Zhang-Yi Wang,Zhao Wang,Yue Wang,Guang-Hong Han,Xiao-Li Pang

1Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China; 2School of Nursing, Tianjin University of Traditional Chinese Medicine,Tianjin,China.

Abstract Objective: To investigate the status quo of spiritual care competence and assocaited influencing factors among clinical nurses in China, and examine the relationships among spiritual care perceptions, spiritual health and spiritual care competence,and the mediating role of spiritual health between spiritual care competence and spiritual care perceptions,in order to provide reference for the construction of spiritual care education intervention program to improve the spiritual care competence of clinical nurses in China.Methods:A total of 1454 clinical nurses from 17 hospitals in Tianjin were selected by convenience sampling method, and were investigated with sociodemographic characteristics questionnaire,the Chinese version of Spiritual Care Competence Scale(C-SCCS),the Chinese Version of the Spiritual Care-Giving Scale (C-SCGS) and the Spiritual Health Scale Short Form(SHS-SF). Results:The scores of spiritual care competence of nurses was (57.52 ± 16.02).The results of multiple linear regression showed that nurses' spiritual care competence was influenced by 9 sociodemographic characteristics such as educational background and nursing age, as well as spiritual care perceptions and spiritual health factors, which accounted for 67.2% of the total variation.And spiritual care competence was positively correlated with spiritual care perceptions (r = 0.639, P < 0.01) and spiritual health(r = 0.596, P < 0.01).Besides,spiritual health played a mediating role between between other two variables,accounting for 27.5% of the indirect effect. Conclusions: The scores of spiritual care competence of clinical nurses was in the lower middle level,which needs to be further improved.It is recommended that nurse managers and educators should pay attention to the spiritual care education of nurses, and improve spiritual care perceptions and spiritual health level of nurses in multiple ways, at multiple levels, so as to improve their spiritual care competence and to maximize the satisfy spiritual care needs of patients.

Keywords: Spiritual care competence; Spiritual care perceptions; Spiritual health; Clinical nurses; Spiritual care education;China

Introduction

The word spirituality is a broad concept, derived from the Latin word "pirius", meaning "breathe" and "make alive", is usually given the spirit of life, making life more abundant and vigorous, subjective feeling and inner experience, and exists in all individuals,including the exploration of the meaning of life,personal value and growth, which is the essence and basic characteristic of human beings.Also, spirituality is the embodiment of an individual's ability to transcend oneself in the process of life, and it is a spiritual force which is intrinsically related to the meaning of existence [1,2].The World Health Organization (WHO) points out the fourth dimension of health, namely spiritual health in 1998, and advocates value and satisfy the harmony and unity of patients in the four aspects of physical, psychological,social and spiritual.Spiritual care refers to a nursing activity or method that nursing staff who identify and evaluate the patients' concerns, distress and spiritual needs during the nursing process, and according to their individual characteristics to allow the patient's physical, mental, and spirit to reach comfortable by accompanying, listening, respecting or directly discussing the meaning and value of life with the patient, has not been explicitly incorporated into clinical nursing practice so far[3,4].

At present, the treatment and rehabilitation of most diseases is a long process, and patients not only have to face the suffering of the disease,but also have to bear the pressure of family and society, which can easily lead to "holistic suffering" on the physical,psychological, social, and spiritual levels.When there are spiritual distress and spiritual care needs, if they are not relieved and satisfied,it may affect the patients'physical symptoms and psychological treatment effects,and even cause spiritual pain [5].Spiritual care emphasizes maintaining the dignity of the patient,respecting the faith of patients, reducing the sense of disease uncertainty, helping to restore inner peace,exploring the value of life,finding the meaning of life,and improving the quality of life[6,7].

Spiritual care competence refers to the knowledge,attitude and skills of spiritual care possessed by nurses,which can significantly improve the physical and mental health of patients and their satisfaction with the quality of clinical nursing practice services [8].According to the findings of an American scholar [9],69% nurses can confirm spiritual problems of patients,and 76% nurses believe that they lack, knowledge,ability, or resources associated with spiritual care.Nursing practice is an important link and process for nurses to directly contact clinical real cases directly and take care of critically ill and dying patients, and it is also a key step to cultivate their spiritual care competence[10].Nurses are considered to be the main implementers of spiritual care for patients, who are most easily to be aware of their spiritual distress,spiritual pain and spiritual care needs, and nurses'spiritual care competence may be closely related to their own spiritual care perceptions and spiritual health[11].

Background

Sessanna et al.[12]proposed that spiritual health is the cornerstone of nursing practice, and solving the existing or potential spiritual problems of patients is an important part of holistic nursing.The American Nursing Association and the International Nurses Association have incorporated spiritual health into their practice guidelines and norms to assess their spiritual care competence [13].The spiritual health of nurses is an important factor for their quality of life and nursing practice[14].But now,nurses'perceptions and competence of spiritual care are often incompatible with the needs of patients' spiritual care.Related research rarely pays attention to the nurses own spiritual health and spiritual care education.

As studies revealed the spiritual care competence of clinical nurses has a positive effect on cancer patients,which can improve their psychological coping ability, sense of satisfaction, inner spiritual strength and quality of life [2].A study [15] based on 181 oncology nurses and 638 hospice nurses showed that spirituality is significantly related to their ability,personal coping ability and the frequency of providing spiritual care to provide spiritual care.Besides, the spiritual health and spiritual care concept of nurses are important factors affecting the provision of spiritual care.Professor McSherry pointed out that the obstacles affecting spiritual care include both intrinsic and extrinsic aspects [6].The International Nurse Education Guidelines also hold that spiritual care is a part of nursing education, and the best spiritual care effect is required to improve nurses' understanding of the essence and connotation of spiritual care through spiritual care education [4,10,16].Only by deeply understanding and exploring the relevant knowledge of spiritual care, maintaining adequate spiritual health,improving spiritual care competence, and making full use of existing resources to better apply spiritual care to clinical nursing practice, can patients' spiritual care needs be met to the greatest extent and the quality of nursing services and satisfaction of patients be improved [6,17,18].However, in the current domestic researches,little is known about the level and results of spiritual care education.The spiritual curriculum is not perfect, and there is no systematic and standardized integration [16].In addition, spiritual concepts and connotations are abstract and vague, so it is difficult to define clearly in the curriculum.With the differences of traditional culture and religious belief between the East and the West, some Chinese nurses may confuse spirituality with religious belief, and even refer spiritual care services to other professional nursing groups.Many factors have combined to make it difficult for nurses to improve their spiritual care competence.

However, the research for spiritual care competence in China is mainly focused on oncology nurses, reproductive center nurses, hospice nurses,pension institution nurses, nursing interns.And the research content mainly focuses on the status quo of single spiritual care competence and its influencing factors,and hardly takes spiritual care competence as a dependent variable to study the correlation among the three variables.Therefore, the purpose of this study is to investigate the level of spiritual care competence,explore spiritual care perceptions, spiritual health and its relationship with spiritual care competence among nurses in China, and the mediating role of spiritual health between spiritual care competence and spiritual care perceptions.So as to provide reference for further strengthening the spiritual care education training and intervention research of nurses in China.

Methods

Study design

A cross-sectional, quantitative design was used, and the study was adherent to the strengthening of the reporting of observational studies in epidemiology(STROBE)statement.

Participants and sample

The convenience sampling was used to recruit clinical nurses from 17 hospitals in Tianjin, China.Respondents met the following criteria:Inclusion criteria:(a) obtained a nurse's professional qualification certificate; (b) worked for one year or more;(c)informed consent and voluntary participation in the study.Exclusion criteria:(a) intern nurses; (b)advanced training, rotation and regular training nurses;(c)not on duty during investigation period.

According to Kendall's sample estimation method[19],5～10 times of the variable number were taken as the sample size in this study.Three scales with 34 variables need to be analyzed,considering 20%invalid questionnaires, so the sample size is 204 ～ 408, and 1454 sample sizes are included in this study to meet the requirements.

Data collection

Data was collected from 17 hospitals in Tianjin,China,from October 2020 to March 2021.The investigation was conducted with the prior approval of the university and hospital administrator.The researchers with standardized training used the unified instruction language to explain the basic information to the participants, including the purpose, significance and confidentiality of this study,and take the department as the unit, with the assistance of the head nurse of each department distribution.The researchers issued questionnaires to nurses who met the standards of admission, and the nurses were asked face-to-face to fill in the questionnaires.The questionnaire is anonymous and confidential, and the data obtained is only used for academic research and will not be used for other commercial purposes.A total of 1478 questionnaires were distributed and a total of 24 questionnaires with regular answers or obviously contradictory answers were eliminated.In total, 1454 valid questionnaires were selected for analysis.The effective recovery rate was 98.4%.The flow chart of included participants was presented in Figure 1.

Figure 1.The flow chart of included participants

Instruments

Sociodemographic characteristics questionnaire was designed by the researchers after referring to the relevant literature, including 19 items, such as gender,age, nationality, religious belief, marital status and education background,etc.,as shown in Table 1.

Table 1.Sociodemographic characteristics and the scores of C-SCCS based on sociodemographic differences among clinical nurses(n=1454)

Table 1.Sociodemographic characteristics and the scores of C-SCCS based on sociodemographic differences among clinical nurses(n=1454)(Continue Table 1)

Table 1.Sociodemographic characteristics and the scores of C-SCCS based on sociodemographic differences among clinical nurses(n=1454)(Continue Table 1)

The Chinese Version of the Spiritual Care Competence Scale (C-SCCS) with good reliability and validity was used to assess the spiritual care competence [20].The scale consists of 22 items in 6 dimensions:"assessment and implementation","professionalisation and improving quality of care","personal support and patient counselling", "referral to professionals", "attitude towards patients spirituality","communication".A total Cronbach's α is 0.974, and content validity is 0.98.In this study, its Cronbach's α was 0.969.All items scores ranged from Likert 1 ～ 5 and a total score is 22 ～ 110 with higher scores indicating greater spiritual care competence.

The Chinese Version of the Spiritual Care-Giving Scale (C-SCGS) has been used in various studies in China and its validity and reliability have been confirmed which was used to assess the spiritual care perceptions of clinical nurses [21].The scale consists of four dimensions, including "attributes for spiritual care", "defining spirituality and spiritual care","spiritual perspectives", and "spirituality and spiritual care values".In this study,its Cronbach's α was 0.951.Likert 6 rating method is used, with the 1 ～ 6 score indicating a range from "strongly disagree" to"strongly agree".The total score of C-SCGS is 34 ～206.

The Spiritual Health Scale Short Form (SHS-SF)[22] with good reliability and validity was used to assess the spiritual health.The Cronbach's α is 0.93 and its Cronbach's α was 0.911 in this study.There are 5 dimensions in SHS-SF, including "connection to others","meaning derived from living","transcendence","religious attachment" and"self-understanding", a total of 24 items.Using Likert 5 rating method, 1 ～ 5 score indicates "strongly disagree" to "strongly agree".The higher score demonstrates better spiritual health.

According to the preliminary structure of spiritual care put forward by Professor Zhao in Taiwan and the"Z" theory in Maslow's hierarchy of needs theory[23,24], which is the theoretical basis in this study.Figure 2 showed the conceptual framework of this study.

Figure 2.The flow chart of the conceptual framework

Statistical analysis

Data was analyzed using IBM SPSS version 21.0.Descriptive statistics(numbers,percentage distribution)were used to describe clinical nurses'sociodemographic characteristics.Mean ± Standard deviation (ˉx± s), or median as well as interquartile spacing [M (Q, R)] were used to describe the measurement data, respectively.Independentttest,one-way ANOVA, Mann-Whitney U test, and Kruskal-Wallis analysis were used to compare between two or more groups.Pearson productmoment correlation was used to explore the correlation among them with statistical significance set toP< 0.05(two-tailed), and using the process plug-in Bootstrap program method in SPSS to analyze the mediating effect.

Ethical considerations

Ethical approval for conducting this study was obtained the ethics committee of a university in China.After granting the official permission from nursing directors and managers in 17 selected hospitals, the participants were approached by the researchers.The purpose and significance of this study were explained to the clinical nurses who met the inclusion criteria.The participants were given the right to decide whether to participate in the study.And they were also informed about their right to withdraw from the project without having to provide a reason.Anonymity was ensured as the questionnaire contained no marks,names or numbering that could identify participants.And all data obtained will only be used for the academic research and will not be used for other commercial purposes.

Results

Participants'sociodemographic characteristics

1454 clinical nurses were included in this study.The mean age of the participants was 35.37 ± 2.17 years.And the majority of the participants were females(1210, 83.2%), 628 (43.2%) were aged less than 25 years, 1188 (81.7%) were Han nationality, 1252(86.1%) had no religious belief, 826 (56.8%) were married.And other sociodemographic characteristics were shown in Table 1.

Spiritual care competence, spiritual care perceptions and spiritual health level of clinical nurses

The total scores of C-SCCS, C-SCGS and SHS-SF were 57.52±16.02,150.89±18.16 and 88.82±11.16,which was both in the lower middle level.Among the six dimensions of C-SCCS, the highest dimension mean score was "communication" (2.92 ± 0.88), and the lowest was "personal support and counselling of patients" (2.45 ± 0.76).Of the four dimensions in C-SCGS, the highest dimensions mean score was"defining spirituality and spiritual care" (4.47 ± 0.56),and the lowest was "spirituality and spiritual care values" (4.38 ± 0.60).Among the five dimensions of SHS-SF, the dimension with the highest average score is the "meaning derived from living" (3.80 ± 0.51),while the lowest dimension is the "religious attachment" (3.60 ± 0.61).And the scores of other dimensions of questionnaires were shown in Table 2.

Table 2.The scores of C-SCCS,C-SCGS and SHS-SF among clinical nurses[n=1454,M(SD)]

Comparison of spiritual care competence based on sociodemographics

A single factor analysis of spiritual care competence on sociodemographic characteristics showed that there were statistically significant differences in the scores of"spirituality care competence"among clinical nurses in age, marital status, education background, nursing age, monthly income, technical title, administrative position, hospital nature, hospital grade, if a clinical teacher, working section, employment modality, if spiritual care experience, participated in spiritual care training, lectures or courses, needs for spiritual care training, lectures or courses, as shown in Table 1.The results from Table 3 revealed that education background,nursing age,technical title,hospital nature,hospital grade, if a clinical teacher, employment modality, if spiritual care experience, participated in spiritual care training, lectures or courses, needs for spiritual care training,lectures or courses,spiritual care perceptions and spiritual health were the main individual factors affecting the spiritual care competence of clinical nurses, which explained 67.2%of the total variance (R2 = 0.685, adjusted R2= 0.672,P<0.01).

Table 3.A multiple linear regression of spiritual care competence among clinical nurses(n=1454)

Correlation among spiritual care competence,spiritual care perceptions and spiritual health

The Table 4 showed that the results of Pearson productmoment correlation examined that there was a significant positive correlation between spiritual care competence and spiritual care perceptions(r=0.639,P< 0.01), and all dimensions were positively correlated(P< 0.01).And the total score of spiritual care competence was also positively correlated with that of spiritual health (r= 0.596,P< 0.01), and each of dimensions was positively correlated (P< 0.01), as shown in Table 5.

Table 3.A multiple linear regression of spiritual care competence among clinical nurses(n=1454)(Continue Table 2)

Table 4.The correlation between spiritual care competence and spiritual care perceptions among clinical nurses(n=1454,r)

Table 5.The correlation between spiritual care competence and spiritual health among clinical nurses(n=1454,r)

The mediating effect of spiritual health between spiritual care competence and spiritual care perceptions

As a result as shown in Table 6 and Table 7, the direct effect of spiritual care perceptions on spiritual care competence was 0.41 (P< 0.01), the total effect of 0.56(P<0.01),and the indirect effect was 0.16,which was statistically significant and showed that spiritual health plays a part mediating role between spiritual care competence and spiritual perceptions, accounting for 27.5%of the indirect effect.

Table 5.The correlation between spiritual care competence and spiritual health among clinical nurses(n=1454,r)(Continue Table 5)

Table 6.The mediating effect of spiritual health between spiritual care competence and spiritual care perceptions among clinical nurses(n=1454)

Table 7.The total,direct and indirect effect(n=1454)

Discussion

The status quo of spiritual care competence,spiritual care perceptions and spiritual health

In this study,the total score of clinical nurses'spiritual care competence was (57.52 ± 16.02), and the whole was in the middle and lower level, which was similar to that of Chen et al.[25]and Liu et al.[26],and there was much room for improvement.Besides, the total spiritual perceptions score was (150.89 ± 18.16),which was generally at the lower-middle level and was consistent with the results of Shi et al.[27].The total score of spiritual health was (88.82 ± 11.16), which was in the lower middle level as a whole and was consistent with the results of Hsiao[22].

The results of this study showed that 98.4% of clinical nurses considered spiritual care was necessary for patients, indicating that clinical nurses could recognize the importance and value of spiritual care for patients, but only 12.5% of nurses had spiritual care experience,which may be one of the important factors that caused the spiritual care competence of clinical nurses in this study to be in the moderate and lower level as a whole and their spiritual care perceptions ambiguous and inaccurate.The reasons may be as follows:Firstly, there are few curriculum related to spiritual care education and no special teaching resources,teachers and authoritative teaching materials in China, which directly leads to the low overall level of spiritual care competence of clinical nurses; What's more, spirituality is an abstract concept, and there is currently no uniform and clear definition.Due to the differences in region, nationality, history culture,individual characteristics, as well as the lack of systematic spiritual related knowledge learning and spiritual care clinical practice of clinical nurses, which caused differences in understanding of their essence and connotation.However, domestic spirituality related studies lack spiritual care education for clinical nurses, and there were no unified teaching content,independent curriculum, spiritual care plans,supervision standards, and inability to guarantee the continuity of spiritual care [28], which all limit the improvement of nurses'spiritual care competence.

The scores of spiritual care competence of clinical nurses in this study were lower than those of research on oncology nurses [29], reproductive center nurses[30], hospice nurses [31], elderly care institutions nurses [32] and nursing interns [33].The reason may be that the development of spiritual care in China started late, and is mainly focused on patients with advanced cancer [34], heart failure [35] and other chronic diseases, while little attention is paid to the spiritual health and spiritual needs of patients in other departments.Because of the particularity of department atmosphere and working environment,compared with nurses in general hospital, oncology nurses and hospice care nurses and tend to care for critically ill patients or patients with advanced disease,and elderly care nurses tend to care for elderly or empty nesters, who have more more spiritual sustenance and needs, so as to nurses have more opportunities to get in touch with spiritual care practice and experience the diversity of patients' religious beliefs and spiritual care needs in clinical practice,which may gradually promote a deeper understanding of spiritual care in the care process, leading to a qualitative change in their spiritual care competence.While nursing interns have more purposeful and sufficient time to communicate with patients in clinical practice,giving patients more time to think about their personal value and meeting their demands to the greatest extent.In addition,the scores of this study are also lower than those of Green et al.[36]and Ebrahimi et al.[37].

And among the scores of various dimensions, the"communication"dimension is the highest, which may be related to the nature of nursing profession.Nurses can actively listen and maintain moderate silence in clinical practice, so that patients can be allowed to express themselves as much as possible and have sufficient time to think about personal value and meet their spiritual needs to the greatest extent, so as to establish a good communication relationship and achieve resonance and empathy with patients; and the lowest was "personal support and patient counselling"dimension may be related to nurses'little knowledge of spiritual care,understanding of spiritual caregivers and high workload of daily care.And many objective factors limit the failure to provide patients with effective spiritual care support.In a nut shell, the reason for the low spiritual care competence of clinical nurses is that spiritual care is still in the early stage of exploration in China, and most nurses lack knowledge and training experience related to spiritual care,spiritual care perceptions and spiritual health, causing the spiritual care competence to be low.

Associations and mean differences in the spiritual care competence among clinical nurses across individual factor

The results revealed that the higher the level of education, nursing age, technical title, hospital grade,the stronger the nurses' spiritual care competence.Compared with the low level of education clinical nurses,the high level of education clinical nurses have the wider and deeper knowledge, the more comprehensive and perfect education, the richer spiritual knowledge, the more clinical practice topics,and the stronger sensitivity to the spiritual needs of the patients.In addition, nurses with high level of education and technical titles have higher demand levels and pay more attention to the cultivation and development of their own abilities [32].The hospitals have given them more opportunities to develop their abilities, such as further education and management training, which promoted the development and improvement of their own quality and comprehensive ability [25].With the increase of nursing age, the ability of psychological tolerance,humanistic care and hospice care will be enhanced [38], the life experience is richer,and the thinking and viewing of problems are more comprehensive and objective.They will have more resonance and empathy for the problems of spiritual distress expressed by patients, and they can also more sensitively perceive the spiritual needs of patients, help patients review the course of life,experience the meaning of life, and guide patients to think rationally about the value of life.At the same time, the empathy fatigue produced in the process of spiritual care has great tolerance.The spiritual care competence of nurses in third-class hospitals was significantly higher than that in first-class and second-class hospitals.Hospital grade is one of the main factors affecting the working ability of medical staff, and it is also an important index to measure the comprehensive strength of hospitals.Higher grade hospitals recruit nurses with higher requirements, and pay more attention to the training of nurses in the later period.At the same time, nurses in tertiary hospitals have higher overall level of educational and professional knowledge, better working environment,stronger work autonomy, more learning opportunities,more standardized and mature training and assessment,and richer resources for continuing education, which can quickly change into the concept of spiritual care thinking[29].

As a result, compared with general hospitals,nurses in specialized hospitals have higher spiritual care competence,which may be different from those in specialized hospitals, such as cancer hospitals and chest hospitals, whose patients are often seriously ill and change rapidly,and even there are a large number of critically ill and dying patients, leading to a significant increase in the spiritual care needs of most patients compared with ordinary people.Thus they have more access to get in touch with spiritual care practice,and experience the diversity of their religious beliefs and spiritual care needs in clinical practice,which may lead to a deeper understanding of spiritual care in the care process.With hospice care and spiritual care have been gradually accepted in China,and some specialized hospitals serving as pilot subjects,spiritual care is paid more attention.Therefore, there are more opportunities for spiritual training and learning than general hospitals, resulting in a qualitative change in their spiritual care competence.

Nurses who are clinical teacher score higher in spiritual care competence than non-teacher.There may be the following reasons:First of all, clinical teachers have rich clinical practice experience and more comprehensive thinking, so as to identify the spiritual distress and spiritual needs of patients, resonate and think about the spiritual problems expressed by patients in daily work; The second is that clinical teachers are direct providers of humanistic care,"teaching by word and example"to show spiritual care is an important way for nurses to carry out spiritual care education and training.As a clinical teacher,nurses pay more attention to spiritual care, which is similar to the results of Shang et al.[39]found that the humanistic care quality of clinical teachers is better than non-teachers.The level of clinical teachers will directly affect the training quality of nurses.Therefore,strengthening the spiritual care competence of clinical teachers is conducive to improving the level of spiritual care of nursing professionals.

There was a positive and significant correlation between spiritual care competence and spiritual care perceptions

This study showed that there is a positive correlation between nurses' spiritual care competence and their spiritual care perceptions,which means that the greater the nurse's spiritual care perceptions, the more frequently spiritual care is included in that nurses'practice and the stronger spiritual care competence,this correlation is vital and meaningful, which is consistent with Azarsa et al.[8]and Shi et al.[27].The study of Mthembu et al.[40] found that nurses'spiritual care perceptions can directly affect their judgment and treatment of providing spiritual care to patients.Nurses should first grasp the diversity,essence and connotation of spirituality, spiritual care and religious belief, then improve their own level of spiritual care perceptions, and learn to assess patients'spiritual health and understand spiritual needs, which is a prerequisite for good quality spiritual care.On the one hand，the reason may be that nurses with high of spiritual care perceptions tend to have strong ability of transposition thinking and compassion care, and can correctly understand the verbal and non-verbal behavior of patients in nursing practice, accurately perceive and understand their inner experience from the perspective of themselves and spirituality, identify spiritual distress and pain,and perceive their emotional changes such as anxiety, depression, fear and spiritual care needs, so as to promote nurses to better provide high-quality and comfortable spiritual care services to patients in clinical practice.On the other hand, Nurses with high spiritual care competence have high learning needs, actively participate in relevant training and learning, pay attention to clinical practice, consolidate their theoretical knowledge of spiritual care through spiritual care practice, strengthen their spiritual awareness,beliefs and values,enhance their sensitivity and skills, and constantly reflect on and summarize their experiences, emotions, actions and spiritual responses to improve their level of spiritual care perceptions.

There was a positive and significant correlation between spiritual care competence and spiritual health

The results of this study showed that spiritual care competence of nurses has a positive and meaningful relationship with their health towards spiritual, which is consistent with Markani et al.[41] and Zare et al.[42].Chen et al.[43] considered that spiritual health is an important predictor of spiritual care competence,and that high level of spiritual health is a prerequisite for providing high-quality spiritual care.Nurses must have the belief so that they can provide psychological care and spiritual care to patients, and be able to identify the obstacles and challenges in providing spiritual care and maintain adequate spiritual health to provide high-quality spiritual care.It may be reasons as following, on the one hand, nurses with high spiritual care competence tend to have strong communication skills and harmonious relationships with patients, and it is more inclined to think,understand and accept views, emotions and behaviors of patients from the perspective of spiritual care,which can improve their spiritual health imperceptibly in the process of spiritual care.On the other hand, nurses with high level of spiritual health can correctly understand their own shortcomings and the importance of spiritual care, listening and empathy, actively seek harmonious relationship with patients and avorable resources to deal with their own spiritual perceptions,emotion and living conditions, and desire systematic and scientific spiritual care training and learning to improve the efficiency and standardization of spiritual care, so as to achieve real spiritual health and self-harmony, which can improve their spiritual care competence from the root.

Spiritual health played a partial mediating role between spiritual care competence and spiritual care perceptions

According to the results of this study, spiritual health plays a part mediating role between spiritual care competence and spiritual care perceptions of clinical nurses, accounting for 27.5% (P< 0.01), indicating that hospitals and nursing managers can improve nurses' spiritual care competence not only by enhancing nurses' spiritual care perceptions, but also by cultivating their spiritual health.Nursing administrators should combine the characteristics of nurses and departments to create more opportunities for nurses to participate in specialized training on spiritual care.They can regularly invite senior nurses and experts of spiritual care to give lectures or discussions on spiritual care, give more appreciation and encouragement to junior nurses, fully authorize them to give full play to their subjective initiative,and actively guide nurses to consciously infiltrate spiritual care in nursing practice.And they should make nurses aware of the significance and importance of spiritual care, and take the initiative to improve their spiritual care perceptions and spiritual health, and create a supportive environment of love, tolerance, listening,companionship and empathy, so as to promote the improvement of spiritual care in departments.

The spiritual care education system of clinical nurses urgently needs to be improved and perfected

This study showed that only 12.5% of nurses had spiritual care experience, and the higher the spiritual care competence of nurses who had previous spiritual care experience in the past.80.1% of nurses did not attend spiritual care training, lectures or courses, and 96.8% of nurses need to be offered spiritual care training, lectures or courses, indicating that the spiritual care education of clinical nurses in China is deficient and the demand for them is high, which is similar to the results of Cooper et al.[44] on nursing students.Spiritual care education, as a systematic teaching and supervision guarantee for nurses to provide spiritual care for patients, can improve the ability of individuals to cope with difficulties [45],enable nurses to update their knowledge of spiritual care, enhance the sensitivity of spiritual response, and understand the spiritual care elements in holistic care,thus promoting a positive spiritual transformation of patients to meet their spiritual needs [46].Caldeira et al.[47]suggested that spiritual care should be included in nursing education and nursing practice, and they also believed that spiritual care competence should be included in the evaluation of developing nursing profession and nursing service standards.Numerous studies [40,48] have shown that the level of nurses'spiritual care perceptions can directly affect their judgment and handling of spiritual care.Through spiritual care training, which can not only improve nurses' spiritual care perceptions and spiritual health level of spiritual care [49,50], but also can improve nurses'insight into spiritual care to a certain extent,for providing high-quality spiritual care services in future clinical practice [51].Therefore, it is urgent to attach importance and carry out nurses' spiritual care education, improve nurses' spiritual care competence,which can promote the harmony and unity of patients'"physical-psychological-social-spiritual"aspect.

At present, the spiritual care education of nurses in China is still in its infancy and has not been paid attention to.The teaching curriculum, contents,methods, objectives and evaluation methods of spiritual care are not clear, lacking independence and positivism.And spiritual care education system and mechanism are not yet perfect, lacking strong theoretical and practical support.Furthermore,spiritual care education is mainly carried out based on medical colleges and resources distribution is unbalanced,resulting in the lack of spiritual care education resources in some affiliated hospitals.Due to the differences in religious beliefs, traditional culture and values between the East and the West, and the characteristic spiritual care service mode suitable for China's national conditions has not been developed.In a nut shell, the reasons above jointly restrict the improvement of nurses'spiritual care competence.

It is recommended that we should pay more attention to nurses' spiritual care education in the future, perfect the spiritual care education system,formulate a comprehensive, multi-level and scientific assessment standard,evaluation and training system of spiritual care competence, and equip with appropriate and optimized teaching resources.And nursing managers should pay special attention to training of methods, skills and emotion, insist on explicit integration, and integrate the invisible module of professional emotional education into the whole process of explicit module of spiritual care education,such as spiritual communication.In clinical teaching,we must be good at using problem-oriented and nurse-oriented teaching models, such as PBL teaching,experiential teaching, case teaching, role-playing,narrative education and film-television teaching, pay attention to the combination of spiritual care theory and clinical practice, actively guide nurses to consciously infiltrate spiritual care in clinical nursing work, let nurses feel and experience the significance and value of spiritual care in practice, reflect on their own shortcomings, and evaluate the teaching effect of spiritual education with scientific and objective indicators.What's more, actively build a"school-hospital" cooperation platform to maximize the use of resources.On the one hand,regular spiritual care lectures and symposia are held and invite senior nurses with rich spiritual care experience to preach.On the other hand, we should make full use of the school teaching resources to carry out spiritual care continuing education and training for clinical nurses to improve their theoretical knowledge of spiritual care.And drawing on the experience of advanced spiritual care education foreign countries and Taiwan, and combining the cultural characteristics of Confucianism,Taoism, Buddhism, such as the "goodness","benevolence", "kindness" and "love" in China,integrating traditional Chinese philosophy, religion,traditional Chinese medicine and Tai Chi into spiritual care education and training,and developing assessment

tools for the spiritual needs of patients and nurses'spiritual care competence suitable for Chinese cultural background.In this way, a scientific nurses' spiritual care competence training goal centered on the spiritual needs of patients is formulated, and then a set of spiritual care service mode with Chinese characteristics with strong applicability, economy,science, feasibility and convenience for clinical operation is formed to improve spiritual care competence of nurses.

Strengths and limitations

There were some limitations in this study.Firstly, the study was conducted using a convenience sampling method, which might affect the generalisability of the findings.Additionally, the research instruments are all Chinese versions, due to the complexity and individuality of the concept of "spirituality and spiritual care", there may be some deviations in the research results.Thirdly, the data was only collected from 17 hospitals in Tianjin, China.Therefore, the generalisability of the findings might be affected and may not represent the total spiritual care competence level of clinical nurses across all secular and religious groups, especially rural regions in China.Further research using more rigorous design, that is suggested to include more clinical nurses from different regions in the future and to examine factors influencing spiritual care competence of clinical nurses in China.

Conclusions

To sum up, the findings of this study showed 1454 nurses in this study were all in the middle and lower level of spiritual care competence, spiritual care perceptions and spiritual health, which need to be improved.And eleven factors, such as education background and nursing age, are the main influencing factors of nurses' spiritual care competence.Also, a significant and positive correlation was found among spiritual care competence, spiritual care perceptions and spiritual health,and spiritual health plays a partial mediating role between nurses' spiritual care competence and spiritual care perceptions.It is suggested to strengthen immediately the spiritual care education of clinical nurses, improve the spiritual care perceptions and spiritual health.Through perfecting the spiritual care education system, then spiritual care competence of clinical nurses can be improved in multiple ways and at multiple levels,so as to grasp the spiritual care needs of patients, identify spiritual distress and spiritual pain in future nursing practice,provide holistic care and achieve human health.