Health, Spirituality and Medical Ethics

Introduction
Human as the most amazing creation of God has four dimensions, including physical, mental, social, and spiritual each of which has been separately studied by the researchers (1, 2). Lack of attention to each of these dimensions eliminates a crucial part of human existence (3). The spiritual dimension is one of the most important dimensions of human. Adding spiritual health to the concept of health was proposed by scientists and has faced health experts with an important dimension of individual and group life (4).
Over recent years, studies have observed that how religion and spirituality affect various aspects of physical and mental health (5). Currently, medical science has declared a close connection between physical and mental health. According to the scientific results, the relationship among body, soul, as well as psychology, and the effects of individual beliefs and desires have affected physical health (6). Two aspects of human's spiritual health are: 1) the perspective of religious health expressing the connection with a higher power and 2) the perspective of the existential spiritual health focusing on the social and psychological concerns of individuals (7). It can be stated in a comprehensive definition that spiritual health is a sense of acceptance, positive feeling, ethics, and positive reciprocal relationship with a supreme saintly authority that is achieved through a cognitive, emotional, and action process, as well as personal consequences (8).
Some scholars have presented that spirituality highly correlates with the individual's overall health and behavior (9). Moreover, in some studies, it has been concluded that there is a positive correlation between nurses' spirituality and their performance in caring for patients (10, 11). Healthcare personnel are in a complex interactive system with patients due to their critical role in providing the patients with complete and comprehensive care (9, 12, 13).
Spiritual health has a crucial role in adaption to stress and positive effect on the enhancement of mental health, as well as reduction of mental disorders. Therefore, spiritual and religious beliefs have a significant relationship with health symptoms, such as decreasing anxiety and depression, as well as increasing self-esteem, and self-control (14, 16). If spiritual health is at risk, an individual will suffer from mental disorders, such as loneliness, depression, and loss of life meaning (17) all of which affect the manner of an individual performance and nurses' duty fulfillment.
Regarding the role of spiritual health, although no Iranian valid native tools have been used up to now several studies have been carried out through some tools used by other countries. As an example, Assarroudi et al. stated that spiritual health has a positive relationship with different dimensions of the nurses' quality of life and satisfaction (18). In a study conducted by Tavan et al., it was demonstrated that there is a statistically significant correlation between age and physical health, as well as spiritual health score in girls (19).
The results of a study performed by Jafari et al. have proven the important role of variables, including the meaning of life, religious well-being, and well-being in nurses' mental health (9). Moreover, a study carried out by Rahimi et al. investigated the level of the spiritual health of students and reported this level related to nursing and midwifery students in a moderate range (20). There is also a significant correlation between spiritual health and job involvement in faculty members (21).
Operating room personnel as an important spectrum in the field of healthcare are prone to behaviors that can endanger the safety of patients. This finding can be due to the pressure in work challenges, the sensitivity of patients and their families, disease complications, job-related crucial accidents, lack of support on behalf of the managers and community, labor-intensive demands, as well as work-family conflicts (22).
The managers of healthcare centers should try through available capacities to change work environments towards providing the service without any tension and pressure by personnel. Furthermore, on the other hand, managers should select people qualified as highly committed and dedicated. Despite the correlation between the spiritual health and the way of duty fulfillment, stress adaptation and anxiety reduction, there are few studies regarding the assessment of the spiritual health level of the operating room personnel in the healthcare centers and its relationship with job performance. With this background in mind, the present study aimed to investigate the relationship between spiritual health and job performance in operating room personnel working in the academic hospitals of Qom, Iran.
 
Materials and Methods
This cross-sectional research was conducted on 95 operating room personnel with a university degree (i.e., associate diploma and BSc degree in surgical care practice), as well as anesthesia personnel in the academic hospitals of Qom, Iran, though census sampling in 2017-2018. The gathering data were carried out using three questionnaires. In order to collect demographic information of the participants, the demographic questionnaire was applied included information regarding age, work experience, educational level, gender, marital status, job system, and place of residence. The second questionnaire was a comprehensive spiritual health measurement tool for Iranian society. This questionnaire had 48 questions with the items 1-28 related to cognitive/emotional domain focusing on the individual's insights and orientations and 29-48 referring to the behavioral components during the last year (23).
Moreover, the standard questionnaire of Paterson's job performance, including 15 questions, was another research tool (24). After obtaining permission to enter the operating room, the surgical technologists were asked to complete the questionnaire in the presence of the researcher in order to resolve the probable ambiguity. Finally, data analysis was performed by SPSS software (version 20) using independent t-test and Pearson’s correlation coefficient. It should be noted that the cases participated in the study knowingly and voluntarily after the necessary explanations about the study objectives, and they were ensured that their information remained confidential.
 
Results
Overall, 95 returned questionnaire were analyzed. The study population, including 95 operating room personnel from which 50 subjects were men and the rest were women. Bachelor's degree had the highest frequency (n=69). The majority of the subjects (97.9%) worked under the rotating shift system and most of the respondents (95%) were natives of Qom. Table 1 tabulates the information regarding the demographic variables. Based on the results the average age and work experience of subjects was 33.05±7 and 9±8 years respectively (Table 2).
The mean score of job performance was 63±11. On the other hand, the mean scores of spiritual health and the two related subsets, including cognitive/emotional and behavioral components were reported as 205±22, 82±10, and, 123±14, respectively (Table 2). The reliability of the two research tools was assessed, rendering Cronbach's alpha coefficients of 0.91 and 0.95 for the spiritual health and job performance questionnaires, respectively.
According to the results of data analysis using the independent t-test and analysis of variance, there was no significant difference in the mean scores of spiritual health and job performance based on the demographic variables (P>0.05). Furthermore, the relationship between age and work experience with job performance, cognitive/emotional, behavioral components, and the total score of spiritual health were examined using Pearson's correlation coefficient. In this regard, the obtained results revealed that there was no significant correlation (P>0.05).
 
Table 1. Description of qualitative studied variables by demographic method (n=95)
 

Variable	Variable subtype	n	%
Gender	Male	50	53
	Female	45	47
Marital status	Married	67	70
	Single	28	30
Educational level	Associate diploma	24	25
	degree  Bachelor	69	73
	Postgraduate and senior degree	2	2
Job system	Working shift	93	97.9
	Working day	2	1.2
Place of residence	Qom province	90	95
	Others	5	5

 
 
Table 2. Descriptive analysis of studied variables (n=95)

	Minimum	Maximum	Mean	Standard deviation
Age	22	51	33.05	7
Work experience	0.001	30	9	8
Job performance	15	75	63	11
Cognitive/emotional component of spiritual health	77	140	123	14
Behavioral component of spiritual health	57	100	82	10
Total score of spiritual health	134	240	205	22

 
 The relationship between job performance with spiritual health and the two related subsets, including cognitive/emotional component and behavioral component, were statistically significant using Pearson's correlation coefficient (P<0.01; Table 3).
Table 3. Correlation coefficients between job performance with spiritual health and its subsets

	Cognitive/emotional component	Behavioral component	Spiritual health
Job performance	0.337*	0.528*	0.466*

 
 
                                                                                  
 
^*P<0.01                                                                                                                                            
Discussion
All previous native studies in the field of spiritual health have used designed questionnaires in western societies based on the concepts and definitions related to their culture and religion (18, 25-28). Moreover, researchers from other countries have assumed spirituality similar to being religious and sometimes emphasized the personal aspect of spirituality (29). According to the above-mentioned findings, the use of designed tools in societies with different culture and religion from the research community will not have consistent results with reality (23). Based on the findings of the present study, the mean score of spiritual health for the participants obtained at 205 showing a high level with respect to the maximum possible score of 240.
High levels of spirituality and spiritual health in the workplace lead to organizational effectiveness (30), promotion of occupational delight and organizational commitment (31), increase in job satisfaction (32, 33), and feeling of happiness (34, 35). Furthermore, spiritual health improves the quality of life, well-being, and comfort of the organizations’ employees and reduces their occupational stress and finally makes individuals feel better and more sociable (36, 37). In healthcare providing environments, nurses and paramedics play a crucial role in maintaining and improving the level of patient safety (38). Based on the mentioned findings, through organizational atmosphere and constructive interaction with individuals in order to promote the constructive thoughts and beliefs and organization enhancement, the status of the individuals can be improved so as to reduce the number of occupational errors and enhance the patient's safety. However, there was a possibility for the variables to be affected by the atmosphere and religious culture of the city. Therefore, it is recommended to carry out similar studies in other parts of Iran.
Furthermore, the variable of job performance was assessed among the participants. Regarding this variable, the mean score of the job performance of the subjects was obtained at 63 out of 75 indicating a high level. Based on the aforementioned evidence, several characteristics of the subjects are anticipated as follows: 1) holding high meaning for their work due to their high spiritual health (39), 2) having good relationship and interaction with other colleagues, patients, other technical and executive staff, doctors, nurses, and managers in the hospital (40), 3) and showing high commitment to work (41). In addition, the results of statistical analysis showed that according to demographic variables, the difference between the scores of spiritual health and job performance was not statistically significant. Moreover, in a study conducted by Amiri et al., no significant difference was observed with regard to the two studied variables among different demographic groups (23). In this regard, Azad Marzabadi et al. achieved similar results (42).
In order to justify this hypothesis, it can be stated that the studied personnel work in an Islamic organization and live in a spiritual society and the factor of religion is considered as one of the fundamental principles of their lives. On the other hand, it is indicative of equal opportunities for men and women in society to achieve the same level of spirituality due to lack of difference in the spiritual health among male and female operating room personnel or individuals with different demographic variables (42). Therefore, no significant difference was observed between the scores of occupational performance in the studied demographic groups.
In the present study, according to a study carried out by Amiri et al., spiritual health was defined in terms of conditions in which all the actions of an individual in relation to other people and the peripheral environment, such as organization, are regulated to realize the divine transcendental purpose (23). Regardless of the studied demographic variables, the operating room personnel in the academic hospitals of Qom obtained high scores in spiritual health (mean score of 205) and acceptable job performance (mean score of 62). In this regard, they have adopted a meaningful view of their occupation and are providing health services with the aim of fulfilling divine satisfaction. Moreover, despite all the organizational deficiencies, such as insufficient financial and human resources, as well as equipment, they try to perform their duties in a correct and accurate manner.
According to this study, spiritual health has not been raised in terms of quality of life; however, it has been regarded as one of the Muslim health dimensions. The present study evaluated spiritual health in two cognitive/emotional and behavioral domains. Based on the obtained results of this study, the relationship between job performance with two subsets of spiritual health (i.e., cognitive/emotional component and behavioral component) and the total spiritual health was statistically significant. In other words, the subjects in the internal domain including beliefs, attitudes, as well as insights, and external domain as shown behaviors were influenced by spiritual health and displayed better performance.
In a study carried out by Yseminejad et al. (2011), it was shown that spirituality can increase the level of job engagement (21). It seems that increasing the spiritual health score among the operating room personnel leads to increase these individuals' job performance. The enhancement of job performance can make people less probable to leave their occupations. In addition, higher occupational engagement results in less stress and more job satisfaction by having hope and faith to work (43). According to the results of a study conducted by Yarmohammadi et al., it was revealed that the nurses' spiritual health affects their occupation and attitude toward the patient and nursing services in a way that those with low spiritual health are expected to show more unethical behaviors. Furthermore, spiritual health grows hope, purposefulness, calmness, positive attitude toward the world, and high adaptability in individuals, increases the person's ability to perform things, and finally causes less emotional dependency to others (27). Consequently, it is expected that the ethical performance of the operating room personnel holds a high level resulting in more effort for better interaction with patients, the reduction of medical errors, and ultimately the improvement of patient safety.
Overall, regarding the positive correlation between spiritual health and job performance, increasing or decreasing the score of an investigated variable also increases or decreases the score of another variable. Despite all the benefits of developing spirituality issues in organizations, there are still challenges and concerns in this regard that need to be addressed. There are some examples, including the possibility of inducing certain beliefs by managers as the topics of spirituality, the risk of putting pressure on workers or looking at the issue as tools and showcases, as well as the problems of converting scientific content and assumptions in the field of organizational spirituality to the law (36).
 
Conclusion
A positive correlation between the variables of the spiritual health and job performance indicated that increasing the level of one of the variables in the studied environment also increased that of the other variable and decreasing the level of one variable reduced that of the other variable. Accordingly, the managers of healthcare centers should seek ways to expand spirituality and promote job performance in related workplaces. Considering the fact that the present study was one of the first in this field, it is recommended to carry out similar studies in other provinces of Iran and in other working environments.
 
Acknowledgments
This study was a project approved by the Research Deputy of Qom University of Medical Sciences with the ethical code of MUQ.REC.1395.107. Hereby, the author would like to thank all the respectable officials of the Faculty of Health and Religion, Research Deputy of Qom University of Medical Sciences, and operating room personnel in the academic hospitals of Qom.