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Spirituality and spiritual care in Iran: nurses’
perceptions and barriers
M. Zakaria Kiaei
1
MSc, A. Salehi
2
MSc, A. Moosazadeh Nasrabadi
3
MSc,
D. Whitehead
4
PhD, M. Azmal
5
MSc, R. Kalhor
6
PhD &
E. Shah Bahrami
7
MSc
1 Lecturer, 6 Assistant Professor, Social Determinants of Health Research Centre, Qazvin University of Medical Sciences,
Qazvin, 7 Researcher, Health Management and Economics Research Centre, Iran University of Medical Sciences, 3 Researcher,
Health Services Management, Department of Public Health, Shahid Beheshti University of Medical Sciences, Tehran,
5 Researcher, Department of Treatment Affairs, Bushehr University of Medical Sciences, Bushehr, Iran, 2 Research fellow,
Menzies Health Institute Queensland, Griffith University, Br isbane, Queensland, Australia, 4 Senior Lecturer, Faculty of
Medicine, Nursing and Health Sciences, SoNM, Flinders University, SA, Australia
ZAKARIA KIAEI M., SALEHI A., MOOSAZADEH NASRABADI A., WHITEHEAD D., AZMAL M.,
KALHOR R. & SHAH BAHRAMI E. (2015) Spirituality and spiritual care in Iran: nurses’ perceptions
and barriers. International Nursing Review 62, 584–592
Aim: This study aimed to explore the perception of Iranian nurses concerning spiritual care and to reveal any
confronted barriers.
Background: Although the context of spiritual care is a substantial aspect of holistic care, the delivery of
spiritual care has been problematic due to lack of nurses’ understanding of this concept.
Introduction: Nurses’ perceptions of spirituality and spiritual care directly influence their performance as well
as their relationships with patients.
Methods: This cross-sectional survey was conducted in 2013 with 259 nurses working in hospitals affiliated
with Qazvin University of Medical Sciences, Iran. Data were collected using the Spirituality and Spiritual Care
Rating Scale alongside qualitative open-ended questions. Descriptive and inferential statistics were used for the
quantitative data and content analysis for the qualitative data.
Results: The overall average for spirituality and spiritual care was 2.84 (score range: 1–4), indicating a
moderate mean score. A significant relationship was found between education level and spiritual care. The
majority of participants believed that they did not receive enough training in this aspect of care. The main
obstacles regarding delivering spiritual care included busy working schedules, insufficient knowledge regarding
spiritual care, low motivation, diversity of patients’ spiritual needs and feeling ‘unqualified’ to provide spiritual
cares.
Correspondence address: Mrs Elham Shah Bahrami, Health Management and Economics Research Centre, School of Health Management and Information Sciences, Iran
University of Medical Sciences, No 6, Rashid Yasemi St., Vali-e-asr Ave., Tehran-Iran. 1995614111 Iran; Tel: +98 2188794300; Fax: +98 2188794300; E-mail:
eshahbahrami@yahoo.com.
This manuscript has not been submitted anywhere else.
Funding
There have not been any supports for funding of this study.
Conflict of interest
Authors clarified no conflict of interest for this study.
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Clinical Practice Research
© 2015 International Council of Nurses 584
Discussion: Consistent with the previous studies, this study has demonstrated that nurses had low confidence
to meet the spiritual needs of patients due to lack of knowledge and training in this regard.
Conclusion: Iranian nurses’ perception of spirituality and spiritual care is moderate, reflecting that they do
not receive sufficient training regarding spiritual care.
Implications for nursing and/or health policy: Despite the attention focused on spiritual care in clinical
settings in Iran, there remains a significant gap in terms of meeting the spiritual needs of patients in nursing
practice. This finding assists nursing clinicians, educators and policy makers to more effectively approach
spiritual care as a beneficial component of holistic care. It is proposed that more emphasis is placed on
integrating spirituality content into educational programmes to enable more effective clinical delivery. In
addition, it would be beneficial to implement more widespread cultural assessment in order to further benefit
spiritual care practices.
Keywords: Iran, Nursing, Perceptions, Spirituality, Spiritual care
Introduction
Holistic nursing is a practice that draws on nursing knowledge,
theories, expertise and intuition to help nurses in becoming
therapeutic partners with people in their care. This practice rec-
ognizes the totality of the human being: the interconnectedness
of body, mind, emotion, spirit, social/cultural, relationship,
context and environment (Gallison et al. 2012). It aids healing
processes through meeting the individuals’ physiological,
psychological and spiritual requirements (Abbasi et al. 2014).
Spirituality and spiritual care are considered central elements of
holistic nursing. As spirituality is often a broad, multidimen-
sional and nebulous concept, defining it is challenging. Accord-
ing to the literature, related spiritual care in nursing practice is
not well developed when compared with other elements of care
(Tirgari et al. 2013). It encompasses certain values such as
clients’ need to find value and meaning in life as it relates to
their illness, a need for hope and will, and the need for belief in
self, others and, in some cases, a superior power or God
(Callister & Khalaf 2010; Ozbasaran et al. 2011).
In Islamic societies, such as Middle East countries, religion
has a major role in society and health care. Religion and medical
care in Islamic societies is closely related regarding the imper-
fect creation of human beings and the need for evaluation
towards their ‘ideal statuses’. Healthcare providers are often
influenced by religion, culture and geographical location. In
Islam, religion is considered a component of spirituality and
there is often no distinction between spirituality and religion
(Silbermann & Hassan 2011; Tirgari et al. 2013). On the other
hand, some authors believe that it is a misconception in
nursing; that spirituality is inexorably intertwined with religion
(meta-physical view) (Ramezani et al. 2014). However, this is
not always the case and this misconception is part of the
problem in the delivery of spiritual care. Many clients do not
believe in a ‘higher external power or God’, but do believe that
they possess an ‘internal’ strength, power or resolve that can
help them overcome adverse events (existential view)
(Whitehead 2003). This conceptual problem exists despite the
attempts of authors such as Ramezani et al. (2014) to clarify
spirituality misconceptions in the pages of International Nursing
Review (Ramezani et al. 2014).
Spiritual care in health care and nursing is not a recent
concept and has accompanied nursing history with different
definitions and perceptions (Wong et al. 2008). In addition,
many of the contemporary nursing theories have evolved from
spiritual roots (Yuan & Porr 2014). Nurses’ perception of spir-
ituality and spiritual care directly influence their performance
as well as their relationships with patients (McSherry et al.
2008). Patients often perceive nurses as a source of spiritual
information and comfort and may assume they are able to fulfil
patients’ spiritual needs (Ramezani et al. 2014). Therefore,
respecting and addressing the spiritual needs of patients, when
they request or require it, should be considered as a fundamen-
tal role for nurses, not merely as an ‘additional’ task. In order to
achieve this, various skills are required such as enhancing inter-
personal skills and relationships with patients and their families,
respecting patients’ personal values, honesty and multidiscipli-
nary cooperation (Baldacchino 2008). Spiritual care can include
diverse activities such as listening to concerns and anxieties of
patients; a working knowledge of various faiths, beliefs and reli-
gions; providing hope and comfort; recognizing the importance
of spiritual concerns in acutely ill and dying clients; and the
necessary processes for referring clients to clergy or other spir-
itual counsellors (Ramezani et al. 2014).
Although studies demonstrate the need to understand spir-
ituality and spiritual care in healthcare services, many highlight
the difficulties in providing optimal spiritual care (Yardley et al.
Spirituality and spiritual care in Iran 585
© 2015 International Council of Nurses
2009). Despite the wide-ranging discussion regarding the sig-
nificance of spiritual care, observing its impact and effects in
clinical nursing practice is not that common (Garcia-Zamor
2003; Sawatzky & Pesut 2005). According to Strang et al. (2002),
only 42% of nursing staff associate that spiritual care is pro-
vided in their care unit, although 87% believe that nurses
should routinely consider the spiritual needs of patients (Strang
et al. 2002). There exist numerous reasons for this state of
affairs regarding spiritual care in healthcare settings. Some of
these include time and workload constraints, lack of confidence
in providing spiritual care and lack of specific education/
training, with resultant confusion regarding the nature and role
of spiritual care (O’Brien 2007).
The historical role of spirituality and religion in Iran has been
identified by some authors as a crucial component of ‘curing’
and support in traditional Iranian medicine. Two notable
authors in this regard are Muhammad ibn Zakariya Razi and
Ibn Sı-na- (Avicenna) who have identified spiritual care as the
main component of healthcare services (Jafari et al. 2014;
Mbolghasem 2008). However, recent studies regarding spiritual
care in Iran have demonstrated low levels of spiritual care pro-
vision in such settings (Jafari et al. 2014). In addition, a poor
level of spiritual well-being has been reported by patients in
Iran in comparison with other countries (Jafari et al. 2013).
According to this literature, being Muslim and/or living in a
Muslim society should provide regular opportunity for practic-
ing spirituality and drawing on spiritual care provision for
earlier recovery (Jafari et al. 2014). This gap indicates a valid
reason for exploring nurses’ perception of spiritual care, the
related issues and barriers in practicing spirituality and spiritual
care provision in Iran.
Aim
The main aim of this study was to explore the perception of
Iranian nurses concerning spirituality and spiritual care and
reveal any confronted barriers. More specifically this study was
conducted to (1) determine the perception of nurses regarding
spirituality and spiritual care activities in Iran, (2) investigate
relationships between demographic factors and spiritual care
provision, and (3) explore the barriers nurses face in relation to
spiritual care provision.
Methods
Study design and procedure
Stratified randomized sampling was used for recruiting partici-
pants from different nursing departments of six educational
hospitals affiliated with Qazvin University of Medical Sciences
with an overall population of 781 nurses in 2013. Each hospital
was considered as one stratum, and the participants were
chosen randomly based on this stratum. Then the final subjects
were selected from different strata through simple random sam-
pling. The estimation of sample size was 250 considering an
alpha error of 5% using the related sampling formula.
The self-administered paper-based questionnaires (including
both closed Likert scales and open-ended questions) were dis-
tributed among 308 nursing staff in the presence of researchers
who spoke the same language as the participants in order to
encourage completion of the survey and provide assistance.
Ethical approval for this study was granted by the human
research ethics committee of Qazvin University of Medical
Sciences.
Measures
The data collection instrument is composed of two sections,
including socio-demographic factors and spirituality and spir-
itual care perceptions and experiences.
Socio-demographic variables
Socio-demographic variables were age, gender, marital status,
type of employment, education and types of shift work.
Spirituality and Spiritual Care Rating Scale (SSCRS)
The Persian version of the SSCRS was used to measure the per-
ception of nurses regarding their spirituality and spiritual care
practices. It comprises nine main aspects and 17 items indicat-
ing spiritual activities perceived and/or provided by nurses. This
includes meaning and purpose (one item), relationships (one
item), forgiving (one item), hope (two items), values and beliefs
(one item), faith in God (two items), creativity (one item),
morals (two items) and spiritual care (six items). These nine
components comprise a 17-item scale with 5-point Likert scales,
from strongly disagree to strongly agree. The closer the score is
to 5, the higher the level of perception of spirituality and spir-
itual care is. Reverse scoring was used for four items in the scale
(including spirituality involves only going to church/place of
worship; spirituality is not concerned with a belief and faith
in God or supreme being; spirituality does not include art, crea-
tivity and self-expression; and spirituality does not apply to
atheists or agnostics). The reliability and validity of this ques-
tionnaire has previously been tested and confirmed for Iranian
populations (Fallahi et al. 2010). In addition, an item review
process was conducted with a panel of nursing experts to assess
the content validity of the questionnaires. A pilot study was also
conducted to ensure that the instrument was population appro-
priate. For measuring the reliability of scales, Cronbach’s alpha
and test–retest techniques were undertaken. The Cronbach’s
alpha result was 0.85 that demonstrates an acceptable reliability
586 M. Zakaria Kiaei et al.
© 2015 International Council of Nurses
for the scale. The test–retest procedure was conducted with 15
participants at 2-week interval and showed a correlation coeffi-
cient of 0.82 between two sets of responses, also demonstrating
an acceptable reliability for the scale.
As part of the questionnaire, three open-ended qualitative
questions were also asked regarding education/training courses
in participants’ university curriculum as well as in their voca-
tional training, sufficiency of training on matters concerning
spiritual care and barriers to implementing spiritual care to
patients. The open-ended questions were:
– Can you describe your training/education experiences you
have received in relation to spiritual care in university/college?
– Can you describe the training you have received while in your
workplace?
– What are/have been the main barriers to providing spiritual
care to your patients?
Analyses
Descriptive and inferential statistics were used for analysis. The
chi-square method at a significance level of 5% was used to
evaluate relationships with spirituality and spiritual care. Analy-
sis of variance and t-tests were used to determine the relation-
ship between demographic variables, spirituality and spiritual
care.
Content analysis was used in order to analyse the open-ended
questions. This was performed through an initial line-by-line
coding scheme. After this, each researcher scanned paragraphs
for units of meaning relevant to answering the research ques-
tions and then abstracting into further descriptive codes
(Harding & Whitehead 2013). This member-checking process
aided study trustworthiness.
Results
Quantitative results
A total number of 259 participants out of 308 returned the
questionnaires with a response rate of 84%. The majority of
participants were women (89%) with a mean age of 30 [stand-
ard deviation (SD): 6]. Demographic factors and personal char-
acteristics are summarized in Table 1.
A summary of answers and mean scores to all 17 items of the
SSCRS questionnaire, as well as the nine aspects of spirituality
and spiritual care, is identified in Table 2. According to this
table, the item ‘Spirituality does not include art, creativity and
self-expression’ had the highest mean score and the item ‘Pro-
viding spiritual care by arranging a visit by the hospital chaplain
or the patient’s own religious leader if requested’ had the lowest
mean score. The mean scores of the nine aspects of spirituality
and spiritual care are illustrated in Fig. 1. As can be seen, the
‘creativity’ aspect had the highest average and ‘beliefs and
values’ aspect had the lowest mean score in comparison with the
other nine aspects.
The total mean of the nine aspects of spirituality and spir-
itual care was 2.84 (SD: 0.41; score range: 1–4) and the mean of
spirituality (the average of all aspects except the spiritual care)
was 2.81 (SD: 0.36; score range: 1–4), indicating a moderate
average of spirituality and spiritual care among nurses.
According to other findings, education levels had a statisti-
cally significant relationship with spirituality and spiritual care
(P < 0.05). However, there were not any significant relationships
between other demographic variables such as age, gender and
career profile with the perception and experience of spirituality
and spiritual care.
Table 1 Socio-demographic variables of part icipants (n = 259), Qazvin,
Iran, 2013
Features n %
Gender
Male 28 10.8
Female 231 89.2
Age
Below 23 4 1.5
23–32 171 66.1
33–42 71 30
43–52 10 2.4
Type of employment
Permanent 67 25.9
Conditioned permanent 113 43.6
Long-term contract 30 11.6
Short-term contract 49 18.9
Wor k e xp er ien ce
Less than 3 years 103 39.9
4–8 years 66 25.5
9–13 years 58 18.6
14–18 years 30 11.7
More than 18 years 103 3.4
Education level
Postgraduate 4 1.5
Graduate 229 88.4
Undergraduate 13 5
Diploma 11 4.2
Middle school 2 0.8
Shift-work type
Morning 22 8.5
Permanent evening 4 1.5
Permanent night 6 2.3
Internal rotation 227 87.6
Spirituality and spiritual care in Iran 587
© 2015 International Council of Nurses
Qualitative results
Based on the findings of the open-ended questions, two main
‘themes’ were revealed: ‘low education/training regarding
spiritual care’ and ‘organizational barriers to spiritual care
provision’.
– Low education/training regarding spiritual care
A strong theme to emerge centred on participants’ education
and/or training barriers in relation to spirituality and spiritual
care. Participants believed that they had not received any special
training in the university/colleges neither in their workplace.
Hence, they perceived that they possessed insufficient knowl-
edge and they felt unqualified to providing spirituality-related
cares.
We did not have any specific courses related to spirituality
and spiritual care neither in our curriculum in university nor
Table 2 Descriptive analysis of SSCRS aspects and the items (n = 259), Qazvin, Iran, 2013
Items number Question Strongly
disagree
Disagree Uncertain Agree Strongly
agree
M
n % n % n % n % n %
Spiritual care
(M: 2.78)
Providing spiritual care by arranging a visit by the hospital
chaplain or the patient’s own religious leader if
requested
6 2.3 38 14.7 77 29.7 121 46.7 17 6.6 2.40
Providing spiritual care by showing kindness, concern and
cheerfulness when giving care
0 0 4 1.5 20 7.7 190 73.4 45 17.4 3.06
Providing spiritual care by spending time with a patient
giving support and reassurance especially in times of
need
0 0 11 4.2 40 15.4 185 71.4 23 8.9 2.85
Providing spiritual care by enabling the patients to find
meaning and purpose in their illness
3 1.2 13 5 74 28.6 145 56 24 9.3 2.67
Providing spiritual care by listening to and allowing
patients time to discuss and explore their fears, anxieties
and troubles
4 1.5 19 7.3 54 20.8 160 61.8 22 8.5 2.68
Providing spiritual care by having respect for privacy,
dignity and religious and cultural beliefs of a patient
1 0.4 4 1.5 18 6.9 202 78 34 13.1 3.20
Forgiving
(M: 3)
Spirituality is concerned with a need to forgive and a need
to be forgiven
0 0 5 1.9 34 13.1 176 68 44 17 3.00
Faith in God
(M: 2.86)
Spirituality involves only going to church/place of worship 10 3.9 20 7.7 24 9.3 142 54.8 63 24.3 2.45
Spirituality is not concerned with a belief and faith in God
or supreme being
2 0.8 2 0.8 16 6.2 157 60.6 82 31.7 3.27
Meaning and purpose
(M: 2.73)
Spirituality is about finding meaning in the good and bad
events of life
0 0 17 6.6 56 21.6 165 63.7 21 8.1 2.73
Hope
(M: 2.9)
Spirituality is about having a sense of hope in life 1 0.4 10 3.9 36 13.9 175 67.6 37 14.3 2.91
Spirituality is a unifying force that enables one to be at
peace with oneself and the world
2 0.8 11 4.2 36 13.9 172 66.4 38 14.7 2.90
Creativity
(M: 3.37)
Spirituality does not include art, creativity and
self-expression
13 5 114 44 64 24.7 60 23.2 8 3.1 3.37
Relationships
(M: 2.55)
Spirituality involves personal friendships and relationships 3 1.2 27 10.4 66 25.5 148 57.1 15 5.8 2.60
Values and beliefs
(M: 2.51)
Spirituality does not apply to atheists or agnostics 10 3.9 46 17.8 67 25.9 103 39.8 33 12.7 2.51
Morality
(M: 2.59)
Spirituality has to do with the way one conducts one’s life
here and now
0 0 28 10.8 74 28.6 131 50.6 26 10 2.60
Spirituality includes people’s morals 0 0 10 3.9 22 8.5 179 69.1 48 18.5 3.02
SSCRS, Spirituality and Spiritual Care Rating Scale.
588 M. Zakaria Kiaei et al.
© 2015 International Council of Nurses
in our workplace. However, there were some general courses
in university which were mostly based on the religious
matters. (P 41, 35 years old)
We do not feel confident in providing spiritual care to
patients as there is not a structured guideline regarding the
spirituality, and spiritual care in hospitals in Iran. The main
consideration in this regard in based on nurses’ attitude and
their religious beliefs. So in my point of view providing spir-
itual care is dependent on nurses’ level of religiosity rather
than a structured guideline/regulation in this regard. (P 20,
31 years old)
Although participants did mention that they had undertaken
general vocational courses, such as Islamic knowledge and
Islamic morals, building efficient relationships with patients,
patients’ privacy and care of acute and chronically ill patients,
they were unclear about the concept and context of spirituality
aligned to their religious beliefs and how this interacted and/or
interconnected with their clinical spirituality and spiritual care
duties.
I consider myself as a religious person, and I think there are
many moral recommendations based on religious beliefs and
values in order to understand and care about patients. I really
do not have specific knowledge about spirituality, and spir-
itual care. However, my feeling is that there should not be a
big difference between religion and spirituality, and having
high level of religiosity could be helpful for providing spir-
itual care to patients. (P 93, 40 years old)
– Organizational barriers to spiritual care provision
The open-ended question responses clearly highlighted
notable organizational barriers in this study. They were mainly
centred on time constraints and/or busy working schedules and
low motivation to perform spiritual cares. Participants reported
that they face inflexible working schedules due to lack of human
resources, busy working shifts, numerous procedures and tasks
and heavy patient workloads. The low motivation particularly
related to issues of salary and resources.
I think with such busy schedule and the pressure of work, we
hardly can allocate enough time to communicate with
patients and their families in order to deliver spiritual care.
Even sometimes feel like I am under such immense pressure
at work that I am worried whether I transfer my stress to
patients! (P 28, 26 years old)
I think with the low salary/income, I do not have that much
motivation to provide more service to patients. (P 201, 45
years old)
Discussion
Because of their caring relationship with patients, nurses are in
a unique position to extend and enhance for healthcare services
through delivery of effective spiritual cares with patients. They
can play a significant role in recognizing and meeting the spir-
itual needs of patients through interaction with patients, their
family or friends (Tirgari et al. 2013). According to this study’s
findings, participants had a moderate level of perception of
2.73
2.55
3
2.9
2.51
2.86
3.37
2.59
2.78
0
1
2
3
4
Strongly Disagree
Disagree
Uncertain
Agree
Strongly Agree
Fig. 1 Mean scores of the aspects of spirituality and spir itual care (n = 259), Qazvin, Ir an, 2013.
Spirituality and spiritual care in Iran 589
© 2015 International Council of Nurses
spirituality and spiritual care. However, the majority of partici-
pants believed that they do not feel confident to meet the spir-
itual needs of patients, and often ‘shied away from it’. This result
has been confirmed by previous studies (Cetinkaya et al. 2013;
McSherry 2006). For example, McSherry & Jamieson’s (2011)
study demonstrated that only a low percentage of nurses were
equipped to fulfil appropriate levels of spiritual care. Another
study by McSherry confirmed that spirituality is often so inap-
propriately defined and poorly understood to such an extent
that many nurses do not consider spiritual care as part of their
role or responsibility (McSherry 2006). This demonstrates that
nurses’ failure to routinely incorporate spiritual care into their
practice is likely to be related to poor knowledge and under-
standing of spirituality and what such care entails (Tiew et al.
2013).
The findings of this study highlighted that a low percentage
of nurses had received little specific education in spiritual care
within their university programmes. In addition, participants
suggested that their knowledge regarding spirituality and spir-
itual care had been limited to ‘general’ content in university pro-
grammes and mostly based on religious issues, which possibly
had resulted in a limited perception of the wider role and func-
tion of spirituality and spiritual care. This was compounded by
the fact that most of them had not received additional clinically
based vocational training following graduation. Furthermore,
where nurses had received education or training in spiritual-
based care it was reported that it was often ineffective, and in
agreement with the results of previous studies (McSherry &
Jamieson 2011; Wu & Lin 2011). A more concerted and consist-
ent approach has long been advocated (Stranahan 2001; Wu &
Lin 2011). This would be in line with research that suggests
practical spirituality-based education/training has a major role
in responding to the changing medical health trends within
Iranian society (Salehi et al. 2014a). Hence, including spiritual-
ity and spiritual care training/education in both university cur-
riculum and workplace requires a national agreement in terms
of the content of related courses, learning aims and objectives,
practical educational methods, and continuous evaluation for
measuring the effectiveness of programmes. It becomes essential
to seamlessly integrate spiritual care knowledge and practice in
the national curriculum as part of holistic patient healthcare
services and also as part of continuing professional develop-
ment for nurses, physicians and other healthcare providers
(Jafari et al. 2014). This would increase the assessment of
patients experiencing spiritual distress and enable more effec-
tive planning for appropriate interventions (Shih et al. 2009).
One of the major factors facilitating the delivery of holistic
health care is the promotion of favourable occupational
working environments with less stressful conditions (Salehi
et al. 2014b). According to this study, busy working schedules,
stressful work situations and perceived lack of time and
resources were the main obstacles for delivering spiritual care. A
study conducted by Salehi et al. (2014b) in Iran indicated that
nurses have very high levels of stress, and particularly in public
hospitals, which profoundly affect their general performance in
terms of providing proper care for patients (Salehi et al. 2014b).
In addition, Vance’s (2001) study also confirmed that time limi-
tations and staff shortages are considered as the main barriers to
providing adequate levels of spiritual care in hospitals.
According to the findings from the current study, education
levels had a statistically significant relationship with spirituality
and spiritual care. This is consistent with the literature report-
ing that the perception of spirituality is different among partici-
pants with different educational level. Higher levels of
education have a known positive influence on the perception of
spirituality as well as provision of spiritual care (Wong et al.
2008). This is likely because nurses with higher educational
levels have a broader range of nursing skills and knowledge to
confront with challenges and thereby provide more competent
spiritual care (Wong et al. 2008). In addition to their higher
level education having positive benefits, some of the partici-
pants believed that their strong religious beliefs could also be
assist. It has been highlighted that religion and Islam have a
main role in spirituality and spiritual care (Tirgari et al. 2013;
Wong et al. 2008). Participants with religious affiliations have
been reported to be more sensitive to patients’ spiritual require-
ments and demonstrate a higher level of practiced spiritual care
(Wong et al. 2008). However, in recent years, the role of
spirituality/religion and spiritual care has become weaker in
healthcare provision for Iranian patients (Jafari et al. 2014).
This is an interesting finding given the level of religiosity at the
individual level as well as the fact that the religion itself, in a
cultural and social context, could influence the spiritual care in
nursing. Hence, further research is required, particularly in reli-
gious societies such as Muslim countries, to measure an observe
levels of religiosity in nursing practice and its influence on the
provision of spiritual care, as well as the role of religion as a
code of ethic and/or practice and its impact of spiritual care in
nursing.
Limitation
Although this study has been conducted in one of the biggest
cities of Iran in six hospitals, the sample may not be representa-
tive of other cities in Iran. In addition, as this study was con-
ducted in public hospitals some of the participants may have
answered questions cautiously compared with other groups
due to the possible negative influence of this survey on their
job position (e.g. possible exaggeration regarding nurses’
590 M. Zakaria Kiaei et al.
© 2015 International Council of Nurses
knowledge in terms of spirituality and spiritual care). Finally,
due to budget constraints, only public teaching hospitals were
included in this study. Further studies might be more nationally
widespread and conducted in different healthcare settings (e.g.
public and private hospitals/clinics).
Conclusion
It is highlighted by this study that nurses’ perception and
experiences of spirituality and spiritual-based care is, at best,
moderate, and they do not receive sufficient training regarding
these two aspects of nursing care. The study findings are, for the
most part, consistent with existing international literature that
might not be expected from a study in a country with such a
large faith-based religious population. Therefore, this study
offers a unique Iranian insight into the tension between the
quality of spirituality and spiritual-based care offered by Iranian
nurses in a secular Muslim country, where religious faith is an
important aspect of people’s everyday lives.
Implications for nursing and health policy
As spiritual care has a major role in the biological and psycho-
logical recovery of patients, it is a vital responsibility for policy
makers, health service agencies and nursing services in Iran to
establish structured guidelines, processes and training regarding
spiritual care provision with the support from government
agencies. In addition, it is essential to effectively train and
educate nurses and other health professionals accordingly to
assure that clinical teams are competent in spiritual care provi-
sions. This would have the effect of improving working environ-
ments and conditions and empower nurses to provide more
qualified health care.
In hospitals and community clinics, spirituality and spiritual
care should be routinely and concertedly incorporated into the
curriculum of undergraduate and postgraduate nursing courses
as well as in clinically based vocational training programmes in
order to deliver more effective spirituality-related care. This
could be of specific relevance, although not exclusively, in
Muslim societies such as Iran with large religious populations to
facilitate the delivery of high-quality and informed spiritual
care to patients.
Nurses must be able to recognize the specific beliefs and
values operating within a culture at the same time as they are
able to employ culturally sensitive skills across the spectrum of
ethnic and cultural groups (Tirgari et al. 2013).
Acknowledgement
The authors are thankful to all managers, staff and nurses of
hospitals affiliated with Qazvin University of Medical Sciences
for their cooperation with this research.
Author contributions
RK and AMN: Study design. RK and MA: Data collection. ESB
and MZK: Data analysis. AS and DW: Manuscript writing and
revisions.
References
Abbasi, M., Farahani-Nia, M. & Mehrdad, N. (2014) Nursing students’
spiritual well-being, spirituality and spiritual care. Iranian journal of
nursing and midwifery research, 19 (3), 242.
Baldacchino, D.R. (2008) Teaching on the spiritual dimension in care to
undergraduate nursing students: the content and teaching methods.
Nurse Education Today, 28 (5), 550–562.
Callister, L.C. & Khalaf, I. (2010) Spirituality in childbearing women. The
Journal of Perinatal Education, 19 (2), 16–24.
Cetinkaya, B., Azak, A. & Dundar, S.A. (2013) Nurses’ perceptions of spir-
ituality and spiritual care. The Australian Journal of Advanced Nursing,
31 (1), 5–10.
Fallahi, M., Mazaheri, M., Maddah, S.B. & Rahgozar, M. (2010) Validation
and reliability test of Persian version of The Spirituality and Spiritual
Care Rating Scale (SSCRS). Journal of Clinical Nursing, 19 (19–20),
2939–2941.
Gallison, B. S., Xu, Y., Jurgens, C. Y. & Boyle, S. M. (2012) Acute care
nurses’ spiritual care practices. Journal of Holistic Nursing, 31 (2),
95–103. doi: 10.1177/0898010112464121.
Garcia-Zamor, J.C. (2003) Workplace spirituality and organizational per-
formance. Public Administration Review, 63 (3), 355–363.
Harding, T. & Whitehead, D. (2013) Analysing data in qualitative research.
In Nursing & Midwifery Research: Methods and Appraisal for Evidence-
Based Practice, (Schneider, Z. & Whitehead, D., eds.). Elsevier-Mosby,
Marrickville, Sydney, pp. 141–160.
Jafari, N., et al. (2013) Spiritual therapy to improve the spiritual well-being
of Iranian women with breast cancer: a randomized controlled trial.
Evidence-Based Complementary and Alternative Medicine, 2013, 353262.
Jafari, N., Loghmani, A. & Puchalski, C.M. (2014) Spirituality and health
care in Iran: time to reconsider. Journal of Relig ion and Health, 53 (6),
1918–1922.
McSherry, W. (2006) The principal components model: a model for
advancing spirituality and spiritual care within nursing and health care
practice. Journal of Clinical Nursing, 15 (7), 905–917.
McSherry, W. & Jamieson, S. (2011) An online survey of nurses’ percep-
tions of spirituality and spiritual care. Journal of Clinical Nursing, 20
(11–12), 1757–1767.
McSherry, W., Gretton, M., Draper, P. & Watson, R. (2008) The ethical
basis of teaching spirituality and spiritual care: a survey of student
nurses perceptions. Nurse Education Today, 28 (8), 1002–1008.
Mbolghasem, M.S. (2008) Spirituality in nursing care and its application in
hospitalized patients. Medical Ethics, 2 (6), 121–154.
O’Brien, M.E. (2007) Spiritual Care: The Nurses Role. Spirituality in
Nursing: Standing on Holy Ground, 2nd edn. Janes and Bartlett Publish-
ers, UK.
Ozbasaran, F., et al. (2011) Turkish nurses’ perceptions of spirituality and
spiritual care. Journal of Clinical Nursing, 20 (21–22), 3102–3110.
Spirituality and spiritual care in Iran 591
© 2015 International Council of Nurses
Ramezani, M., Ahmadi, F., Mohammadi, E. & Kazemnejad, A. (2014) Spir-
itual care in nursing: a concept analysis. International Nursing Review,
61 (2), 211–219.
Salehi, A., et al. (2014a) Reform in medical and health sciences educational
system: a Delphi study of faculty members’ views at Shiraz University of
Medical Sciences. Eastern Mediterranean Health Journal, 20 (3), 151–161.
Salehi, A., Javanbakht, M. & Ezzatababdi, M.R. (2014b) Stress and its deter-
minants in a sample of Iranian nurses. Holistic Nursing Practice, 28 (5),
323–328.
Sawatzky, R. & Pesut, B. (2005) Attributes of spiritual care in nursing prac-
tice. Journal of Holistic Nursing, 23 (1), 19–33.
Shih, F.-J., et al. (2009) Spiritual needs of Taiwan’s older patients with ter-
minal cancer. Oncology Nursing Forum, 36, E31–E38.
Silbermann, M. & Hassan, E.A. (2011) Cultural perspectives in cancer care:
impact of Islamic traditions and practices in Middle Eastern countries.
Journal of Pediatric Hematology/Oncology, 33, S81–S86.
Stranahan, S. (2001) Spiritual perception, attitudes about spiritual care,
and spiritual care practices among nurse practitioners. Western Journal of
Nursing Research, 23 (1), 90–104.
Strang, S., Strang, P. & Ternestedt, B.-M. (2002) Spiritual needs as defined
by Swedish nursing staff. Journal of Clinical Nursing, 11 (1), 48–57.
Tiew, L.H., Kwee, J.H., Creedy, D.K. & Chan, M.F. (2013) Hospice nurses’
perspectives of spirituality. Journal of Clinical Nursing, 22 (19–20), 2923–
2933.
Tirgari, B., Iranmanesh, S., Cheraghi, M.A. & Arefi, A. (2013) Meaning of
spiritual care: Iranian nurses’ experiences. Holistic Nursing Practice, 27
(4), 199–206.
Vance, D.V. (2001) Nurses’ attitudes towards spirituality and patient care.
Medsurg Nursing, 10 (5), 264.
Whitehead, D. (2003) Beyond the metaphysical: health-promoting existen-
tial mechanisms and their impact on the health status of clients. Journal
of Clinical Nursing, 12 (5), 678–688.
Wong, K., Lee, L. & Lee, J. (2008) Hong Kong enrolled nurses’ perceptions
of spirituality and spiritual care. International Nursing Review, 55 (3),
333–340.
Wu, L.F. & Lin, L.Y. (2011) Exploration of clinical nurses’ perceptions of
spirituality and spiritual care. The Journal of Nursing Research, 19 (4),
250–256.
Yardley, S.J., Walshe, C.E. & Parr, A. (2009) Improving training in spiritual
care: a qualitative study exploring patient perceptions of professional
educational requirements. Palliative Medicine, 23 (7), 601–607.
Yuan, H. & Porr, C. (2014) Integrating spiritual care into a baccalaureate
nursing program in mainland China. Journal of Holistic Nursing, 32 (3),
240–243.
592 M. Zakaria Kiaei et al.
© 2015 International Council of Nurses
