Relationship between Spiritual Attitude and Protecting Patient Privacy in Nursing Students in Khoy

Shahriar Sakhaei , Hossein Motaarefi , Esmayil Zeynali , Mostafa Momeni , Hassan Ebrahimpour Sadagheyani 1 Department of Nursing, Khoy University of Medical Sciences, Khoy, Iran. 2 Department of Islamic Teachings, Khoy University of Medical Sciences, Khoy, Iran. 3 Department of Islamic Teachings, Neyshabur University of Medical Sciences, Neyshabur, Iran. 4 Department of Health Information Technology, Neyshabur University of Medical sciences, Neyshabur, Iran

"spiritual" defined as a method of life with the cognition of immaterial dimension and values referring to others, itself, nature, and life (10).
It is one of the human dimensions that generate the sense of being alive with such qualities as nature, holy subjective experiences, and finding meaning for existence (11,12). Abraham Maslow believed that 'spirituality' is a general responsibility that is assigned to all human beings. Furthermore, he thought that spiritual experience leads us from conventional wisdom to the realm of existence and provides us with the meaningfulness of noble values, such as truth, beauty, art, and love (13).
All human beings are endowed with potential spiritual tendencies which are specific to each person, highlighting human superiority over other creatures, and the existence of spiritual tendencies refers to reasoning potential in human. Spiritual tendencies with reasoning result in creating spiritual capabilities in humans (14). The people with higher levels of intellectual foundation in human attitudes are more involved in process of spiritual growth. Following the process of spiritual growth, as well as having faith in God and his presence in life, strongly affects personal attitude, selfrelationship, and relationship with others. Moreover, it helps human beings find a purpose in life; therefore, it is the best way to obtain spiritual capability and healthy spiritual attitudes (15,16). Attitude consists of three dimensions, namely cognitive, emotional, and behavioral (17).
Spiritual care of patients is recognized as a multi-dimensional concept, including issues related to activities in such fields as respecting, maintaining patient privacy, listening carefully, and raising patients' awareness of the disease process (8,18). Based on related studies, hope and spiritual health were meaningful aspects in life that assisted individuals in adapting to disease, reduced their mental tension, and promoted their life quality and mental-social health (11,19). In this regard, a study showed that nursing students had a high level of spiritual health, and fourth-year students placed more emphasis on supporting the patient's spiritual beliefs, compared to other students (20). In nursing, the spiritual dimensions of individuals are placed in the framework of care, and considering the variable of spirituality is necessary for principled care and having a comprehensive outlook. To provide spiritual care, nurses should extend their knowledge and understanding of spirituality and incorporate spirituality in their nursing care (21). Privacy protection is regarded as a fundamental need of human beings, a critical concept in nursing, as well as a necessary factor in creating patiencecenteredness, individualism, and ethical healthcare (1,22). The concept of personal privacy is derived from the Latin word 'Privatus' defined as deprivation (23). Respect for personal privacy dignifies patients and instills trust so that a safe environment leads patients to physical and mental health and accelerates their treatment and discharge at the earliest possible time (24). Considering personal privacy puts emphasis on the establishment of an effective relationship between the medical team and the patient, as well as the maintenance of patient peace and satisfaction. Despite the critical importance of this issue, when people are admitted to hospitals, their privacy is usually violated during hospitalization by the medical team due to various reasons (25). In a study conducted by Woogara, one-fourth of the admitted patients in the hospital stated that their privacy was not respected during the hospitalization period (26). The concept of patient privacy involves physical, physic, social, and informational dimensions, and its physical dimension has been already considered. In various examinations, cases, such as entering patients' rooms without permission, exposure of body parts, unawareness of disease, insufficient data about the therapy process, and irresponsiveness have been regarded as breaches of patient rights. Nowadays, increased technology and application of patient data in performing research have highlighted the necessity of respecting the personal privacy protection. The breach of patient privacy not only can impose irreparable damage to the patients but also affects the whole healthcare system (27). The violation of patient privacy leads to serious consequences, such as concealing disease background, preventing physical test, increasing anxiety and stress, the arousal of aggression and violent behavior, and lack of trust in the medical teampatient relationship (28), which in turn, causes a reduction in care quality and dissatisfaction. Protection of personal privacy which is a fundamental value deeply rooted in the traditions and history of the nursing profession is regarded as the central conception of nursing care. Moreover, previously conducted studies indicated that the realization of patient privacy protection is related to spiritual capability and culture of nursing (29). In their study, Kuzu et al. showed that patients' privacy was observed in 86.1% of the cases (30). Protection of patient privacy can be considered one of the basic ethical requirements of maintaining individual dignity and patient-centeredness in the spiritual care system of nursing and during hospitalization. Protection of patient privacy can be accounted as one of basic moral requirement, protection of individual dignity and patient-centeredness in spiritual care system of nursing and during hospitalization, nursing students are accepted to facilitate improvement to more extent in the personal realm, but consideration of limitation will be influential in making effective relations, maintaining peace, improving care quality and satisfying patients. There have been different influential cultural, personal, and social factors in considering patient privacy which needed strengthening to modify attitude and notify timely. Furthermore, spiritual attitude, as personal, innate impressions, and holy mental experience directs all life aspects of humans in considering norms specifically respecting personal privacy. Nursing care involves spiritual nature intrinsically and it requires that nursing students take into account a deep understanding of spiritual beliefs and values to provide the basic needs of patients concerning realm limitation. Therefore, this study aimed to determine the relationship between spiritual attitude and tendency to the protection of patient privacy from perspectives of Khoy nursing students.

Methods
The present cross-sectional study was conducted in 2018. The study population included all students of Khoy university of Medical Sciences (n=220), among whom 196 subjects completed the questionnaire. Data collection tools included two questionnaires of spiritual attitude and privacy protection. The spiritual attitude questionnaire )43 items) was designed on the 5-point Likert scale ('I strongly agree' to 'I strongly disagree'). The scores were within the range of 43-215 rated as negative=<100, indifferent=101157, and positive=˃158. The reliability and validity of the spiritual attitude questionnaire have been confirmed with the Alpha coefficient of 91.0 in the previous study conducted by library search and referring to different sources (31).
The privacy protection questionnaire (31 items) was rated on a 5-point Likert scale with the scores ranging from 31-155 (undesirable=˃100, rather undesirable=74-115, and desirable=˃115). The content validity of the questionnaire was approved by eight faculty members of Khoy University of Medical Science, and reliability of this scale was obtained 0.79 at based on a primary study on 20 students and calculating the Cronbach alpha coefficient. Data were analyzed in SPSS V22 using descriptive statistics (frequency, percentage, mean and standard deviation) and inferential statistics (independent T-Test and Pearson correlation Coefficient) at a significant level of 0.05.
The essential permissions were obtained from the Research Council of Khoy University of Medical Science. At the commencement of the study, informed consent was obtained from all subjects; moreover, they were provided with the objectives of the research and were assured of the confidentiality of their responses.

Result
Out of 196 participants, 116(59.2%) cases were male, and 80(40.8%) subjects were female. The majority of cases (75%) were third semester students and city dwellers (88.3%) with a mean age of 21.59±2.9 years and a grade point average of 14.9±1.3 ( Table 1).
The spiritual attitude of students was positive (83.7%); moreover, the tendency to respect patient privacy was desirable (83.7%) ( Table 2). Based on the findings, the highly desirable spiritual attitude of nursing students resulted in more respect for the personal privacy of patients, and there was a direct statistically significant relationship between spiritual attitudes and a tendency to observe patient privacy (P=0.045, r=0.203). Furthermore, in statistical analysis, a significant relationship was detected between a tendency toward privacy protection and gender (P=0.031), as well as the spiritual attitude and tendency toward privacy protection with the place of residence (P=0.001). There were no significant differences in other cases ( Table 3).
The most frequently observed "strongly agree" was related to protective measures and consideration of individual hygiene in the prevention of nosocomial infections (72.4%), the screening requirement during care (65.3%), and appropriate coverage of patient to prevent unnecessary exposure (62.2%), respectively.
The least frequency referred to the possibility of the presence of a family member (20.4%), giving personal satisfaction for releasing (26.5%), providing patients with information, and participating in decision making (28.6%) (

Discussion
As evidenced by the obtained results, the majority of students (83.7%) had a positive spiritual attitude which was indicative of the critical importance nursing student attached to spirituality as the fourth dimension of health. Moreover, they had a great tendency to respect the personal privacy of patients, and this inclination was affected by family nature, cultural factors, and training on basic lessons of ethics, as well as nursing methods. In a study carried out by Shahr Abadi et al., 56% of nursing students and 51.8% of medical students in the final term of Iran University of Medical Science had a positive attitude toward the spiritual care of patients (32). In line with the results of the current research, in a study conducted by Fatemi et al., nurses' attitudes toward providing spiritual care in the selected hospitals of Ardebil Medical University were positive and high (33). The results of the mentioned study demonstrated that most of the nurses 83.7% respected patient privacy. Along the same lines, Karimi et al. compared nurses' understanding and hospitalized teenagers' perceptions of the importance of patient privacy. They reported that nurses valued patient privacy more than hospitalized teenagers (34).
In the same vein, in their study in turkey, CKuzu et al. indicated that the right of personal privacy of patients was observed in 68.1% of cases, and the most frequently observed dimensions of privacy protection were related to protective measures and consideration of individual hygiene (72.4%), screening requirements of care (65.3%), and appropriate coverage of patient to prevent unnecessary exposure (62.2%) (30). In partial agreement with the present study, in another study conducted by Aghajani et al., the fulfillment of patient needs and a neat environment in some dimensions were highly critical from teenagers' perspective (1). Previous studies in the field of respecting personal privacy reported the most frequently observed cases of patient privacy breaches, such as sitting on the patient bed without permission, exposure of some body parts, excessive noise, lack of control over personal space boundaries, irresponsiveness to patient questions, and unawareness of disease (25,26,35). In a study performed by Lin et al. in Taiwan, patient privacy breach occurred due to high working volume, lack of employed persons, congested areas, and inappropriate physical space (22).
Aghajani and Dehghanniri indicated that unnecessary touching in half of the patients and sitting on the patient bed without permission occurred in 13% of cases. There were significant differences in the relationship between gender and privacy protection, as well as the association of respecting patient privacy with the place of residence and spiritual attitude. In the mentioned study, no significant relationship was observed between gender and respecting patient privacy; nonetheless, there was a significant relationship between age and privacy protection (1). These findings were incongruent with our results and showed that attitudes of nursing students in Khoy significantly differed according to the place of residence and gender in terms of respecting patient privacy and attitude toward spiritual issues. Based on the correlation between spiritual attitude and personal privacy protection, a positive spiritual attitude was highly influential on respecting patient privacy.
Based on the results of the study and the correlation between spiritual attitude and patient privacy, raising nursing students' spiritual awareness can exert positive effects on clinical care and quality of treatment, which in turn, leads to increased patient satisfaction and professional competence in nurses.

Conclusion
All humans have a spiritual orientation potential that with the support of reasoning and learning is amendable. In spiritual care, activities such as respecting, protecting patient privacy, listening carefully to patients, and helping to disease process are fundamental concepts. According to the results of the study and the direct correlation between spiritual attitude and respect for patients 'privacy, a positive attitude in nursing students improve spiritual capability in terms of respect to the patient realm and privacy protection. Since spiritual attitude and a tendency toward patient privacy protection are factors that require studies in various fields and each kind of activity for need assessment, notices, and interventions can assist students to present spiritual care relied on respecting humanity and morally right. It is necessary, nursing faculty members strengthen the spiritual attitude in nursing students by using practical and role-playing teaching methods.