factors and spiritual care competence
According to the results in Table 4, there was no significant relationship observed in the sociodemographic factors (p>0.05).

Discussion
This study explored the competence of nurses toward providing spiritual care to patients. The results of the study showed that the mean score of spiritual care competence was 95.44, and the competence of nurses was at the average level, which is consistent with other studies conducted among nurses in Iran (Jahandideh et al., 2018) and Taiwan (Chen et al., 2020;Ebrahimi et al., 017), which demonstrated that the nurses have average competence in providing spiritual care. In contrast, the results of this study were higher than a study in the United States among nurses, which showed the mean score of SCCS was 71.96 (Hellman et al., 2015). This indicates a need to provide educational programs on spiritual care for the nurses to improve their competence and capabilities, which is congruent with studies by Melhem et al. (2016) and Abell et al. (2018).
In addition to exploring the competence of nurses in spiritual care, the results showed that each domain's mean scores were significantly above average. However, the highest mean difference was personal support and patient counseling (5.789). This is different from a study conducted by Ebrahimi et al. (2017), which showed that the mean difference was (3.0). Based on van Leeuwen et al. (2009), this domain was considered as the heart of spiritual care due to the actual provision and evaluation of spiritual care with patients and their families. However, the highest results in the current study could be related to the spiritual care services provided by the team from the Islamic center in the hospital where the study took place.
The second highest domain was the attitude towards patient spirituality (MD=3.919), which was almost similar (MD=4.0) to a study conducted by Ebrahimi et al. (2017). Based on van Leeuwen et al. (2009), this domain is referred to as personal factors that are relevant in providing spiritual care. It is known that Malaysia has different cultures and races (Ramalu & Subramaniam, 2019). These results indicated the extent to which the nurses would accept and provide spiritual care to their patients irrespective of their race.
For other domains, the mean difference score was lower than 2.0, which indicated an apparent deficiency of knowledge and practice among nurses in providing spiritual care to the patients and a need for the hospital nursing management to assess, implement and evaluate the nursing spiritual care plan. Not only that, the need to increase the relationship between nurses and patients and develop nurses' communication therapy to meet the patients' needs should not be overlooked. This is supported by Kourkouta and Papathanasiou (2014) which confirmed the importance of having good communication between nurses and patients for a positive and effective outcome of patients' nursing care.
Surprisingly, this study showed no factors that had a significant difference in the spiritual care competence score. The results were similar to a study conducted by Vogel and Schep-Akkerman (2018). In contrast, it was different from a study conducted by Chen et al. (2020), which showed that the SCCS was significantly associated with the educational level variable and previous education experience in spiritual care. In addition, van Leeuwen and Schep-Akkerman (2015) believed that demographic factors, such as gender, age, level of education, and nursing experience, play an important role in providing spiritual care to the patients. Meanwhile, Melhem et al. (2016), in their study among Jordanian nurses, discovered that female nurses have a high perception of spirituality and spiritual care than male nurses. This may be due to the way that females have a superior capacity to impart feelings and emotions to patients. Male nurses, on the other hand, caring more about the physical sides of the patients.
In the current study, it is not easy to interpret the results. However, spiritual care competence is a skill that all nurses should have to be able to meet patients' spiritual needs, and they have to be aware of their spiritual care regardless of their gender, age, experience, or any other factors. This is supported by McSherry et al. (2008), which reported that staff nurses should have the ability to provide spiritual care to the patients.

Implication and limitation
The results of this study could be a valuable input for the head of nurses and nursing management to evaluate nurses during their practice of providing spiritual care to the patients. This study has limitations that can be summarized in two points. The first was the usage of selfreported measures. The self-reported measures could have specific high response biases, which could have decreased the acquired data accuracy. However, the participants aware that their identity and names were not involved in the study, which can reduce the bias in response and increase the confidence and honesty of participants in answering the questionnaire. Secondly, this study was carried out in one hospital only, which might limit the ability to generalize the results to other hospitals in Malaysia. However, it is important to note that there was enough sample size obtained which had strengthened the conclusions and findings of the study. Therefore, the researchers would recommend further studies to include a larger sample size from various healthcare professions or a more generalized population of nursing specialties from different hospitals. Another recommendation to be made in the future study may explain the natural association between sociodemographic factors and spiritual care competence. It is also important to explore the barriers and motivators for providing spiritual care among the patients.

Conclusion
The present study revealed that the competence of nurses toward providing spiritual care was at an average level. Thus, nursing administrators should give more attention to increasing nursing competence by providing training and educational programs on spiritual care. Nurses also need to continue to discover their spirituality and must make more effort to involve themselves in spiritual activities. Lastly, developing a validation educational program on spiritual care is required to increase nurses' and other healthcare providers' competence.