Health, Spirituality and Medical Ethics

Introduction
Humans are beings with physical, mental, and spiritual aspects. Spirituality is an internal and intangible asset that helps to establish a connection between people and their surroundings. These connections can create harmonious relationships, and trust and help to have a meaningful life [1].
The World Health Organization (WHO) defines health as a state of complete physical, mental, and social well-being and not just the absence of disease and organ defects, and currently, the relationship between spirituality and religion with mental health is increasingly recognized. There is a connection between the body, soul, and mind and the effects of individual beliefs and desires on the health of the body [2]. Religion and spirituality are related but with different concepts. Religion may be considered as a defined set of beliefs, texts, customs, and ways of communicating with excellence, but spiritual health is a human experience from two perspectives. The perspective of religious health expresses the connection with the higher power, and the perspective of existential spiritual health focuses on the social and psychological concerns of people [3].
Religious health (belief in God and having a sense of satisfaction in connection with God) and existential health (purposefulness and having meaning in life) are considered two dimensions of spiritual health. Spirituality can have a positive effect on people’s life satisfaction and increase their psychological well-being. Also, there is a significant relationship between spirituality and the improvement of psychological, emotional, and occupational components in health workers. Spirituality can positively and meaningfully explain the increase in happiness and well-being and the increase in the ability of health workers. Spiritual health can be a source of comfort and hope for those facing many stressful factors daily and are responsible for patient care [4].
Spiritual health is the only force that is closely related to all dimensions of people’s health. Religious health measures the relationship between the understanding of a person’s health and the Almighty God, and existential health focuses on people’s adaptation to the environment and society and attention to social and psychological issues [5].
Because the physical, mental, and social dimensions of humans are related and affect each other, spiritual health is also related to other dimensions of health and affects them, and it is better to pay attention to it to improve health.
Russell and Osman’s proposal to include the dimension of spiritual health in the concept of health brought an important dimension of individual and group life to the experts involved in health [6]. Spiritual health is the newest dimension of health, which is placed next to other dimensions of health, such as physical, mental, and social health. Religious health reflects the relationship with God or infinite power, and existential health also includes a person’s relationship with himself, others, and the environment, which can be considered the ability to integrate different dimensions of existence and have different choices. In general, spiritual health means having a sense of acceptance, positive emotions, ethics, and a sense of positive mutual connection with a sovereign and superior holy power, others, and oneself, which is achieved through a dynamic and coordinated cognitive, emotional, action, and personal consequence process. The results of various research show that without spiritual health, other aspects of health do not perform well [7]. Also, it will not be possible to reach a high level of quality of life. Researchers believe that there is an extraordinary power in spiritual health that gives a kind of spiritual strength to a person and helps him/her in the depth of the difficulties of daily life and removes him/her from worry and anxiety. In other words, spirituality helps to have a purposeful and meaningful life. Similar research in many parts of the world has determined that spirituality can improve the ability to deal with problems and play an effective role in physical and mental health [8].
Health as a dynamic process is of great importance in the four dimensions of human existence, and without considering the spiritual dimension of man, it is not possible to achieve a complete definition of health only with physical, mental, and social health. Spiritual health is a sense of connectedness, and harmony between self, others, nature, and a transcendent being that can be achieved through a dynamic and coherent growth process, which leads to knowing the ultimate goal of life and finding meaning. According to various studies, spiritual health also plays a role in preventing mental disorders [9]. Because the human being acts as an integrated system, these two dimensions, while being independent, interact and overlap, and as a result, they create a sense of spiritual health, satisfaction, and purpose in life. People who have spiritual health are capable and strong, have more power of control and social support, and have the ability to adapt to mental tensions and interventions necessary to adapt and deal with problems and crises. On the other hand, when spiritual health is jeopardized, a person may suffer from depression, loneliness, and loss of meaning in life [10].
The most important indicator of progress and the guarantor of the survival of any society is the favorable health status of the people of that society, and if efforts are not made to maintain and provide for it, it will not last. The concept of spirituality is related to areas of health in all ages. Spiritual health is the only force that coordinates the physical, mental, and social dimensions and is characterized by the characteristics of stability in life, peace, harmony, and harmony, and a feeling of close connection with oneself, God, society, and the environment. Spiritual health is one of the dimensions of health that causes the integration of other dimensions and has a significant impact on the treatment of many psychological and physical problems. Every day, several people believe in spirituality; it is the way to treat neuroses and mental helplessness, and some specialists focus on spiritual beliefs and behaviors to treat mental illnesses and mental health [11]. Proponents of the role of spirituality in improving mental health and interpersonal compatibility have made several efforts to establish a relationship between the two concepts of health and spirituality, under the title of the construct of spiritual health [12]. Spirituality is a multidimensional and complex concept of human attitude with cognitive, experiential, and behavioral aspects. Its cognitive or philosophical aspects include having meaning and purpose in life and its emotional aspect is mixed with hope, love and dependence, inner peace, comfort and support, and personal experiences. The behavioral aspect is the inner spirituality and personal beliefs that are integrated with the outside world [13].
Spiritual care is meaningful with care and nurturing in the field of the individual’s soul; thus, it is very important to maintain health and promote the spiritual dimension and pay attention to other physical, mental, emotional, and spiritual dimensions [14]. In recent years, there has been significant evidence of the relationship between religiosity, spirituality, and mental health. Spirituality is commonly considered a protective factor against several negative health outcomes. Many studies have indicated the relationship between spirituality and physical and mental health and improving adaptation to illness. There are many studies supporting the hypothesis that spiritual health can enhance psychological functioning and adjustment.
Koenig et al. concluded that in stressful situations, spirituality is an important source of adaptation [15]. The results of O’Brien’s research showed that when spiritual health is seriously compromised, a person may experience mental disorders, such as loneliness, depression, and loss of meaning in life [16]. Nelson et al. stated that high levels of spiritual health are associated with low levels of variables related to mental disorders, such as depression, hopelessness, and suicidal thoughts in patients. In general, researchers assessing the relationship between religion and health in the population of normal people, physical patients, cancer patients, and mental patients, have concluded that religious beliefs and practices have a positive effect on the prevention and improvement of physical and psychological diseases and coping with physical diseases and problems [17].
According to the mentioned issues and despite the importance of spiritual health and its role in improving people’s mental health, spiritual health is an aspect that has received less attention in studies conducted in Iran, and it is necessary to examine its impact on different aspects of people’s lives. Therefore, this study was carried out to determine the correlation between spiritual health and job performance in Qom pharmacy employees.
Methods
This cross-sectional correlational research was conducted on 140 pharmacy personnel working in Qom pharmacies, Iran, selected through census sampling in 2017-2018. Data collection was carried out using three questionnaires. To collect demographic information about the participants, the demographic questionnaire was applied, which included information regarding age, type of pharmacy, rotational job system, work experience, educational level, gender, marital status, and place of residence. The second questionnaire was a comprehensive spiritual health measurement tool for Iranian society. This questionnaire had 48 questions with items 1-28 related to the cognitive/emotional domain focusing on the individual’s insights and orientations and items 29-48 referring to the behavioral components during the last year [18]. Also, Paterson’s job performance questionnaire, including 15 questions, was another research tool [19]. The questionnaires were completed anonymously and it took about 20 to 25 minutes to complete them. Pharmacy personnel was asked to complete the questionnaires in the presence of the researcher to eliminate possible ambiguity. Finally, data analysis was performed by SPSS software, version 21 using an independent t-test, Mann-Whitney U test, and Pearson’s correlation coefficient. The participants completed the questionnaires knowingly and voluntarily after the necessary explanations about the objectives of the study and they were assured of the confidentiality of their information.
Results
Overall, 140 returned questionnaires were analyzed. The study population consisted of 140 pharmacists, of whom 74 cases were male and the rest were female. Most people (39%) worked in the morning or evening shift and most respondents (69%) were natives of Qom. Table 1 provides information on demographic variables. The mean age and work experience of the subjects were 31.05±8.3 and 7.94±7.4 years, respectively (Table 2).
The mean score of job performance was 70±10. The mean scores of spiritual health and two related subsets, including cognitive/emotional and behavioral components, were reported as 211.9±23, 127±13.7, and 84±11.6, respectively (Table 2). The reliability of the two research instruments was evaluated and Cronbach’s α coefficients were 0.92 and 0.96 for the spiritual health and job performance questionnaires, respectively.
According to the results of the independent t-test, analysis of variance, and Mann-Whitney U test, based on demographic variables, no significant difference was observed in the mean scores of spiritual health and job performance (P>0.05). According to the Kolmogorov-Smirnov test, the distribution of data was abnormal; thus, the Spearman correlation coefficient was used to assess the correlations. There was no significant correlation between age and work experience with the job, cognitive/emotional performance, behavioral components, and total spiritual health score (P>0.05).
The relationship between total job performance and spiritual health (r=0.379) and two related subsets, including the cognitive/ emotional component (r=0.233) and behavioral component (r=0.410) using the Spearman correlation coefficient was statistically significant (P<0.01).
Discussion
The purpose of this study was to determine the correlation between spiritual health and job performance in pharmacy employees in Qom City. There was a relationship between spiritual health and the job performance scores of employees. This finding is consistent with that of Hamid [20] and Khandan [21]. The term performance includes a set of actions and activities performed by employees to achieve the predetermined goals of the organization. If performance management is designed and implemented with its requirements and prerequisites in the organization, it can identify some problems of organizations and provide practical solutions to solve them. Spiritual intelligence and spiritual health can predict the job performance of employees [22]. Also, people who have higher spiritual health should improve their level of satisfaction with their superiors by creating better communication and understanding the conditions of the work environment. Improving the conditions of the work environment and improving job relationships and communications is in the shadow of efficient management and finally using collective wisdom in important organizational decisions [23].
In this study, the average total score of spiritual health for the participants was 211, which is at a high level, considering the maximum score of 240. High levels of spirituality and spiritual health in the work environment lead to organizational effectiveness, increased job satisfaction and organizational commitment, and feeling happy. Also, spiritual health; improves recuperation gives, well-being, and relief to the organization’s employees and decreases their work stress, and ultimately makes people feel better and more social.
The presence of spirituality in the work environment can lead to advantages and benefits, such as increasing creativity, increasing honesty and trust, increasing the sense of personal development, increasing organizational commitment, improving the job attitudes of employees and reducing intentions to leave the work environment, increasing work ethics and conscience and more motivation, and finally increasing job performance. It can also be stated that spirituality improves the sense of commitment and duty of the health staff in the work environment, which causes a lot of effort and ultimately job performance and higher organizational productivity. Personnel who have a deep sense of meaning and meaning in their work believe that humans are connected; they feel solidarity with others in the work environment. They see their values and goals in line with the values of the organization and believe that the organization cares and considers them. The workers looking for spirituality in the work environment are more loyal to the organization and have more commitment to fulfilling their duties. Job performance as the overall expected value of any organization is an indicator for determining its productivity level [20].
In the current study, the average job performance score of the participants was 70, which is at a high level, considering the maximum possible score of 75. Therefore, several characteristics can be considered for the participants, such as 1) The high importance of their job due to high spiritual health, 2) Having good communication and interaction with colleagues, patients, doctors, clients, and managers, and 3) Having high responsibility in the work.
The organization can achieve the necessary effectiveness and efficiency if it pays attention to the internal and external factors of the work environment that affect the vitality and happiness of the employees and consequently, their job satisfaction. Examples of work-life balance for employees include having enough free time, loyalty to work, organizational support, flexibility in the work schedule, job security, and improving job performance. Investigations conducted in organizations show that employees’ mental health and happiness and work-life balance mediate the effect of spirituality in the workplace on job performance. Considering the two dimensions of soul and mind and body and applying programs and principles that respect all human duties is essential for the success of organizations. To create coordination and improve employees’ performance, spirituality should be used in a work environment that respects the employees themselves and provides a safe environment for them.
The introduction of spirituality in the organization gives the employees the ability to gain a more integrated perspective in the context of their organization, family, and society [24].
In healthy organizations, employees are committed and conscientious, have high morale and performance, and communication channels are open and beneficial. A healthy organization is one where people are proud to work there. These organizations are dynamic phenomena that grow and develop with the provision of necessary and sufficient facilities, and through the provision of healthy and valuable products and services, they provide environmental needs and facilitate the process of growth and prosperity of the society, but the researchers believe that health promotion is not a one-dimensional and one-step action and a continuous work that is influenced by the key components create organizational health. Because spiritual health is today considered a dynamic process of achieving higher levels of health in each of the four dimensions of human existence, the existence of an educational program for spiritual health is a suitable solution for healthcare professionals to pay attention to all dimensions of human existence. The existence of a significant relationship between organizational commitment and spirituality in the workplace has been proven [25].
Previous indigenous studies on spiritual health have used questionnaires designed in Western societies based on intention and definitions related to non-native culture and religion. However, using tools designed in societies with different cultures and religions from the research society cannot provide actual results matched with that society and cannot be generalized. Therefore, we used a native questionnaire in this study.
The difference between spiritual health scores and job performance in terms of demographic variables was not statistically significant, which was in line with reports by Amiri [18] and Azad Marzabadi [26]. It can be concluded that the studied employees live in a spiritual and religious society, and religion is one of the basic principles of their lives.
Pharmacy personnel in Qom, regardless of demographic variables, obtained very good grades in job performance and medium to high grades in spiritual health. In this regard, they have a committed look at their job and provide health and treatment services to gain divine satisfaction. Also, despite all the job problems, including the lack of financial resources, manpower, and equipment, they try to perform their duties correctly and accurately.
In this research, we examined spiritual health in two cognitive/emotional and behavioral dimensions. The relationship between job performance and two subgroups of spiritual health, including the cognitive/emotional part and the behavioral part, and overall spiritual health, was statistically significant. In other words, the criteria of the internal field, including values, tendency, and intelligence, and the outward field, such as people’s manners are persuaded by spiritual health, and these results are in line with the results of Shamsaei [27], Rafiei [28], and Hsia [29]. In a study conducted by Yseminejad et al. spirituality could progress the degree of job performance [30].
Increasing the score of spiritual health among pharmacy personnel leads to an increase in the job performance of these people. The increase in job performance reduces the probability of people leaving their jobs. These results were in line with the results of Osarrodi [31], Mohammadi [10], and Jokar [32] who studied nurses. In jobs with higher involvement, having hope and faith in work leads to less stress and more satisfaction and work quality [28, 29, 33].
According to Sotoodeh [4] and Markani [34], the spiritual health of nurses affects their tendency toward the patient and their nursing care. It is expected that people who have low spiritual health will have unprincipled and unprofessional behavior [27, 32, 35].
Also, spiritual health causes the growth of motivation, purposefulness, calmness, a positive attitude to life, lofty resilience in people, progress in the capability to do the works, and ultimately reasons minor intrinsic dependence on others. As a result, it is anticipated that the moralist proficiency of pharmacy staff will be of a high degree, and as a result, more efforts will be made to better interact with clients and patients, reduce medical errors, and ultimately improve patient safety. In general, due to the positive correlation between spiritual health and job performance, progressing or regressive the score of one property will increase or decrease the grade of another property.
Having neutralized all the interest in spreading spiritual concepts in business, there are still worries and anxieties that need to be taken care of. Examples include the possibility of inducing some beliefs by managers as spiritual issues, the risk of putting pressure on workers or looking at the issue as a tool, as well as the problems of converting the content and scientific assumptions in the field of organizational spirituality into the law of that organization.
Healthcare provider environments, nurses, and paramedics play an important role in the conservation and recovery of patient safety. Based on the above description, it is possible to improve the status of people through organizational culture and constructive interaction with people to promote positive thoughts and beliefs and the growth of the organization to reduce occupational errors and improve patient safety.
Conclusion
The positive correlation between spiritual health variables and job performance showed that an increase in the level of one of the studied variables causes an increase in the level of another variable and a decrease in the level of one variable causes a decrease in another variable. Therefore, managers of health centers should seek to expand and strengthen spirituality and improve job performance to pay more attention to and participation of employees in work environments. This work requires the creation of spiritual training courses in scientific and up-to-date methods. The investigated factors might have been influenced by the atmosphere and religious culture of the city; thus, it is recommended to conduct similar studies in other areas and other work environments.
Ethical Considerations
Compliance with ethical guidelines
This study was a project approved by the Research Deputy of Qom University of Medical Sciences (Code: MUQ.REC.1395.152).
Funding
This research did not receive any grant from funding agencies in the public, commercial, or nonprofit sectors.
Authors' contributions
All authors equally contributed to preparing this article.