Health, Spirituality and Medical Ethics

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Introduction
piritual care is one of the most important
topics in health research due to its significant
effects on patients’ physical and mental
well-being [1]. Assessing the spiritual
needs of patients and performing spiritual care for them
leads to reducing pain, increasing life expectancy, and
faster recovery of the disease [2, 3]. Spiritual care has
a significant role in prevention, health promotion, and
relief of pain and discomfort as the goals of the nursing
profession [4]. Spiritual care is a complex and multidi-
Ashraf Khoramirad1 , Zahra Abedini1* , Hoda Ahmari Tehran1 , Zohreh Khalajinia2 , Sarallah Shojaei1 , Akram Heidari1 , Sadegh Yousefi1
1. Spiritual Health Research Center, Qom University of Medical Sciences, Qom, Iran.
2. Department of Midwifery, School of Nursing, Qom University of Medical Sciences, Qom, Iran.
* Corresponding Author:
Zahra Abedini, Assistant Professor.
Address: Spiritual Health Research Center, Qom University of Medical Sciences, Qom, Iran.
Phone: +98 (912) 7576929
E-mail: abediny1354@yahoo.com
Research Paper
Educational Needs Assessment of Spiritual Care in
Nurses in Iran in 2021: Using Delphi Technique
Background and Objectives: Nurses are professionally and ethically obliged to provide
spiritual care as part of comprehensive care for patients. The present study was conducted to
determine the educational needs of nurses to provide spiritual care.
Methods: This study was performed descriptively using the Delphi technique from September
2020 to April 2021 at Qom University of Medical Sciences. In the first stage, 10 specialists were
selected by purposive sampling method and answered an open-ended question to determine the
educational needs of spiritual care. After collecting opinions in three rounds, the needs with an
agreement coefficient of more than 51% were prepared in the form of a 15-item questionnaire
and the importance of the items was determined by 144 nurses. Needs with scores of 3 or higher
were finalized and general and behavioral goals were set for them.
Results: In the first, second, and third rounds, 47, 25, and 15 educational needs were determined,
respectively, and five general objectives, including familiarity with the holistic approach to human
beings and dimensions of health, familiarity with the concepts of spiritual care, familiarity with
how obtaining a spiritual history, familiarity with the types of diagnoses and spiritual interventions,
and familiarity with the principles of communication in spiritual care were determined.
Conclusion: The results of the study can be used for developing a spiritual curriculum and a
practical guide to providing spiritual care for nurses and other groups of the health team.
A B S T R A C T
Keywords:
Needs assessment,
Nursing care, Spirituality
Please cite this article as Khoramirad A, Abedini Z, Ahmari Tehran H, Khalajinia Z, Shojaei S, Heidari A, et al. Educational
Needs Assessment of Spiritual Care in Nurses in Iran in 2021: Using Delphi Technique . Health, Spirituality and Medical
Ethics Journal. 2022; 8(4):201-208. http://dx.doi.org/10.32598/hsmej.8.4.1
: http://dx.doi.org/10.32598/hsmej.8.4.1
Use your device to scan
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Article info:
Received: 10 Aug 2021
Accepted: 23 Nov 2021
Publish: 01 Jan 2022
S
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January 2022. Volume 8. Number 4
mensional concept and is defined in different ways [5].
Spiritual care refers to care activities and procedures that
lead to improved spiritual health and performance as well
as improved quality of spiritual life. It is also believed
that providing spiritual care is effective on stress responses,
spiritual well-being (balance between physical, psychosocial,
and spiritual aspects), feelings of honesty and
excellence, and interpersonal relationships [6, 7].
Spiritual care as one of the areas of nursing care is
known with eight characteristics: healing presence,
therapeutic use of self, visual sense, spiritual perspective
exploration, patient-centered, meaning-oriented,
therapeutic interventions, creating a spiritually nurturing
environment, and documenting and the evaluation of
spiritual care [8]. Recent studies have indicated a lack of
knowledge and participation of nurses in providing spiritual
care so that in a study in 2021, the results showed
that nurses are afraid and anxious to address spirituality
in nursing practice and provide spiritual care to patients.
Ambiguous attitudes toward spirituality, lack of adequate
education about spirituality, limited knowledge,
and lack of appropriate structures were all considered as
factors in causing these fears [9]. A study in Iran in 2017
also showed that only 26% of nurses under study have
good competence in providing spiritual care [10].
Nurses are professionally and morally obliged to provide
spiritual care; thus, having sufficient knowledge and
skills to provide spiritual care is necessary to achieve this
goal. For this reason, the introduction of spirituality and
spiritual care as important concepts in the syllabi of nursing
education is one of the important priorities of nursing
education [11]. However, spiritual care has not been properly
considered in nursing education, and factors, such as
neglect of spiritual care in the undergraduate nursing curriculum,
insufficient training in the field of spiritual care,
lack of agreement on how to teach spiritual care in nursing
education curricula, and lack of clear guidelines, are
obstacles to the operation of spiritual care on the clinical
performance of the nursing profession [11]. Therefore, it
is necessary to form an educational program appropriate
to the Iranian-Islamic context and culture [12].
The first step in designing an educational program is
to examine the educational needs [11] Educational planning,
when done with the correct identification of needs,
prevents re-work, and selected programs are held with
more appropriate quality and quantity. The needs assessment
is an integral part of planning, during which the
needs are identified and acted upon according to priority.
Needs assessment is the source of determining educational
goals and is based on educational goals, educational
planning, and curriculum planning and activities
within the educational system [11]. Various methods
have been proposed to assess the training needs of
personnel, and the Delphi needs assessment technique
is one of the most reliable, this technique provides the
needs using the opinions of experts in several stages and
prevents the application of individual opinions (dictatorship)
and wasting time in the form of unnecessary discussions
and debates. In addition, needs assessment is
more useful in terms of preventing bias and outspokenness
than surveying [13]. The Delphi method is a regular
method for determining the consensus of experts that is
useful for answering questions that cannot be answered
by laboratory and epidemiological methods [14].
This study was designed and conducted to determine
the educational needs of nurses in the field of spiritual
care using the Delphi method.
Method
The current study was a needs assessment that was
performed by the Delphi agreement-based method from
September 2020 to April 2021 at Qom University of
Medical Sciences. Delphi is a systematic approach or
method for extracting expert opinions on a topic or question
and reaching group consensus through a series of
questionnaire rounds while maintaining the anonymity
of respondents and feedback to panel members [15].
This method as an agreement-based method that can be
a good way to assess needs. Delphi technique is also one
of the systematic analytical approaches. This method is
used by collecting opinions of experts several times using
consecutive questionnaires and is used to show the
convergence of opinions and to identify differences of
opinion or divergence of opinions. Each repetition forms
a period. The questionnaire is a tool for communication
and assesses the influence of experts on each other [15].
Ten members of the Center for Spiritual Health Research
and faculty members of the School of Nursing and Midwifery
and experts, interested and have a resume in the
field of spiritual health and training programs, were invited
to participate as an expert group.
The stages of research based on the study by Rahmaninejad
et al. [15] were designed as follows:
1. Explaining the problem
2. Asking an open-ended question entitled “In what areas
do nurses need to receive training in providing spiritual
care?” (First round)
Khoramirad A, et al. Educational Needs Assessment of Spiritual Care in Nurses. Health Spiritual Med Ethics J. 2022; 8(4):201-208
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3. Presenting the proposed titles of the first round as a
semi-structured framework and receiving comments on
the necessity of each title and suggestions on removing
the change or adding a new item (second round)
4. Finalizing the titles of nurses’ educational needs
(third round)
5. Survey of nurses working in university hospitals using
a questionnaire
The open-ended question of the first stage was formulated
and presented as follows: “In what areas do nurses
need to receive training in providing spiritual care?”
The question was sent to the experts via email after
making a phone call and explaining the purpose and
importance of the study, and the answers were collected
after a week. The results of the first round were collected
under 47 items. In the second round, a questionnaire
with 47 questions was given to the members of the experts
and they were asked to express their opinion on
agreeing or disagreeing with the defined need, and the
items that were agreed upon by more than 51% were
maintained and a 25-item questionnaire was extracted.
In the third round, a questionnaire with 25 questions was
given to the group of experts and again the request was
made with an emphasis on modifying, summarizing, and
merging similar cases and the results of the survey were
prepared in the form of a 15-item questionnaire. Individuals
were free to remove, modify, or add options. The
final agreement level was set at 51%. The questionnaires
were completely anonymous and in the first stage were
open-ended and in the next two stages were closed-ended.
The answers received in each round were examined
Table 1. Needs identified from the perspective of experts in the second round
Needs Identified
1. Anthropology
2. The concept of spirituality (concepts of being spiritual and being religious)
3. The concept of spiritual care
4. Dimensions of health and their relationship with each other
5. Identifying spiritual needs and diagnoses
6. The role of spiritual care in promoting health
7. The role of the nurse in providing spiritual care (and considering the role of other medical groups)
8. Principles of nurse-patient relationship to provide spiritual care
9. How to get a spiritual biography
10. Spiritual diagnoses
11. Spiritual interventions (components and content of spiritual interventions)
12. Facilitators of providing spiritual care
13. Challenges of providing spiritual care
14. Considerations of spiritual care (individual characteristics of the provider and recipient of spiritual care, cultural and ethnic differences,
disease status, providing bad news, etc.)
15. The effects of spiritual care on the spiritual health of the care provider
16. The effect of spiritual care on the health dimensions of the care recipient
17. Considerations of spiritual care in children
18. Spiritual care for the companions of ill patients
19. Considerations in spiritual care in cultural and ethnic differences
20. How to provide spiritual care in different patients according to the type of disease (acute - chronic)
21. Spiritual health with Islamic attitude
22. Identifying your values, beliefs, and convictions in life
23. Providing spiritual care to the patient’s companions
24. Nurses and the need to promote spirituality and the impact on the quality of patient care
25. A holistic view of human beings
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Table 3. General and behavioral goals of spiritual care and the scope of each goal
General Goals Specific Behavioral Goals
Scope of Each Goal
Cognitive
Emotional
Psychomotor
General goals No. 1:
Familiarity with ontological
epistemological
approaches and holistic
approach to humans and
dimensions of health
1. Explaining the approaches to knowing existence and human beings
2. Explaining the holistic approach to human beings
3. Explaining the multidimensional concept of health
4. Being sensitive to understanding the dimensions of health and how they relate
to each other.
**--
--**
----
General goals No. 2:
Familiarity with the
concepts of spiritual
care and the history of
spiritual care in Iran and
the world
1. Explaining the difference between the concepts of spirituality and religion
2. Explaining the concepts of care and spiritual care
3. Explaining the place of spirituality in nursing care
4. Being sensitive to the necessity of the concept of caring for spirituality
5. Telling the history of spiritual care in the world
6. Describing the history of spiritual care in Iran
7. Explaining the consequences of spiritual care (on care provider, care recipient,
health system).
-------
--**--*
-------
General goals 3: Familiarity
with how to obtain a
spiritual history
1. Expressing and applying the principles of communication
2. Stating the purpose and necessity of obtaining a history
3. Explaining and applying the methods of obtaining a history
4. Expressing and using the tools for obtaining a spiritual history
****
**--
*-**
General goals 4: Familiarity
with the types of
diagnoses and spiritual
interventions
1. Enumerating the types of spiritual diagnoses
2. Using the available tools to determine the patient’s spiritual diagnosis
3. Using a variety of spiritual interventions in different patients
4. Providing spiritual care challenges with solutions
***-
----
-**-
General goals 5: Familiarity
with the principles
of communication in
spiritual care
1. Explaining the importance of communication in spiritual care
2. Explaining the four human communications
3. List communication skills and techniques in spiritual care
4. Using communication strategies in spiritual care based on Quran and hadiths
***-
----
---*
Table 2. The level of necessity of educational needs for spiritual care
Needs Mean±SD
1. Recognizing the holistic approach to human beings 4±0.001
2. Concepts of spirituality and religion 3±0.001
3. The concept of spiritual care 4±0.001
4. Dimensions of health and their effect on each other 3±0.001
5. Principles of nurse-patient relationship in spiritual care 4±0.001
6. Obtaining a spiritual history and identifying spiritual needs 4±0.001
7. The role of the nurse in providing spiritual care (and considering the role of other medical groups) 4±0.001
8. Ways to know spirituality (epistemology - ontology) 4±0.001
9. Spiritual diagnoses 5±1.03
10. Spiritual interventions (components and content of spiritual interventions) 4±0.001
11. Special considerations in providing spiritual care 4±1.07
12. Challenges of providing spiritual care 4±0.001
13. Consequences of spiritual care (on care provider, care recipient, and health system) 4±0.001
14. The need for spiritual care in promoting health 5±0.001
15. History of spiritual care in Iran and the world 4±0.001
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by three members of the research team in the form of
group discussions.
To assess the importance of the educational needs, the
final questionnaire consisted of 15, 5-choice questions
on the Likert scale. Five options of very high (5 points),
high (4 points), no-comment (3 points), low (2 points),
and very low (1 point) to determine the importance of
the items from the perspective of the target group and
taking into account the required sample size using Morgan
table were provided to 150 nurses working at Qom
University of Medical Sciences. Items that scored an
average of 3 or more were considered and maintained
as essential training needs. Sampling was - purposeful
and based on inclusion criteria, including having at least
ten years of work experience in various departments of
internal medicine, surgery or special, emergency, pediatric,
and the subjects with a formal probationary or final
employment status that agreed to participate in the study
were selected. After completing the list and collecting
them, the average score and standard deviation for each
need were calculated.
After determining the educational needs, during several
sessions of the three-member research group, they
prepared content, including identified and classified
needs, general goals, partial goals, and behavioral goals.
Results
The group of experts consisted of ten people specializing
in the fields of nursing, health psychology, medical
education, medical etiquette, and the sciences of hadith
and medical ethics. The target group consisted of 150
nurses working in university hospitals, of whom 144
completed the questionnaire. The Mean±SD age of the
studied nurses was 34.3± 6.6 years and their Mean±SD
work experience was 15.3±3.36 years. Also, 42% were
men, 58% were women, and 30% were working in three
shifts, and the rest were working only in the morning
shift and considered the implementation of spiritual care
training program to improve the quality of knowledge
and services of nurses necessary.
The results of the first round were collected under 47
items in a table and provided to the group of experts for
the second round. After applying their opinions, 25 items
were considered as the needs of nurses (Table 1).
Finally, after applying the opinions of the expert group,
a questionnaire containing 15 needs was prepared and
provided to the target group, i.e. employed nurses, and
the necessity of each need was estimated. The results of
this survey are presented in Table 2.
Finally, based on the identified needs, four general objectives
were extracted and specific objectives were set
for each general objective and the scope of each objective
was determined (Table 3).
Discussion
Although one of the areas of activity of nurses is to
provide spiritual care, no agreement has been reached on
the needs and educational content to prepare nurses to
provide spiritual care. Therefore, the present study was
conducted to determine the educational needs of nurses
and to formulate educational goals related to each need.
Based on the findings, most of the needs of nurses were
summarized in 15 items. In confirmation of the findings
of the present study, Rassouli et al. reported the educational
needs of nurses in the field of spiritual care in 25
cases that the items identified in their study are in line
with the results of the present study [11].
Consistent with the results of the present study, what
is spirituality, why there is a need to institutionalize the
concept of spirituality in health, what is spiritual health,
and the World Health Organization’s strategic approach
to spiritual health, are among the topics that form the
basis of spiritual education programs in other countries’
curricula [16]. In a study conducted at the University of
Missouri School of Medicine entitled “Determining the
Needs for a Spirituality in Patient Care Curriculum”,
the philosophy of spirituality and the discussion about
this concept and the importance and effect of patients’
spiritual status on other aspects of their health were emphasized,
which is completely consistent with the educational
goals extracted in the present study [17].
In another study, the principles of communication,
spiritual diagnoses and interventions, challenges and
facilitators of spiritual care, and cultural and ethnic differences
were identified as educational needs that are
consistent with the present study [18]. The findings of
the study led to five general educational goals; the general
goal number one and two to explain the place of
spirituality in human health and basic concepts of spiritual
care, and goals number three to five to ensure the
readiness of nurses to provide spiritual care. In confirmation
of these findings, we can refer to the study by
Pirat Paal et al. in 2015, who during a systematic review,
introduced the need for spiritual self-knowledge as one
of the goals of spiritual care for members of the health
care team [19]. Also, Rassouli et al. in Iran in 2018 con-
Khoramirad A, et al. Educational Needs Assessment of Spiritual Care in Nurses. Health Spiritual Med Ethics J. 2022; 8(4):201-208
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sidered three main goals for educating nurses in the field
of spiritual care, which are in line with the goals set in
the present study. In Rasouli’s study, the main goals were
introduced under the headings of spontaneous evolution,
sometimes from the spiritual dimension, explaining
spirituality in the nursing profession and its role in nursing
care and preparing nurses to provide spiritual care,
which the goals number one or two of the present study
are relatively consistent with the goals number one and
two of the Rassouli et al.’s study [11].
The third goal of Rassouli et al.’s study was to prepare
nurses to provide spiritual care. Goals three to five of the
present study were designed in line with this goal but
in more detail and precision. The second general goal
extracted in the present study was to get acquainted with
the basic concepts of spiritual care and its place and role
in the health system to meet the estimated needs, familiarity
with the concepts of spirituality and religion, concepts
of spiritual care, and health dimensions and their
impact on each other, and also familiarity with the consequences
of spiritual care (on care provider, care recipient,
and health system). In a similar study that aimed to
identify the educational needs for the integration of spirituality
in medical education in Iran, by conducting interviews
with various people, including those working in
medical education and curriculum design and also health
care providers, etc., the above needs were identified [20].
The findings are also consistent with those of Rassouli
et al. In their study under a different format, they emphasized
the need to explain the educational goals related to
the concepts of spirituality and religion and explained the
role of spirituality in the nursing profession in the training
of spiritual care to nurses [11]. Although spirituality
and religion evoke similar meanings, or in practice the
two concepts may overlap, nurses in their professional
position encounter patients who have no religious affiliation
but address their spiritual needs and it is expected
that nurses fulfill them. On the other hand, and precisely
for this reason, the familiarity of nurses with different
religious rituals that patients perform in line with their
spiritual or religious beliefs is another necessity and only
familiarity and acceptance of the concept of spirituality,
does not seem to be enough in professional practice to
help patients meet their spiritual needs.
Conclusion
Gathering information from a group of experts with a
history of working in the nursing profession as well as
surveys of nurses working in the nursing profession with
history led to two effective outcomes in the present study.
On the one hand, it prevented the non-identification of
some needs due to the possible unfamiliarity of working
nurses with the concept of spirituality and spiritual
care due to the lack of a coherent and scientific encounter
with relevant issues (a problem that in previous studies
led to insufficient data), and on the other hand, led to the
development of fully practical and integrative goals in
the performance and job description of the nursing profession,
so that in intensive and short training courses,
the formulated goals can be met. Some of the needs and
goals set in other studies were not met in the findings of
this study, including ethical considerations in providing
spiritual care, which in explaining this issue, it is necessary
to point out that in expert surveys, attention to nursing
education curriculum is emphasized. Therefore, the
repetition of cases that overlap with other courses and
have already been provided and can be provided in academic
or in-service training has been avoided.
It was not possible to attend and benefit from the opinion
of all domestic and foreign professors, which can affect
the results of the study.
Ethical Considerations
Compliance with ethical guidelines
This research was conducted after approval by the Educational
Council of the School of Nursing, Qom University
of Medical Sciences. Written consent was obtained
from all participants. Participants were reassured that
their presence in the study was completely optional and
that they could leave the study. They were also assured
that their information would be kept confidential.
Funding
This research did not receive any grant from funding
agencies in the public, commercial, or non-profit sectors.
Authors' contributions
Methodology and Data collection: Khoramirad and
Abedini; Data analysis and Writing-review & editing:
All authors.
Conflict of interest
The authors declared no conflict of interest.
Acknowledgments
The authors appreciate all the participants, especially the
experts who contributed of this research.
Khoramirad A, et al. Educational Needs Assessment of Spiritual Care in Nurses. Health Spiritual Med Ethics J. 2022; 8(4):201-208
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January 2022. Volume 8. Number 4
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