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The Relationship between Spiritual Intelligence and
Attitudes toward Spirituality and Spiritual Care of
Nurses: a cross-sectional study
Korosh Abbasi
Islamic Azad University
Azam Alavi ( azam_alavi92@yahoo.com )
Islamic Azad University
Research Article
Keywords: Spiritual Intelligence, Spiritual Care, Nurses
Posted Date: April 18th, 2023
DOI: https://doi.org/10.21203/rs.3.rs-2790092/v1
License: This work is licensed under a Creative Commons Attribution 4.0 International License.
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Abstract
The Relationship between Spiritual Intelligence and Attitudes toward Spirituality and Spiritual Care of
Nurses: a cross-sectional study
Background: The present study was conducted to determine the relationship between spiritual
intelligence and attitudes toward spirituality and spiritual care of nurses.
Methods: This correlational, cross-sectional study was carried out on 193 nurses (in Iran) that selected
using census sampling method. Data were collected using spiritual intelligence self-report inventory
(SISRI) designed by King (2008) and spirituality and spiritual care rating scale (SSCRS) developed by Mc
Sherry et al., (2002). Then, data were analyzed by descriptive and inferential statistical tests in SPSS
software (ver. 16, Chicago, IL, USA).
Results: The results showed that mean ± SD of nurses' spiritual intelligence score (45.83 ± 61.14) was
above average and mean score of spirituality and spiritual care (61.45 ± 30.12) was at moderate level. A
positive and signicant relationship was found between mean spiritual intelligence score and nurses'
attitude towards spirituality and spiritual care (r = 0.764, and p < 0.001). According to the results of the
regression analysis of the four dimensions of spiritual intelligence, transcendental awareness (beta =
0.471) followed by critical existential thinking (beta = 0.371) were the most important predictors.
Conclusion: According to the research results, there was a signicant and positive relationship between
spiritual intelligence and attitudes toward spirituality and spiritual care. Therefore, it is necessary to
include the training of spiritual intelligence in the nursing curriculum and fostering spiritual awareness
and existential awareness through methods such as case studies and workshops should be considered
as in-service nursing education.
Background
Considering spiritual dimension of human being from the viewpoint of the scientists, especially the
experts of the world health organization (WHO), who have dened humans as a biological, psychological,
social, and spiritual being, concepts of spirituality have been introduced and developed(1).
It is necessary to take into account spirituality in order to have a comprehensive and true vision and
proper patient care. Spirituality as an excellent nursing component is regarded as basis for nursing
activities. From the perspective of holistic nursing, humans are multi-dimensional being and spirituality is
the central dimension and has a signicant effect on health (2–5). Spiritual care is a type of care that
seeks and identies spiritual existential needs and challenges associated with disease and crisis (6–8).
Today, spiritual care is an important part of nursing care. Spiritual care is a multidimensional concept and
includes practice and activity in areas, such as respecting and maintaining the patient's privacy and
dignity, supporting the cultural and religious beliefs, careful listening to the patient, kindness while
interacting with patient, empathy and helping the patient to understand nature of the disease (9–11).
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This type of care is introduced as an intrinsic value and a basic and central element to nursing, which is
interrelated with nursing education and practice (8, 12). Nursing profession claims to provide holistic
care. From the point of view of some nursing theorists, spirituality is an important dimension of holistic
nursing and can help to promote patients' health. Helping to meet spiritual needs of the patients and their
families is a key element of clinical care. There is a consensus in most of the previous studies on the role
of spirituality in recovery and the effect of spirituality on quality of care, power to improve, and also
ability to cope and adapt with change, and health and disease-related conditions (13–15).
Spiritual intelligence, as one of spiritual concepts includes a kind of adaptation and problem-solving
behavior accounting for the highest levels of development in various areas, i.e., cognitive, moral,
emotional, and interpersonal areas(16, 17). This intelligence enables the individual to adapt to
surrounding phenomena and achieve internal and external integration and express a set of spiritual
abilities and capacities, which in turn help to increase adaptability, problem-solving ability, coping with
pressure, and showing calmness and freshness in personal and professional life (17, 18). Spiritual
intelligence is the basis of human beliefs that has a positive effect on their performance and increases
exibility in solving problems(19). Spiritual intelligence is essential because of using one's internal
resources to increase capacity for attention, tolerance, and adaptability, develop people's perception in
job-related relationships, the ability to recognize true meaning of events, identify and regulate personal
values, and ensure having a violence-free life in organizations(20).
Review of the literature showed that not only it is considered in individual areas but also it is regarded in
organizational areas. Also, it seems that increasing number of research in the eld of spirituality may be
due to its tangible signicant effect on improving individual and organizational performance (14, 21, 22).
Additionally, Beni et al., (2019) carried out a study entitled “Roles of Spiritual Intelligence to Improve
Quality of Nursing Care: A Systematic Review” and reported that spiritual intelligence could improve
nurse's competency, moral performance, and personal meaning about caring(17). The Indonesian study
showed that spiritual intelligence was negatively correlated to job burnout and positively correlated with
caring behaviors(23). Also, Haryono et al., (2018) reported that nurse's spiritual intelligence had positive
and signicant effects on organizational commitment (24). In this regard, the concept of spiritual
intelligence is also taken into account in nursing profession and the evidence shows that spiritual
intelligence is one of the factors inuencing nursing care behaviors and clinical competence of
nurses(25). Besides, studies have demonstrated that nursing care combined with spirituality improves
nursing practice and quality of patient care. This type of care reduces physical pain, depression, anxiety,
increases mental relief, speeds up recovery, increases life expectancy, improves quality of life, and
deepens the patient-nurse relationship(26, 27).
Although, the approach towards spiritual care is a familiar term in nursing and most nursing models
address the concept of spirituality, and spiritual care has been widely recognized as a necessary aspect
of clinical care, spiritual dimension is the most neglected dimension in the nursing eld, and in practice,
adequate attention has not been paid to spiritual care while providing care(28). However, it is not possible
to separate spiritual care from care processes, and it is important to address these spiritual concepts in
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the nursing profession. Therefore, the present study was done to determine the relationship between
spiritual intelligence and nurses' attitudes towards spirituality and spiritual care considering the approach
that, nurses’ ability to provide spiritual care should be increased in clinical setting and it should be
regarded as a basis for enhancing quality of patient care and patient's satisfaction.
Methods
This correlational, cross-sectional study was conducted in 2020. A total of 222 eligible nurses referred to
the Seyed Al-Shohada Hospital in Farsan, (Shahrekord City, Chaharmahal and Bakhtiari Province, Iran)
were selected by census sampling method to be included in the study. Inclusion criteria included having
at least an associate's degree, having at least one year of working experience in various types of
employment including permanent, temporary-to permanent, contractual, conscription, and willingness to
participate in the study. Nurses who were not working in the hospital or those who were unwilling to
participate in this study were excluded from the research.
Finally, a total of 193 questionnaires were completed. After receiving the letter of introduction from the
Islamic Azad University of Shahrekord and referring to the Vice Chancellor for Research and Technology
of the Shahrekord University of Medical Sciences, the questionnaires were distributed. This study was
performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics
Committee of Falavarjan Islamic Azad University (IR.IAU.FALA.REC.1399.040). Prior to the study, the
subjects, method, and purpose of the study were explained to the participants by the main author and
their consent was obtained. They were also assured that their private and personal information would be
kept condential.
Data collection tools included two standard questionnaires: Kings spiritual intelligence self-report
inventory (SISRI-24), consisting of 24 items and four dimensions of critical existential thinking, (questions
1, 3, 5, 9, 13, 17, and 21), personal meaning production (questions 7, 11, 15, 19, and 23), transcendental
awareness (questions 2, 6, 10, 14, 18, 20, and 22), and conscious state expansion (questions 4, 8, 12, 16,
and 24). This questionnaire is scored based on a 5-point Likert scale (strongly disagree: 1 to strongly
agree: 5). The possible score range is between 24–120, with higher scores indicating more spiritual
intelligence. A score equal to and higher than the average was considered as optimal spiritual intelligence
and non-optimal spiritual intelligence was indicated by scores lower than the average. Validity of this tool
has been conrmed in the study done by King and its reliability has been reported to be 0.95 (29). Validity
and reliability of this questionnaire have been conrmed in several studies conducted in Iran. Cronbach's
alpha method was used to assess its reliability (α = 0.89)(30).
Spirituality and spiritual care rating scale (SSCRS), as the modied scale developed by Mc Sherry
consists of 23 questions on spirituality and spiritual care. The rst part of this scale includes 9 items
related to spirituality, including hope, meaning, purpose, beliefs, values, relationships, belief in God, ethics,
innovation, and self-expression. The second part includes 14 questions on spiritual care. Spirituality and
spiritual care rating scale scored based on a 5-point Likert scale (strongly agree = 4 to strongly disagree =
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0). The possible score range is between 0–92, with scores ranging between 63–92, 32–62, and 0–31
indicating high and optimal, moderate and somehow optimal, and low and non-optimal spiritual care,
respectively(31). This tool has been validated in Iran in a study by Fallahi et al and Cronbach’s alphas
value (α = 0.85) was reported.(32).
Data were analyzed using descriptive and analytical statistics, such as linear regression analysis and
Pearsons correlation coecient test in SPSS software (ver. 16, Chicago, IL, USA).
Results
Out of 222 questionnaires distributed in the present study, 193 questionnaires were fully completed and
29 questionnaires were excluded from the study due to non-answering and answering less than 10% of
the questions. Data analysis showed that out of 193 participants, 110 subjects (57%) were women.
Majority of the studied participants aged between 31–35 years old (n = 66, 34.2%), 88 subjects (45.6%)
had a working experience of 1–5 years, and 146 subjects (75.6%) had a bachelor's degree.
Mean score ± SD of nurses' spiritual intelligence (83.45. ± 14.61) was higher than mean and optimal level
and mean score of spirituality, and spiritual care (61.45 ± 12.30) was at moderate to relatively high level.
(Table1)
The results of Kolmogorov-Smirnov test showed normal distribution of the data. The results of Pearsons
correlation coecient test also showed a strong and signicant positive relationship between spiritual
intelligence and its dimensions with spirituality and spiritual care (r = 0.764 and p < 0.001). (Table2)
According to the results of regression analysis, among the four dimensions of spiritual intelligence,
spiritual consciousness (β = 0.471) was the most important predictor of attitudes toward spirituality and
spiritual care. Also, creation of personal meaning and conscious development were not signicant
predictors of attitudes toward spirituality and spiritual care. (Table3)
Discussion
Findings of the present study showed that mean score of nurses' spiritual intelligence was above the
average and based on the scoring of the questionnaire, a score higher than the average was considered
as optimal spiritual intelligence. In this regard, mean nurses' spiritual intelligence score has been higher in
the studies by Salmani, Sabzianpour, BarkhordariSharifabad, Sunaryo and Kaur than the average and
optimal level, which is consistent with the present study (23, 30, 33–35). However, in this regard,
Abdolrazaghnejad et al., and Bahrami et al., showed that mean score of nurses' spiritual intelligence was
lower than the average(21, 36), which may be different from the present study due to research
environment. Findings of the present study also showed a moderate score for nurse's attitude towards
spirituality and spiritual care, which is consistent with the study by Abdollahyar et al and Rezapour-
Mirsaleh et al (1, 37). Results of the study done by Kaddourah in Saudi Arabia as well as those performed
by Atarhim and Herlianita in Malaysia and Indonesia, respectively, showed that nurses had moderate to
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high attitude towards spirituality and spiritual care (7, 38, 39), which are consistent with the present study.
It seems that similar level of attitude toward spirituality and spiritual care in the present study and those
studies can be due to cultural and religious values among nurses in countries. Of course, it should be
noted that the attitude of our samples was similar to other studies’ samples with different religions for
example, Reig-Ferrer reported a satisfactory mean score on nurses’ self-reported spirituality in Spanish
Nurses(40). Also in this regard, the results of the study by Egan et al show that many New Zealand nurses
consider spirituality and spiritual care to be important dimensions of nursing practice(41). According to
the international consensus, the concept of spirituality is "a dynamic and inherent thing", in fact
Spirituality is dened as a constant search for the meaning and purpose of life, a person's search for
sanctities, superiority, close connection with oneself, others and the environment, a deep understanding
of the value of life, and a personal belief system(16). In fact, Spirituality is not just for people who are
religious, and that a person with no particular religious’ faith may feel "one with the world" through nature
or follow humanist or secular belief systems. Spiritual care is situated in holistic care in nursing and
nurses in religious and non-religious contexts attend to patients’ spiritual care needs and believe they are
important(11). Actually Spiritual care as a multidimensional concept is different from religiosity, but they
are not mutually exclusive in religious contexts. The concept of Spirituality can related with religious
beliefs and spiritual care includes religious (praying and praying with the patient, talking to the patient
about God, clarifying the relationship between the patient and God, using religious texts) and nonreligious
care (communication skills, counseling, emotional and active listening, encouraging the patient to
express feelings, encouraging positive thinking, empathetic communication)(1).
The results of this study showed a signicant, positive relationship between spiritual intelligence and its
four dimensions with spirituality and spiritual care of nurses. Comparing the standardized coecient of
regression analysis, among the four dimensions of spiritual intelligence, there was a stronger relationship
between transcendental awareness (0.471) and critical existential thinking (0.371) with nurses' attitude
towards spirituality and spiritual care. Unfortunately, according to literature review, there has been no
study on the exact relationship between these two variables so far. However, in this regard, In the study of
Bar-Sela et al, the lack of spiritual self-awareness is introduced as one of the most important obstacles in
providing spiritual care by nurses(42). Also Pinto et al emphasized that spiritual self-awareness is crucial
to the provision of spiritual care and strengthening spiritual intelligence is an approach to improve
spiritual care and holistic practice. In addition to Riahi et al, showed that spiritual intelligence training has
a positive and signicant effect on spiritual care of nurses in intensive care units (ICUs) and concluded
spiritual intelligence can be considered a factor in spiritual care because it can improve self-awareness in
a person(43) which are consistent with the present study. Also Emamqholian found a positive and
signicant relationship between spiritual intelligence and competence in Providing Spiritual care of
nursing students(25). Sabzianpour and Sunaryo also showed a positive and signicant relationship
between spiritual intelligence and quality of nursing care, Caring Behavior (23, 34). In a study, Salawati
Ghasemi demonstrated a signicant relationship between spiritual intelligence and communication skills
of nurses(22). In their study, Salmani, Arsang-Jang and Haryono found a positive and signicant
relationship between spiritual intelligence and nurses' support for patients and also between spiritual
Page 7/12
intelligence, ethical decision making of nurses and nurses’ organisational commitment. (20, 24, 33). In
this regard, Pinto et al., (2020) stated that nurses with higher spiritual intelligence are less arrogant,
behave more wisely, and have more compassion and empathy for patients. They communicate more
effectively with patients and colleagues, and provide high quality of caring (16). Considering that the
items of the SSCRS also include concepts, such as communication, ethics, and patient care and support,
these studies indirectly conrm the results of the present study. Spiritual care is a unique aspect of care
and addressing spiritual needs of patients is regarded as an essential component of holistic nursing care.
The results of the present study conrmed that spirituality has been accepted by nurses and they
consider spirituality as an integral part of the nursing profession. Also, high level of spiritual intelligence
among nurses is one of strengths and advantages regarding attitude towards nursing care, including
spiritual care.
Conclusions
The results of this study showed a signicant, positive relationship between spiritual intelligence and
attitudes toward spirituality and spiritual care. In particular, this study highlights the role of spiritual
intelligence on spirituality and spiritual care. The growing evidence on spiritual intelligence brings new
insight into the importance of spiritual self-awareness and existential awareness for the development of
spiritual care by nurses. Spiritual intelligence as a cognitive concept can be taught and learned. In this
regard, it is necessary to include the training of spiritual intelligence in the nursing curriculum and
fostering spiritual awareness and existential awareness through methods such as case studies and
workshops should be considered as in-service nursing education.
One of the limitations of this research is the non-random sampling, and therefore one should be careful in
generalizing the results. Therefore, it is suggested to conduct similar research with random sampling
method and in countries with more diverse cultural backgrounds.
Abbreviations
SISRI
spiritual intelligence self-report inventory
SSCRS
spirituality and spiritual care rating scale.
Declarations
Ethics approval and consent to participate: This study was performed in line with the principles of the
Declaration of Helsinki. Approval was granted by the Ethics Committee of Falavarjan Islamic Azad
University (IR.IAU.FALA.REC.1399.040). Informed consent was obtained from all individual participants
included in the study
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Consent for publication: Not applicable.
Availability of data and materials:
Data and materials are condential but they will be available upon reasonable request from the
corresponding author.
Competing interests: No conict of interest has been declared by the authors.Funding: No funds, grants,
or other support was received.
Authors' contributions: All authors contributed to the study conception and design. Material preparation,
data collection and analysis were performed by K.Abbasi, the rst draft of the manuscript was written by
A.Alavi and all authors commented on previous versions of the manuscript. All authors read and
approved the nal manuscript.
Acknowledgement: We hereby express our gratitude to the Research Deputy of Shahrekord Islamic Azad
University for their support of this thesis. We also thank all nurses for spending time and sharing their
valuable experiences.
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Tables
Table (1): Average total score and dimensions of spiritual intelligence and attitude towards spirituality
and spiritual care
Dimensions of spiritual intelligenceSpiritual
Intelligence
Spirituality
and
spiritual
care
Critical
Existential
Thinking
Personal
Meaning
Production
Transcendental
Awareness
Conscious
State
Expansion
24.2618.9124.1516.1183.4561.45Mean
5.453.603.843.9114.6112.30SD
35.0024.0031.0025.00113.0082.00Maximum
13.0012.0017.009.0060.0030.00Minimum
Table (2): Correlation coecient between spiritual intelligence and its dimensions with attitude towards
spirituality and spiritual care
Page 12/12
Spiritual
Intelligence
Critical
Existential
Thinking
Personal
Meaning
Production
Transcendental
Awareness
Conscious
State
Expansion
193193193193193Nspirituality
and
spiritual
care 0.7640.7200.5510.7320.624Pearson
correlation
0<0010<0010<0010<0010<001P
Table (3): Regression coecients of the relationship between the dimensions of spiritual intelligenceand
attitudes toward spirituality and spiritual care
Dimensions of spiritual intelligence B SE Beta (β) P
Critical Existential Thinking
0/837
0.182
0.371
0<001
Personal Meaning Production -0.256 0.222 -0.075 0.249
Transcendental Awareness 1.507 0.206 0.471 0<001
Conscious State Expansion 0.333 0.225 0.106 0.142
ADJR square = 0.629 R square= 0.637 R=0.798
