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   Table of Contents      
ORIGINAL ARTICLE
Year : 2022  |  Volume : 27  |  Issue : 6  |  Page : 575-580

Barriers to providing spiritual care from a nurses' perspective: A content analysis study


1 The Center for Developing Interdisciplinary Research of Islamic Teaching and Health Sciences, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
2 Nursing & Midwifery Care Research Center, Faculty of Nursing & Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Submission14-Nov-2021
Date of Decision24-Aug-2022
Date of Acceptance11-Oct-2022
Date of Web Publication18-Nov-2022

Correspondence Address:
Zeinab Hemati
Nursing & Midwifery Care Research Center, Faculty of Nursing & Midwifery, Isfahan University of Medical Sciences, Isfahan
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnmr.ijnmr_422_21

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  Abstract 


Background: Spirituality is an important dimension of holistic nursing, and spiritual care is essential to ensure the achievement of optimal care in nursing profession. The aim of this study was to explain the obstacles to providing spiritual care from the perspective of nurses. Materials and Methods: The present qualitative study was conducted between November 2020 and June 2021 with a content analysis approach. Participants included 30 nurses, selected through purposive sampling, working in the general wards and intensive care units of Isfahan University hospitals. Data collection method was semi-structured personal interviews. After recording and transcription word by word, all data were analyzed through qualitative content analysis. MAXQDA 11 was used for data analysis.Results: Research findings included 323 primary codes and two main categories “individual barriers and organizational barriers” and eight subcategories “non-compliance with human resources standards, lack of attention of organizational managers to the importance of holistic care, motivational barriers, training barriers, barriers to interprofessional collaboration, environmental barriers, barriers related to the nurses, and communication barriers.”Conclusions: Using the results of the study, policymakers and nursing managers will be able to help facilitate spiritual care, and ultimately, improve the quality of nursing care by improving the infrastructure and removing existing barriers.

Keywords: Care, nurses, qualitative study, spirituality


How to cite this article:
Momeni G, Hashemi MS, Hemati Z. Barriers to providing spiritual care from a nurses' perspective: A content analysis study. Iranian J Nursing Midwifery Res 2022;27:575-80

How to cite this URL:
Momeni G, Hashemi MS, Hemati Z. Barriers to providing spiritual care from a nurses' perspective: A content analysis study. Iranian J Nursing Midwifery Res [serial online] 2022 [cited 2022 Dec 1];27:575-80. Available from: https://www.ijnmrjournal.net/text.asp?2022/27/6/575/361479




  Introduction Top


The ultimate goal of health services is to provide quality care in order to improve the outcome of services for the patients and the community. In professional care, the focus is on the individual as a biological, psychological, social, and spiritual being, and the balance of body, mind, and spirit is essential to maintain health.[1] Spiritual care is a multidimensional concept, which includes issues such as observing patients' respect, patients' privacy, listening carefully to the patients' words, and helping them to be aware of the disease process.[2],[3] Recent research has suggested that spiritual care is a sort of care that can reduce anxiety and contribute to positive health outcomes.[4],[5]

Spiritual care along with other nursing care will cause a balance between body, mind, and spirituality in order to achieve complete and comprehensive health. In other words, spiritual and religious beliefs are significantly associated with symptoms of mental health and mental well-being such as reducing anxiety and depression, increasing trust and self-control and can speed up the process of recovery, increase hope, reduce physical pain, cause a deeper relationship between nurse and patient, and create meaning and purpose in life.[3] In this regard, nurses claim to be holistic caregivers, being able to help maintain patients' health.[6]

In Iran, spiritual health does not have a clear framework for health system staff. Cases such as problems in explicit definition of the concept of spirituality, ambiguity in the use of the concept of spiritual care, lack of correct understanding of this concept, the type of attitude of caregivers towards spirituality,[7] lack of professional training in this field, especially experimentally, lack of topics, related to spirituality contents, in nursing reference books, weakness in effective communication with the patient, negative experience, and understanding of religious beliefs in the past,[8] and shortage of nurses' time have been suggested as the reasons for neglecting spiritual care.[9],[10] Also, in studies, conducted in Iran, most of the patients' complaints were about no nurse–patient gender matching, lack of knowledge about how to access religious resources, lack of private space for spiritual and religious practices, lack of attention and respect to patients' spiritual beliefs and values.[11] Inadequate observance of psychological issues, related to patients' age and gender, lack of confidentiality, and no referral of the patients in need of supportive and spiritual services to other centers have been suggested as the barriers to providing spiritual care.[10]

In a qualitative study, conducted by Ramezani et al.,[12] the results showed that spiritual self-care, nurse's interest in active learning of spiritual care, sense of belonging to the nursing profession, personal and professional competencies, nurses' knowledge in the field of spiritual care, and the harmony between the principles and beliefs of patients and healthcare providers are the most important facilitators of spiritual care, but on the other hand, the role of environmental and organizational factors in providing spiritual care has not been explained. In a study by Mahmoodishan et al.,[13] although the concept of spiritual care from the perspective of nurses has been explained, the barriers and facilitators of providing spiritual care have not been studied.

Therefore, spirituality is more intertwined in culture and religion, so qualitative research allows the researcher to enter into the participant's internal experience to find out how spirituality is formed in this field.[14],[15] So the present study with a qualitative and purposeful approach aimed at the explanation obstacles to providing spiritual care from the perspective of nurses.


  Materials and Methods Top


The present study was a qualitative content analysis study in which 30 nurses are working in hospitals, affiliated to Isfahan University of Medical Sciences (Al-Zahra, Noor and Hazrat Ali Asghar, Kashani, Seyed Al-Shohada, Amin and Chamran hospitals) through purposive sampling. This study was conducted between November 2020 and June 2021. Inclusion criteria were nurses with clinical experience for a maximum of 2 years, having no hearing impairment, speech, or any known mental illness, and having the necessary motivation to conduct the interview. Exclusion criteria were “hearing or speech impairment and mental illnesses” and not only “unwillingness to participate in study whenever want.”

The method of data collection was personal interviews, conducted in nurses' lounge room in general wards and intensive care units of relevant hospitals. The interview lasted for 45–60 minutes. The interviews started with the following questions: What do you think are the needs of patients' spiritual care? What are the barriers to this relationship? What is the role of nurses in providing spiritual care? With regard to the existing conditions and facilities, what strategies do you suggest to promote the spiritual health of patients? Finally, the interview process continued with exploratory questions. The interviews continued until the data saturation, and the statements were repeated, so that no new codes were obtained in the last three interviews. All personal and group interviews were recorded on tape, and immediately, transcribed verbatim and analyzed. Data analysis was conducted in a short period of time from data collection through the conventional content analysis approach. In this study, qualitative content analysis method was used to analyze the qualitative data with the approach of Graneheim and Lundman.[16]

In the present study, an attempt was made to maintain the validity of the data and to increase rigor of the findings with the help of the following methods: The researcher was present in this study for about 10 months to collect qualitative data and tried to help gather credible data by attending interviews for a long time. In this study, in-depth interviews were used to obtain in-depth data. Participants were selected with maximum diversity in terms of type (age, sex, level of education, socioeconomic level, work experience, turn-based schedule, and type of ward and hospital). The researcher used the review method by the participants to verify the data and the extracted codes or to correct them. Thus, after coding five interviews, their texts were returned to the participants along with the given codes to ensure the accuracy of the codes, and in special cases, the codes that did not express the participants' views were corrected. The peer-review method was also used to confirm the validity (acceptability of the data), so that the research data and the stages of coding and reaching the classes could be reviewed by three experts who were familiar with qualitative research but did not participate in the research, and ensure that codes and classes matched the data.[17],[18] MAXQDA 11 was used for data analysis.

Ethical considerations

The present study is part of the research project approved by the Vice Chancellor for Research and Technology of Isfahan University of Medical Sciences with ethics code of IR.MUI.RESEARCH.REC.1397.028 issued by “University Research Ethics Working Group.” Research process, from data collection to the end of analysis and reporting of the findings, issues such as informed consent, anonymity, the confidentiality of information, the right to withdraw at any time, and the provisions of ethical obligations were observed.


  Results Top


Participants in this study were 30 nurses working in general wards and intensive care units of university hospitals in Isfahan with mean age of 45 years. 5 of the participants had a master's degree and 25 of them had a bachelor's degree. They had a mean age of 15 years of work experience. Findings from the analysis of data, extracted from the conducted interviews, in line with the purpose of the research as the barriers to providing spiritual care to patients, included 323 primary codes, two main categories “personal and organizational barriers,” and eight subcategories [Table 1].
Table 1: Barriers to spiritual health from the perspective of nurses

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Organizational barriers

Non-compliance with workforce standards

Participants cited the shortage of nursing staff, overwork, heavily workload shifts, non-standard nurse-to-patient ratio, lack of time, and burnout as some of the most important barriers to providing holistic care and spiritual health care. One of the nurses said: “The first point in improving giving service is the ratio of nurses to patients. When you have fifty patients instead of two, the condition becomes different. I can see the effects of observing such standards in everything” (P7).

Lack of attention of managers to the importance of providing holistic care

From the perspective of some participants, lack of some managers' expectation to provide spiritual care, consideration of spiritual care out of the vision and mission of hospitals, not considering holistic care in hospital accreditation metrics, the focus of management system on just recording the care rather than performance, lack of motivations for employees (such as job promotion, salary increase, gratuitous loan, increase of work coefficient), and lack of planning for staff training are organizational barriers to provide spiritual care. One of the nurses said: “Managers and officials should know that motivation of the manpower is effective in survival and dynamism of the organization and will help implement the policies and strategy of the medical center, but unfortunately, the current medical system does not know how to manage that and only pursues its own interests and pays little attention to employee's welfare and satisfaction” (P20).

Motivational barriers

One of the most important factors in improving the quality of care, that nurses placed great emphasis on, was improving their salaries and benefits. One of the nurses said: “Now the person who has been selected to take over the management of the hospital is a general practitioner. He has been appointed based on the relationship, not on competence and ability. For him, the quality of work does not matter at all, he only pays attention to that the things are well written, even if you have not done them, it matters to him that his bosses are satisfied, he doesn't differentiate between those who are sympathetic and give comprehensive care and those who do not work, but just write their reports” (P1).

Educational barriers

From the perspective of some participants, many nurses do not understand the concept of spiritual care due to the absence of spiritual education in the curriculum of undergraduate students and nursing texts as well as the lack of specialized training in the field of spiritual care. One of the nurses said: “A person's religious beliefs affect his/her lifestyle and can make a person believe that everything is in the hands of God and that God can help him/her. For example, a physician or paramedic who is familiar with the subject of spiritual health can suggest solutions to the patient and can refer the patient to a cleric” (P19).

Barriers to interprofessional collaboration

In the present study, participants claimed that lack of teamwork culture in Iran, extreme territorialism, especially among physicians, their power and supremacy have made the physicians unable to understand the nurses' capabilities, limitations, and responsibilities. One of the nurses said: “.... Unfortunately, we still do not know the principles of establishing a proper relationship with our colleagues. Each member of the treatment team must interact with one another in a respectful, responsive, and cooperative manner” (P16).

Environmental barriers

In the present study, participants believed that lack of space and facilities for worship, lack of facilities for performing ablution and keeping religiously clean, environmental noise, crowdedness in the wards, and lack of privacy of the patient are obstacles to provide spiritual care. One of the nurses said: “Lack of suitable conditions and environment deprives the patient of worship. In the urology department, a patient was bleeding so much that his clothes were filled with blood. The patient came and asked if we had facilities for bathing and washing. “He said that he did not want to pray until he cleaned himself. We also do not allow the patient to be alone. “Patients are forced to pray in their rooms. There is so much commuting of the doctors, interns, residents and interns that he/she does not understand what he is saying” (P30).

Individual barriers

Barriers related to nurses

In the present study, participants believed that lack of interest in nursing, negative perception of religious beliefs, problems in nurses' family relationships, nurses' financial problems, and lack of motivation are barriers to provide spiritual care. One of the nurses said: “When a nurse himself/herself does not have peace of mind, he/she fails to convey this peace to the patient. Due to their problems with salary, benefits and their low job status, nurses' motivation to work comes down” (P7).

Communicational barriers

In the present study, participants believed that lack of time, lack of communication skills, lack of specialized training in effective communication, local dialects and not understanding the meaning of the patients' remarks, patients' distrust of treatment team members, non-compliance with the principle of confidentiality, and the disclosure of the patients' medical information are the obstacles of providing spiritual care to patients. One of the nurses said: “Other problem that the nurses have is the issue of respecting the patients' confidentiality. We have not yet learned how to be secretive, and by the time we get to the station, everyone is aware of the patients' problem” (P11).


  Discussion Top


Findings from data analysis of the present study showed that there are individual and organizational barriers to providing spiritual care. Based on in-depth interviews, conducted with participants, one of the most important obstacles included lack of the nursing staff, heavy workload of the staff, heavy shifts, the non-standard nurse-to-patient ratio, lack of time, and burnout. In this regard, the results of a study showed that lack of the nursing staff, lack of awareness of the patients' spiritual needs, and time constraints are barriers to provide spiritual care to patients.[19] The study of Wong et al.[20] also showed that cultural differences, high workload, lack of managerial support, and lack of sufficient knowledge and skills in providing spiritual care are barriers to provide spiritual care to the patients. The results of a study well illustrated the importance of nurses' workload in providing spiritual care and showed that if the processes related to completing the patient file are done by the ward secretary, nurses' workload can be reduced and it lets them pay more attention to spiritual care and support the families of near death patients.[21]

Another main category that was extracted in the present study was the lack of attention of managers to the importance of providing holistic care. From the point of view of some participants, lack of some managers' expectation to provide spiritual care, consideration of spiritual care out of the vision and mission of hospitals, not considering holistic care in hospital accreditation metrics, the focus of management system on just recording the care rather than performance, lack of motivations for employees, and lack of planning for staff training are organizational barriers to provide spiritual care.[22]

Other barriers extracted from the present study were educational barriers. From the perspective of some participants, many nurses do not understand the concept of spiritual care due to the lack of spiritual education in the curriculum of undergraduate students. The results of a study in this regard showed that nurses were concerned about providing spiritual care due to no relevant information and skills.[20] The results of existing study in this field showed that the lack of private space to talk to the patients is one of the important barriers to spiritual care.[23] Lack of motivation of the nurse to provide spiritual care and their financial and familial problems were other barriers to provide spiritual care, mentioned by the participants in the present study. From the point of view of some participants, work conscience, recognition and appreciation by authorities, salary, career promotion and interest in work, authorities' supervision, and providing correct feedback by the head nurse to staff affect the motivation of nurses, but many nurses have lost their motivation to provide quality services due to lack of verbal encouragement, lack of impact of spiritual care on their salaries and benefits.[24] They also believed that among the motivational factors, job dissatisfaction is the most important component affecting the quality of service delivery. Job dissatisfaction not only quantitatively disrupts the work of patients and the nursing unit, but also qualitatively weakens the morale of staff and patients, and as a result, reduces the quality of nursing care significantly.

Reluctance of nurses to continue working, doing a second job, unrelated to nursing, willingness to leave work, dissatisfaction with administrative regulations, complaining about high workload and lack of manpower, failure to fulfill the promises of officials of the Ministry of Health, no tariffs for nursing services, lack of charge for nursing services, no timely extra payments, huge differences between physicians' and nurses' payments, and non-compliance with the productivity law have led to nurses' dissatisfaction with the system, resulting in a decline in the quality of services.[25]

One of the most important factors in improving the quality of care that nurses placed great emphasis on was improving their salaries and benefits. From the participants' point of view, the salaries paid to them are not fair and equitable, and this issue leads to a decrease in the motivation of the staff to provide appropriate quality services and to provide holistic care and spiritual care. They compared their data (education, experience, effort, and commitment to patient care) with the outputs they received from the organization, the most important and obvious of which was their salary and benefit, and then, compared them with other outputs and data and stated that the salaries and benefits paid to them are not fair, compared to doctors and other hospital nurses.[24] Therefore, by improving the salaries and extra payments of nurses, their job motivation, and consequently, their quality of spiritual care can be improved. Another individual obstacle to providing spiritual care is a negative attitude toward religious beliefs. What is certain is that the spiritual care practices of nurses, like other aspects of care, at least with modern knowledge, cannot be placed in the form of simple and communicative instructions. Spiritual nursing care requires creativity, deep interpersonal understanding, altruism, and requires nurses' awareness, growth, and excellence. Therefore, negative beliefs about religious beliefs affect the quality of spiritual care delivery. The strengths of the present study are that researchers were present in the study environment for about 6 months to collect qualitative data and tried to help gather reliable information by attending and engaging in long-term interviews. In this study, in-depth interviews were used to access deep data. Participants were selected with maximum diversity in terms of age, gender, level of education, socioeconomic status, and type and place of employment. Researchers also used participants' review and peer-review method to confirm validity (data rigor). Study limitations also include as follows: This qualitative study explores barriers to providing spiritual care in Iran. Accordingly, the findings might have limited transferability. Further studies investigating the barriers to providing spiritual care delivery in other contexts and settings are needed.


  Conclusion Top


According to the barriers extracted in the present study, it is necessary for nursing managers to adopt strategies to remove the existing barriers so that nurses as the most important member of the treatment team become more involved and motivated in providing spiritual care. By teaching communication skills to nurses and the role of effective communication in building trust between the nurses and the patients and, most importantly, solving nurses' financial problems, the barriers to spiritual care can be significantly reduced. Therefore, since spiritual care requires interprofessional collaboration, it is suggested that the views of other members of the health team, including physicians, psychologists, spiritual caregivers, and clergy, on individual and organizational barriers to spiritual care delivery are investigated.

Acknowledgements

The researchers consider it necessary to thank all the nurses participating in the present study and the Vice Chancellor for Research and Technology of Isfahan Medical University for approving the research plan (297018).

Financial support and sponsorship

Research and Technology of Isfahan Medical University

Conflicts of interest

Nothing to declare.



 
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