Perception on spiritual care: Comparation of the nursing students of public university and religious-based university

Abstract

Objective

Poor implementation of spiritual care in nursing practice may stem from the nursing education. This study aimed to compare the perception of nursing students of a public university and a religious-based university on spiritual care.

Method

The research used the descriptive-comparative method. 141 nursing students were recruited through consecutive sampling technique in a university in Depok, West Java and a religious-based university in Jakarta, Indonesia. Data were collected using the Spiritual Care Giving Scale (SCGS) questionnaire.

Results

The result showed that the participants had a good perception about spiritual care with the mean score of 171.39. However, there was no significant difference in perception regarding spiritual care between nursing students from the public university and the religion-based university (p value = 0.612).

Conclusions

The perception on spiritual care of nursing students was fairly similar regardless of the type of their university. This may be related with the comparable religious and cultural backgrounds in the two settings, as well as the nursing education curriculum implemented nationally, yet it takes further studies to examine such factors.

Introduction

Nursing views people holistically. Therefore, nurses are required to know the entire necessity of the patients, encompassing their bio-psycho-socio-spiritual needs.^1–6 In reality, health care system is yet dominated by the biomedical model which largely focuses on the physical aspect of the patients and tends to oversee their spiritual needs, hence, applying the spiritual care as part of holistic nursing care is often challenging.⁷

Disparity over patients’ hope and nurses’ performance to provide spiritual care is clear. A study showed that the patients expected to be given prayers along with care, ears to listen, and be facilitated pray while being sick, but such needs were left unfulfilled.⁸ Some nurses argued that they missed spiritual care as it was not written in Standard Operating Procedures and there was no encouragement from the nurse supervisors.⁸ Some nurses stated they gave spiritual care but left it undocumented.⁸ Also, many nurses found that spiritual care was not their job but the job of chaplains or spiritual workers instead.^9,10 This view existed since many nurses considered that spirituality and religion are identical.⁹

Spiritual care is widely understood by nurses as a nursing care that aims to facilitate the spiritual needs of patients which include the need to worship, and to hold onto personal beliefs and values.⁹ For this reason, religion is an essential part of the concept of spirituality.¹¹ However, spirituality contains not only the religious institutions and teachings, but it also encompasses hope, the meaning of life and the connectedness with others, nature and higher power.¹¹

In a narrative review, Baldacchino argued that spiritual care tends to be neglected because of various reasons, including the secularization of the current society that leads the health care professionals be reluctant or feel incompetent to deliver spiritual care.⁷ In addition, the spiritual care competence is also lacking in the nursing education as well as in the interprofessional education curricula.⁷ Consequently, nurses are not well-prepared and less motivated to provide spiritual care.¹²

Nursing education plays an important role in preparing future nurses who are competent in delivering spiritual care.¹ In reality, however, there were many nursing educational institutions across the globe having no spiritual care content in their curriculum,⁷ for example some institutions in Iran and Singapore.^1,4 Whereas, in Turkey and Indonesia, spiritual care topics are integrated into the main nursing science subjects without any emphasis.^12,13

The core curriculum of Indonesian nursing education reflects a minimum attention on spirituality subjects. Despite having a long reputation of being a spiritual and religious society, Indonesian nursing education seems to overlook the importance of spiritual care in nursing. Nevertheless, in practice, since there are religious-based universities among the public and private nursing educational institutions in Indonesia, there might be some differences in how these institutions apply the spirituality curriculum in their education. Thus, the present study aimed to compare the perception on spiritual care of the nursing students in a public university and a religious-based university and to determine the impact of specific spiritual education modules or teaching strategies on the spiritual perception of the students.

Method

This study used a descriptive-comparative design. Faculty of Nursing Universitas Indonesia (FoN UI) was chosen as a sample of a public university and Faculty of Nursing Universitas Muhammadiyah Jakarta (FoN UMJ) was a sample of the religious-based university. A total of 141 students (81 FoN UI nursing students and 60 FoN UMJ students) were recruited using a consecutive sampling technique. The inclusion criteria were currently undergoing the final semester and have passed all practicum subjects. The questionnaire of Spiritual Care Giving Scale by Tiew (2011) which has been translated into Indonesian were used in this study (Cronbach alpha = 0.950).²⁴ This questionnaire consists of 33 statements and uses a six-point Likert scale answer (minimum–maximum score = 33–198). The perception on spiritual care is divided into five categories: (1) attributes in spiritual care; (2) viewpoint in spiritual care; (3) spiritual care definition; (4) attitude towards spiritual care; and (5) spiritual care value. This study was approved by the ethics committee of the Faculty of Nursing, Universitas Indonesia.

Results

Based on the univariate analysis result, almost 89.4% participants of this research were female. The majority of participants (95.7%) were Muslim. Of all participants in FoN UI, 75 of them were Muslims (92.6%), while the participants holding Catholics and Protestant religious affiliations were 2.5% and 4.9%, respectively. Meanwhile, the entire participants in FoN UMJ were Muslims. Another major attributes in the Indonesian society apart from the religion is ethnic group. In this regards, the majority of participants were of Javanese ethnicity (53.1% in FoN UI and 45.0% in FoN UMJ). The mean age of participants from FoN UI is 21.44 years old (95% CI 21.30–21.59, range = 20–23 years old). Whereas, the age profile of the FoN UMJ participants were as follows: median = 22, range = 20–27 years old. The details of the demography characteristics of the participants are presented in Tables 1 and 2.

Table 1.

Participant characteristics (N = 141).

	Frequency	Percentage (%)
Gender
Overall
Man	15	1.6
Woman	126	89.4
Religion
Overall
Islam	135	95.8
Catholic	2	1.4
Protestant	4	2.8
UI
Islam	75	92.6
Catholic	2	2.5
Protestant	4	4.9
UMJ
Islam	60	100
Catholic	0	0
Protestant	0	0
Ethnic groups
Overall
Aceh	2	1.4
Java	70	49.6
Sunda	17	12.1
Betawi	19	13.5
Batak	7	5.0
Minangkabau	13	9.2
Other	13	9.2
UI
Aceh	5	2.5
Java	43	53.1
Sunda	11	13.6
Betawi	10	12.3
Batak	5	6.2
Minangkabau	7	8.6
Other	3	3.7
UMJ
Aceh	0	0
Java	27	45.0
Sunda	6	10
Betawi	9	15.0
Batak	2	3.3
Minangkabau	6	10
Other	10	16.7

Table 2.

Age of the participants.

Institution	Mean/median^* ± std	Min–max
UI	21.44 ± 0.652	20–23
UMJ	22.0^* ± 1.250	20–27

*

Data that is processed using the median.

Mean score of perception of all participants was 171.39, with FoN UI participants scored slightly higher than those of FoN UMJ did (171.96 vs 170.62) (Table 3). The mean score can be considered as high since 83.87% of the participants’ answers favoring the desirable outcome. Further, the perception score in Spiritual Care Giving Scale is elaborated in five factors according to the statement category. In statements indicating the perception to attributes in spiritual care (1st factor), viewpoint in spiritual care (2nd factor), spiritual care definition (3rd factor), and spiritual care value (5th factor), the participants from FoN UI also scored higher than the FoN UMJ counterpart did. Only in the statements that show attitude towards spiritual care (4th factor), the participants from FoN UMJ had higher mean score. However, the independent sample t-test showed no difference in perception about spiritual care between the students of FoN UI and FoN UMJ (p value = 0.612) (Table 4).

Table 3.

Overview perception of nursing student at FoN UI (n = 81) and FoN UMJ (n = 60) about spiritual care.

Institution	Mean ± std	Min–max
UI	171.96 ± 15.405	137–198
UMJ	170.62 ± 16.178	107–197
The entire participants	171.39 ± 1.696	107–198

Table 4.

Comparison of mean scores between the perceptions of students in the FoN UI and FoN UMJ.

Institution	Mean ± std	p-Value
UI	171.96 ± 15.405	0.612
UMJ	170.62 ± 16.178

Discussion

This study result shows that the whole average point of participants’ perception is 171.39 (83.87% of the questionnaire score). The present result was higher compared to the study results conducted by Yuwono¹⁴ in Semarang, Central Java, Indonesia (168.83, 83.32% of questionnaire score) and by Aksoy and Coban¹⁵ in Turkey which yielded mean score of 143.60 (67.03% questionnaire score). In this study, a participant managed to score the maximum point of 198 (100% favorable response). This indicates the considerably good perception on spiritual care among the students in FoN UI and FoN UMJ. We did not perform factor analysis of the captured phenomenon; hence, further studies are needed to explore the plausible factors that contribute to a better perception of spiritual care (Table 5).

Table 5.

Spiritual care giving scale scores at FoN UI (n = 81) and at FoN UMJ (n = 60).

Statement	Mean ± Std UI	Mean ± Std UMJ
Attributes in spiritual care (1st factor)
Spiritual care should take into account what patient think about spirituality	5.23 ± 0.694	5.17 ± 0.763
Nurses who are spiritually aware more likely to provide spiritual care	5.12 ± 0.696	5.23 ± 0.673
Spiritual care requires awareness of one's spirituality	5.17 ± 0.703	5.15 ± 0.633
Indivdual's life experience influence spirituality	4.96 ± 0.782	4.93 ± 1.071
The ability to provide spiritual care can develops through experience	5.06 ± 0.695	5.15 ± 0.709
Spirituality helps when facing life's difficulties and problems	5.25 ± 0.716	5.32 ± 0.748
Spiritual care requires the nurse to be empathetic towards patients	5.12 ± 0.812	5.02 ± 0.748
A trusting nurse-patient relationship is needed to provide spiritual care	5.27 ± 0.671	5.15 ± 0.799
Mean	5.15	5.14
Viewpoints in spiritual care (2nd factor)
Everyone has spirituality	5.54 ± 0.571	5.42 ± 0.619
Spirituality is an important aspect of the human being	5.56 ± 0.592	5.43 ± 0.621
Spirituality is part of a unifying force which enables individuals to be at peace	5.52 ± 0.635	5.52 ± 0.651
Spirituality is an expression of one's inner feelings that affect behavior	5.33 ± 0.725	5.23 ± 0.722
Spirituality is about finding meaning in the good and bad events in life	5.16 ± 0.843	5.12 ± 0.904
Spiritual well-being is very important for one's emotional well-being	5.49 ± 0.635	5.47 ± 0.623
Spirituality drives individuals to search for answers about meaning and purpose in life	5.37 ± 0.679	5.12 ± 0.865
Mean	5.42	5.32
Definitions of spiritual care (3rd factor)
Spiritual care is a process and not a one-time event or activity	5.15 ± 0.808	5.03 ± 0.938
Spiritual care is respecting a patient's religious or personal beliefs	5.42 ± 0.589	5.30 ± 0.788
Sensitivity and intuition help the nurse to provide spiritual care	5.14 ± 0.754	5.10 ± 0.775
Nurses provide spiritual care by respecting the religious and cultural beliefs of patients	5.38 ± 0.644	5.28 ± 0.715
Nurses provide spiritual care by giving patients time to discuss and explore their fears, anxieties, and troubles	5.12 ± 0.765	5.05 ± 0.790
Spiritual care enables the patient to find meaning and purpose in their illness	5.01 ± 0.798	5.05 ± 0.769
Nurses provide spiritual care by respecting patient's dignity	5.25 ± 0.699	5.28 ± 0.640
Mean	5.21	5.15
Attitudes toward spiritual care (4th factor)
Spiritual care includes support to help patients practicing their religion	5.25 ± 0.751	5.28 ± 0.555
I am comfortable providing spiritual care to patients	4.84 ± 0.749	5.07 ± 0.756
Spiritual should be instilled throughout the nursing education programme	5.06 ± 0.827	5.20 ± 0.708
Spiritual care should be positively reinforced in nursing practice	5.11 ± 0.742	5.22 ± 0.783
Spiritual care is very important because it gives patient hope	5.19 ± 0.743	5.12 ± 0.739
A team approach is important for spiritual care	4.74 ± 1.070	4.93 ± 0.800
Mean	5.03	5.13
Value in the spiritual care (5th factor)
Without spirituality, a person is not considered whole	5.00 ± 0.987	4.92 ± 1.124
Spiritual needs are met by connecting oneself with other people, god and entire universe	5.44 ± 0.632	5.25 ± 0.932
Spiritual care is an integral components in holistic care	5.38 ± 0.663	5.22 ± 0.715
Spiritual care is more than just religious practice	5.36 ± 0.913	4.9 ± 0.928
Nursing care itself, when performed well, is the spiritual spiritual care	4.95 ± 0.850	4.9 ± 0.811
Mean	5.22	5.05

Students across groups in this study scored the lowest in the statements of “Spirituality is influenced by individual's life experiences” (attribute to spiritual care domain) and “Spirituality is about finding meaning in the good and bad events in life” (spiritual care viewpoint domain). This finding was somehow in line with a previous study finding done in Saudi Arabia in which the participants did not fully agree with the notion of “spirituality helps people with their illness experience”.¹⁶ Our finding might show a lack of understanding of the spirituality in relation to life experience. Studies have shown that major life events, such as having a chronic or life-threatening illness, could have positive influence on spirituality to a greater extent.⁴ In return, spirituality could be the source of hope for the patients and help them cope with their illness.^17–19 Spirituality is also shown as the key factor to lower stress, depression, and to impact decision-making in the medication.^20,21 Therefore, nurses should stimulate or facilitate the patients to make their illness as a meaningful life experience and a way of self-growth.¹⁵

On the other hand, the highest mean score was obtained in the statement of “a trusting nurse-patient relationship is needed to provide spiritual care” among the participants from the FoN UI and “spirituality helps when facing life's difficulties and problems” amongst the FoN UMJ participants. The latter corresponds with the previously discussed notion that spirituality can help people go through challenging life events such as illness. This result indicates a possibly different vantage point of seeing the significance of the spirituality and spiritual care. Most students of FoN UI agreed on the rather normative attribute of the spiritual care delivery, while FoN UMJ students largely agreed on a deeper meaning of spirituality (Table 4).

Both groups of participants perceived that supporting patients to practice their religion is a part of spiritual care. This research finding supports the previous study results in Saudi Arabia conducted by Cruz.¹⁶ Cruz suggested that the spiritual belief, prayers, and religious practices can help people cope in tough times.¹⁶ A prior study in Indonesia mentioned that Indonesian nurses generally have a high religiosity and it often overlaps with spirituality.²¹ Religious people believe that the faith is the center of their spirituality.²¹ It also reflects the perception on the definition of spiritual care in the questionnaire statement of “nurses provide spiritual care by respecting the religious and cultural beliefs of patients”. The present study results indicate that students viewed spirituality and religiosity as the same things, as also shown in the previous study.^15,16,22,23

The statement of “spiritual care enables the patient to find meaning and purpose in their illness” was among the lowest scored statement. It showed the nursing students’ partial understanding of spirituality and spiritual care. It might also relate to the lower score of the statements regarding teamwork. This finding was different from that of Cruz where participants scored the highest in teamwork statement.¹⁶ Spiritual care is defined as realizing, understanding and providing spiritual needs by allowing space for praying, having conversations, listening, showing empathy, and showing a sense of well-being thus patients can find the meaning of their illness and their whole life.⁷ Aside from prayers, family support plays an important role and has significant impact on illness experience.²⁴ Therefore, nurses should actively collaborate with the family members to provide spiritual care.⁷

Another statement with the lowest average score amongst the participants from FoN UI was “Nursing care, if it was done well is a fulfillment of spiritual care itself”. This result was different with the finding of Aksoy and Coban¹⁵ in Turkey and it showed the lack of understanding that good nursing care does not leave out spiritual aspect. Literature suggests that it is important for nurses to see the spiritual care as a part of their job.^4,15 With this mindset, nurses are more likely to have good perception on spiritual care and vice versa.²⁵ On the other hand, participants from the FoN UMJ gained the lowest mean score on the statement “Without spirituality, a person is not considered whole.” It might also indicate the low understanding of spiritual care value that is defined as one of the major aspects of holistic nursing care in which nurses do not pay attention only to patients’ physics, but also their spirituality.²⁷

Further analysis showed no significant difference in perception regarding spiritual care between nursing students from the public university and the religion-based university. This may reflect the equitable application of the national core curriculum of the nursing education in universities with different philosophical grounds.¹⁵ Moreover, students of the religion-based university were found to score lower compared to those of public university did, possibly since many religious subjects were not well-integrated or delivered to develop the students’ understanding of spiritual nursing care.¹⁶ Using the same curriculum framework, students of the public university whose religious backgrounds were slightly more diverse could form good perception on spiritual care. This finding supports previous study finding conducted by Folami and Onanuga in Nigeria.²⁶ Prior study results also showed that the spiritual wellness and practices of the nurses themselves were associated with the nurses’ attitude and perspective toward spiritual care.^27,28 Additionally, according to Wu et al., the individual perspective about spiritual care was influenced by the religious and cultural context.²⁵

In conclusion, this study found that students of the public and religious-based universities had no significant difference of the perception on spiritual care. The religious and cultural backgrounds which were comparable between those two settings, as well as the nursing education curriculum implemented nationally could be the plausible explanation of this condition. However, this study only captured a cross-sectional perception of the students that may not be generalized in other settings. Spiritual care has been an attractive subject in Indonesia as Indonesian people tend to be religious and spiritual in general. Therefore, further studies with stringent design should be done if we are to strengthen the spiritual aspect of nursing care. The educational bodies may need to evaluate the necessity to produce nurses with good competence in spiritual care and adjust the curriculum implementation accordingly.

Conflict of interests

The authors declare no conflict of interest.

Acknowledgements

This research is supported by Hibah PITTA 2018 funded by DRPM Universitas Indonesia no. 1840/UN2.R3.1/HKP.05.00/2018.