Hao-Mei Zhao,Zhang-Yi Wang,Wei Yan,Jing-Jing Piao,Jian-Ya Ye,Shu-Zhen Di

1 School of Nursing,HeBei University of Traditional Chinese Medicine,Shijiazhuang,050000,China.

2 Graduate School,Tianjin University of Traditional Chinese Medicine,Tianjin,301617,China.

Abstract Objective: To investigate the status quo of spiritual care perceptions and associated factors among nursing students in China, and explore the relationships among spiritual care perceptions, spiritual health and empathy ability, in order to provide reference for the construction of spiritual care education intervention program to improve the spiritual care perceptions and competence of nursing students in China. Methods: A cross‐sectional and correlational design was undertaken and a convenience sample of 3615 nursing students selected from 11 universities and colleges in Hebei Shijiazhuang and Tianjin, China from January to July 2021. Participants provided data on sociodemographic by completing the sociodemographic characteristics questionnaire, the Chinese Version of the Spiritual Care‐Giving Scale (C‐SCGS), Spiritual Health Scale Short Form (SHS‐SF) and Jefferson Scale of Physician Empathy‐Nursing Student (JSPE‐NS). Results: The scores of spiritual care perceptions and spiritual health were 172.44 ± 26.23 and 97.54 ± 12.37, respectively,both in the middle level. The score of empathy ability was 102.92 ± 19.65, lower than the average. Spiritual care perceptions of nursing students were positively correlated with spiritual health (r = 0.635, P ＜0.01) and empathy ability (r = 0.547, P ＜0.01).Conclusions:The level of spiritual care perceptions of nursing students in China needs to be improved. It is suggested that nurse managers and educators should pay attention to the spiritual care education of nursing students, by perfecting the spiritual care education system to improve their spiritual health level and empathy ability in multiple ways and levels, like clarifying and standardizing educational objectives, breaking through the traditional single evaluation system, and formulating scientific comprehensive evaluation standards and systems., so as to improve their spiritual care perceptions and competence level.

Keywords: Nursing students, Spiritual care perceptions, Spiritual health, Empathy ability,China

Introduction

The word spirituality is derived from the Latin "spirius", which means"breathe" and "make alive" and can be understood as being alive [1].Although many studies have focused on spirituality, there is no specific definition of spirituality. Many scholars define spirituality as the general characteristics of human beings [2, 3]. Spirituality is the embodiment of the individual's ability to surpass oneself in the process of life and feel the meaning as well as value of life through surpassing oneself. Spiritual care is the assessment of the patient’s concerns,distress, and spiritual needs during the nursing process. Spiritual care needs nurses to respect patient’s faith or religion, maintain patient’s dignity, listen to the patient’s heartfelt and provide health care,through listening, accompanying, and caring, according to individual's characteristics. During spiritual care, nurses can achieve resonance and empathy with patients, help patients explore the value of life and find the meaning of life, and help patients build a healthy body,psychology, and spirituality [4,5].

At present, the treatment and rehabilitation of most diseases are long‐term processes. Patients not only have to face the torture of the disease, but also bear the pressure of family and society, which can easily lead to "holistic suffering" on the physical, psychological, social,and spiritual levels, so as to arise a need for spiritual care[6‐8].As the core element of "body‐mind‐society‐spirituality", "holistic" care and palliative care, spiritual care help patients explore the value and meaning of life, promote their physical, mental, and spiritual health,and improve their quality of life. Studies have shown that nurses are considered to be the main implementers of spiritual care for patients.The ability of nurses to provide spiritual care for patients is closely related to the nurses’ spiritual perceptions and spiritual health [4,9‐11]. However,many studies at abroad showed that the spiritual care perceptions of nursing students were at a lower level [1, 12‐14].Nursing students, as the reserve force and new force in the nursing industry, should improve their spiritual care perceptions, so that it is of great significance to better apply spiritual care in clinical patients[13, 15].

To achieve the the best spiritual care, spiritual care education is required to enable nurses and nursing students to have a good understanding of the essence and connotation for spiritual care [16,17]. Only when nurses and nursing students have a deep understanding for spiritual care knowledge, and make full use of existing resources to better apply spiritual care to clinical practice, so as to meet the spiritual care needs of patients to the greatest extent,improve the care service quality and satisfaction [17‐19]. However,nursing students' spiritual care perceptions and competence often do not meet the patients' spiritual care needs [19, 20]. Studies have shown that there was a strong relationship between the spiritual care perceptions and spiritual health among nurses and nursing students[11, 21]. However, the understanding for the essence and connotation of spiritual care perceptions, and the practical application ability are inadequate. Besides, studies have shown that empathy ability of nurses is related to spiritual health [22], which is manifested in physical and mental health (depression, anxiety, suicidal tendency,etc.) and health promotion behaviors. Furthermore, the individual’s physical and mental health will improve their empathy ability. The higher the nurses' spiritual health, the more sensitive to patients'spiritual needs, emotion, the better empathy ability [23, 24].Understanding the views and value of nursing students on spiritual care, as well as the challenges and opportunities of incorporating it into clinical practice, has important practical significance for the reform and development of spiritual care education content and shaping the next generation of professional spiritual care workers[25]. Therefore, improving the spiritual care perceptions of nursing students and exploring their spiritual health is not only the top priority of clinical nursing but also the top priority of the current nursing education reform and development.

However,former studies are limited to separate studies on nurses'or nursing students' spiritual care perceptions, spiritual health and empathy ability, and there are few reports on the correlations among them. Therefore, the purpose of this study is to investigate the status quo of spiritual care perceptions and associated factors, explore its relationship with spiritual health and empathy ability, and develop intervention measures to improve the spiritual care perceptions and competence level, so as to provide a theoretical basis for promoting the development of spiritual care education in China.

Objective

The objectives of this study are (1) to investigate the status quo of spiritual care perceptions and associated factors among nursing students in China; and (2) to examine the relationships among spiritual care perceptions, spiritual health and empathy ability among nursing students.

Methods

Study design and setting

A cross‐sectional, correlational 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 nursing students from 11 universities and colleges in Hebei Shijiazhuang and Tianjin, China,from January to July 2021.Respondents met the following criteria: (a)Full‐time nursing students in school; (b) Complete cognitive and behavioral abilities; (c) Informed consent and voluntary participation in the study. Exclusion criteria: (a) Postgraduate nursing students; (b)Suspended or demoted nursing students; (c) Not at school during investigation period.

Figure 1 The flow chart of included participants

Table 1 Sociodemographic characteristics and the scores of C-SCGS based on sociodemographic differences among nursing students(n = 3615)

According to Kendall's [26] sample estimation method, 5‐10 times of the variable number were taken as the sample size in this study.A total of 26 variables need to be analyzed. Considering 20% invalid questionnaire, so the sample size is 156‐312, and 3615 nursing students were included in this study to meet the requirements.

Data collection

Data were collected at 11 universities and colleges in Hebei Shijiazhuang and Tianjin, China, from January to July 2021. The investigation was conducted with the prior approval of the universities and colleges administrator. 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 the nursing students were asked face‐to‐face to fill in the questionnaires. Finally, 3679 questionnaires were distributed and 64 questionnaires with regular answers or obviously contradictory answers were eliminated. In total, 3615 valid questionnaires were selected for analysis. The effective recovery rate was 98.3%. The flow chart of included participants was presented in Figure 1.

Instruments

Sociodemographic characteristics questionnaire was designed by the researchers after referring to the relevant literature, including 14 items, such as gender, age, ethnicity, education background and religious belief, as shown in Table 1.

C‐SCGS with good reliability and validity was used to assess the spiritual care perceptions of nursing students [27, 28]. It consists of four dimensions and 34 items, including "attributes for spiritual care","defining spirituality and spiritual care", "spiritual perspectives", and"spirituality and spiritual care values". Cronbach's α of dimensions were 0.836‐0.941. In this study, its Cronbach's α was 0.984. Likert 6 rating method was used, with the 1‐6 score means "strongly disagree","disagree", "disagree less", "agree more", "agree" and "strongly agree".The total score of C‐SCGS was 34‐206.The higher the score,the higher the spiritual care perceptions of nursing students.

SHS‐SF with good reliability and validity was used to assess the spiritual health of nursing students [29]. The Cronbach's α was 0.930.In this study, its Cronbach's α was 0.937. There were 5 dimensions and 24 items in SHS‐SF, including "connection to others", "meaning derived from living", "transcendence", "religious attachment" and"self‐understanding". Using Likert 5 rating method, 1‐7 score indicates"strongly disagree" to "strongly agree". The higher score demonstrates better spiritual health.

JSPE‐NS was used to assess participants' empathy ability [30]. Its Cronbach's α was 0.836. It consists of 20 items in 3 dimensions:"viewpoint selection", "emotion care" and "transposition thinking". In this study, its Cronbach's α was 0.912. Likert 7 rating method was used, with 1‐7 score indicating "strongly disagree" to "strongly agree".The higher score indicates that the nursing student has the higher empathy ability.

Figure 2 showed the conceptual framework for the relationships among spiritual care perceptions,spiritual health and empathy ability.

Data analysis

Descriptive statistics (numbers, percentage distribution) were used to describe nursing students' sociodemographic characteristics. Mean ±Standard deviation (x±s), or median as well as interquartile spacing(M (Q, R)) were used to describe the measurement data in accordance with normal distribution or non‐normal distribution, respectively.IndependentTtest, one‐way ANOVA, or non‐parametric test were used to compare between two or more groups. Multiple linear regression analysis was used to identify the factors contributing to spiritual care perceptions. And Pearson productmoment correlation was used to explore the relationships among three scales with statistical significance set toP＜0.05 (two‐tailed).

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 the 11 selected universities and colleges, the participants were approached by the researchers.The purpose and significance of this study were explained to the nursing students 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

A total of 3615 nursing students were included in this study, including 372 males (10.3%) and 3243 females (89.7%), and 2285 (63.2%)were aged less than 20 years. And other sociodemographic characteristics were shown in Table 1.

Figure 2 The conceptual framework for the relationships among spiritual care perceptions,spiritual health and empathy ability

Table 2 The scores of C-SCGS, SHS-SF and JSPE-NS among nursing students (n=3615, M(SD))

The total score of spiritual care perceptions among nursing students was 172.44 ± 26.23. Of the four dimensions, the highest score was"spiritual perspectives" (5.17 ± 0.75), and the lowest was "defining spirituality and spiritual care" (4.94 ± 0.69). The total score of spiritual health was 97.54 ± 12.37, which was in the middle level.Among the 5 dimensions, the highest score was "meaning derived from living" (4.39 ± 0.61), while the lowest was "religious attachment" (2.83 ± 0.45). The total score of empathy ability was 102.92 ± 19.65, which was below the average level. Among the 3 dimensions, the highest score was "transposition thinking" (6.09 ±1.21), and the lowest was "emotion care" (4.78 ± 1.05). The scores of other dimensions were shown in Table 2.

The results of univariate analysis showed that there were significantly statistical differences in the scores of "spirituality care perceptions" among nursing students in ethnicity, education background, birth place, served as a class cadre, attended a student association, academic performance at present, go into nursing,attended spiritual care education training, lectures or courses, and needs for spiritual care education training, lectures or courses by schools, as shown in Table 1. A multivariate linear regression analysis was carried out with 9 statistically significant variables in the univariate analysis, spiritual health and empathy ability as independent variables and spiritual care perceptions as dependent variables. The results from Table 3 revealed that ethnicity, education background, birth place, needs for spiritual care education training,lectures or courses by schools, spiritual health and empathy ability were the main factors affecting the spiritual care perceptions of nursing students, which accounted for 48.5% total variation (R2 =0.493,adjustedR2= 0.485,P＜0.01).

The Table 4 showed the total score of spiritual care perceptions was positively correlated with spiritual health (r= 0.635,P＜0.01), and all dimensions were positively correlated (P＜0.01). And the total score of spiritual care perceptions was positively correlated with empathy ability (r= 0.547,P＜0.01), and all dimensions were positively correlated (P＜0.01),as shown in Table 5.

Discussion

In this study, the total score of spiritual care perceptions among nursing students was 172.44 ± 26.23, which was in the middle level according to Hu et al. [28]. Among the scores of each dimension,spiritual perspectives were the highest, and the defining of spiritualityand spiritual care was the lowest. The overall level was at a medium level which is similar to Cao[31],but it needs to be further improved.The reason for the analysis may be that spirituality and spiritual care is an abstract concept. There is no unified and clear definition at present. Due to differences in region, ethnicity, history, culture, and individual characteristic, coupled with the lack of systematic spiritual knowledge learning and spiritual care clinical practice, it is related to the differences in understanding of its essence and connotation among nursing students [32]. Previous studies have shown that nursing students hold different views on the composition of spirituality and spiritual care, and most of them adopt an existential understanding and believe that spirituality is inherent to all people, but they cannot recognize the essential connection between spirituality and ethics [18,29]. Also, the total score and the scores of all dimensions are higher than the research of Hu et al. [28]. This may be due to the increasing importance of school spiritual care education; nursing students can obtain more relevant spirituality and spiritual care knowledge than clinical nurses.However,it is lower than the research of Shi et al.[33]on oncology nurses, which may be related to the higher demand for the spiritual care of oncology patients and the nurses' experience in clinical spiritual care. In this study, the overall spiritual health of nursing students was at a medium level,which was consistent with the study of Hsiao et al. [29]. It may be related to the abstraction of spirituality, the differences in traditional religions and cultural beliefs,and the curriculum of nursing education. The vast majority of nursing students have no religious beliefs and spiritual sustenance, and a small number of religious believers are mostly ethnic minorities. The connection and difference between the both failed to clearly understand [34]. Besides, except for the research results of Yuan et al.[35], the score of the dimension in "connection to others" was lower,and the scores of the other four dimensions and the total score of spiritual health were slightly higher than their research results.It may be related to Chinese modern hospice care originated from the hospice research center established by Tianjin Medical College in 1988 [36],and there are some curses offered in some colleges and universities in Tianjin, such as spiritual care, palliative care, and other related courses [37]. Besides, the overall empathy ability of nursing students in this study was at a lower level, which was consistent with the results of Liu [38] and Ward et al. [39]. Compared with the survey results of undergraduate nursing students by Guo et al. [40], except for the "transposition thinking" dimension with higher scores, the scores of the other two dimensions and the total score are significantly lower. This may be related to the teaching environment, curriculum settings, training goals and paths, and the educational background of nursing students in various colleges and universities, which also verified the conclusions of Qiu et al. [30].

Table 3 A multiple linear regression of spiritual care perceptions among nursing students (n= 3615)

Table 4 The relationship between spiritual care perceptions and spiritual health among nursing students(n= 3615, r)

Table 5.The relationship between spiritual care perceptions and empathy ability among nursing students (n=3615,r)

This research showed that ethnicity, education background, birth place, needs for spiritual care education training, lectures or courses by schools, spiritual health and empathy ability were the main factors that affect the spiritual care perceptions among nursing students.Compared with minority nursing students, Han nursing students have a higher level of spiritual care perceptions, which was contrary to the results of Tiew et al. [27], the analysis may be due to the large difference between the sample size of Han and ethnic minorities in this study. The differences in national cultural connotations and the abstract and vague concepts of spirituality and spiritual care are related. Compared with undergraduates and junior college students,postgraduate nursing students had a higher level of spiritual care perceptions, which might be related to graduate nursing students’more mature spiritual thinking, a higher level of knowledge, richer social experience, and relevant clinical practice topics. They think related issues more rationally, objectively, and comprehensively.However, compared with college students, undergraduates had lower levels of spiritual care perceptions, similar to the results of Tiew et al.[27].It also could be due to the setting up hospice care, spiritual care,and other related courses, more attention to ethics teaching and clinical practice, and nursing students feeling the connotation of spirituality and spiritual care from practice [41]. The level of spiritual care perceptions among nursing students whose birth place of residence was in cities or towns was higher than that in rural areas,which might be related to the differences in educational resources,family atmosphere and concepts, religious beliefs, and ethical concepts between urban and rural areas. Also, in comparison, nursing students who need schools to provide spiritual care education training, lectures, or courses were higher than those who do not need,and had higher level of spiritual care perceptions. The reasons might be that nursing students who needed schools to provide spiritual care education training, lectures, or courses, were more eager for spirituality and spiritual care knowledge. They had a mentality to learn and improve themselves. This does not mean that they have a low knowledge level, but want to pass better, and need the platform and way to understand and learn related knowledge deeply, improve spiritual care perceptions level and spiritual care ability, so as to quickly and efficiently adapt to clinical practice in the future, and provide patients with high‐quality spiritual care.

This study showed that there was a positive correlation between spiritual care perceptions and spiritual health. The higher the spiritual health of nursing students, the higher spiritual care perceptions level,which was consistent with the results of Huber et al. [42]. Chen et al.[43] indicated that the prerequisite for nursing staff to provide patients with quality spiritual care is to have a high spiritual health level. Zou et al. [44] indicated that nursing students should firstly be able to understand and master the essence and connotation of spirituality and spiritual care, improve their spiritual care perceptions,and then maintain adequate spiritual health, which was the prerequisite for good spiritual care. The reason may be that nursing students with higher spiritual health level tend to have better nurse‐patient communication skills and more harmonious nurse‐patient relationship. They are more inclined to think about problems from the perspective of patients and are easier to understand and accept something from the perspective of spirituality and spiritual care. While the nursing students with high level of spiritual care perceptions can actively seek harmonious relationship and favorable resources with patients to cope with their own cognitive emotion and living conditions and realize real spiritual health and self‐harmony.

The results of the study showed that nursing students’ spiritual care perceptions was positively correlated with empathy ability. The higher the nurse’s empathy ability, the higher the spiritual care perceptions level. The reason for the analysis may be that nursing students with high empathy ability often have strong empathy,compassion and care, and can correctly understand the patient’s language and non‐verbal behavior in nursing practice, which in turn encourages nursing students to better provide patients with high‐quality spiritual care service in clinical practice [45]. Nursing students with high spiritual care perceptions level can express their true feelings during providing patients with spiritual care, and achieve inner resonance and empathy with patients.

This research showed that 90.8% nursing students have not participated in spiritual care education, and more than two‐thirds of nursing students needed spiritual care education and courses provided by school, indicating that the spiritual care education of nursing students in China is deficient and the demand for them is high, which was consistent with the results of Cooper et al. [46]. Many studies have shown that the spiritual care perceptions level of nursing students directly affected their judgment and approaches of providing spiritual care to patients [9, 19]. Other studies have shown that the establishment of spiritual care courses,not only improved the spiritual care perceptions level of nursing students, promoted the spiritual health and empathy ability, but also improved the insight of spiritual care in nursing students to a certain extent, so that nursing students provide high‐quality spiritual care service during clinical practice [1,47]. Therefore, it is urgent to pay attention to and carry out the spiritual care education for nursing students, and to improve the spiritual care perceptions level.

At present, the spiritual care education is still in its infancy in China. The system and mechanism are not yet complete, and there was no uniform standard for teaching content and curriculum [48].Many reasons have jointly restricted the improvement of the spiritual care perceptions among nursing students. Therefore, the spiritual care education system of nursing students urgently needs to be improved and perfected. It is recommended to establish and improve the spiritual care education system for nursing students in the future,clarify and standardize the educational goals, break through the traditional single evaluation system, formulate a comprehensive,multi‐level, and scientific comprehensive evaluation standard and evaluation system, and focus on the combination of spiritual care theory and clinical practice. With the help of practical activities, such as internships and voluntary services, more nursing students enter the hospitals and wards. In this process, the theoretical knowledge of spiritual care is fully applied to the clinical practice, and it can be used in patients. The weak connection with family members matches the actual spiritual needs of patients. In addition, the teaching mode is transitioned from the traditional experience‐based and narrative‐based teaching mode to the student‐centered and problem‐oriented teaching mode, such as PBL (Problem Based Learning) teaching mode.Furthermore, it is important to adhere to the integration of explicit and implicit, and integrate the invisible module of professional emotional education into the explicit module of spiritual care education. During the whole process; it is essential to actively build a"school‐institute" cooperation platform. On the one hand, it is necessary to regularly organize special lectures and seminars on spiritual care and invite teachers with rich clinical experience in spiritual care to give lectures. On the other hand, it is significant to make full use of school teaching resources to help clinical nurses conduct continuing education and training on spiritual care, so as to improve their spiritual care theoretical knowledge and achieve complementary advantages. And drawing on the advanced spiritual care education experience of 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 carry out spiritual care education for nursing students under the background of traditional cultural elements with Chinese characteristics. Through high‐quality spiritual care education,we can improve the spiritual health and empathy ability of nursing students in multiple ways, at multiple levels, and increase the positive experience of nursing students, thereby improving their spiritual and spiritual care awareness. Last but not least, developing assessment tools for the spiritual needs of patients and nursing students' spiritual care perceptions suitable for Chinese cultural background. In this way,a scientific nursing students' spiritual care perceptions training goal centered on the spiritual needs of patients is formulated, and then a set of spiritual care mode with Chinese characteristics with strong applicability, economy, science, feasibility and convenience for clinical operation is formed to improve spiritual care perceptions among nursing students, thus to maximize the spiritual care needs of patients.

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, due to the investigation for nursing students only in Hebei Shijiazhuang and Tianjin, China, the generalisability of the findings might be affected and may not represent the total spiritual care perceptions level of nursing students across all secular and religious groups, especially rural regions in China. It is suggested that further research using more rigorous design, instruments for Chinese cultural background, and include more nursing students from different regions and levels in China in the future.

Conclusions

In conclusion,spiritual care perceptions and spiritual health were both in the middle level, and empathy ability was lower than the average level among nursing students, and spiritual care perceptions was positively correlated with spiritual health and empathy ability,respectively. It is suggested that nurse managers and educators should attach importance to the spiritual care education of nursing students in the future, by perfecting the spiritual care education system to improve their spiritual health level and empathy ability in multiple ways and levels, so as to improve their spiritual care perceptions and competence. Thus, nursing students can grasp patients' spiritual care needs in further nursing practice, and use empathy skills to provide holistic care or palliative care, and achieve holistic health of patients.