Spiritual Care for Increasing the Quality of Nursing Service in 21st Century: A Review

Holistic care in the nursing care consists of physical, psychological, socio-cultural, developmental and spiritual aspects. However, the spiritual has received less attention than the other four aspects. The aim of this study was to review paper related to spiritual care in nursing care practices. The method in this study is a review using the CINAHL database. CINAHL was used because the articles focus on nursing topics. The keywords used were "Spirituality" OR "Spiritual care" OR "Spiritual" AND "Nurse". The inclusion criteria for the article were English language and published from 2019-2021, for adult range between 18-44 years old. Exclusion criteria were article not in English language, not full paper article, not in Human and not psychometric study also master thesis. This study recorded 64 articles, screened according to the topic, then the final results recorded 19 articles. This article focuses on the use of spiritual care in patients, nurses and caregivers, as well as both of patients and caregivers. The results of the review showed that spiritual care was important for mental health, physical health, and well-being, quality of life, increasing expectations for patients, nurses or caregivers. The significance of the study was spiritual care should be addressed in nursing care practices and it must include in the nursing curriculum, because spiritual care has many benefits for patients and nurses.


Background
The nursing care process commits to use a holistic care comprehensively to all patient needs (1) .Holistic care consists of physical, psychological, socio-cultural, developmental (life experience) and spiritual aspects (2). Several studies have stated that the spiritual has received less attention compared to the other four aspects (3) (4). So the holistic care in nursing and nursing care has not been achieved and implemented optimally.
Spiritual care is still defined as religious activities such as praying or reading holy book(5) (6). According to NANDA International Nursing Diagnosis, spirituality is a valuable experiencing to get meaning in life through good connectedness with self, others, art, music, literature, and nature (6). In addition it is an important part of human life (7) (8). Meanwhile, spiritual care is an intervention to support spiritual application to patients or clients (9). Further, spiritual care is a code of ethics in nursing as well as nursing guideline (10).
The definitions of religion and spiritual are still being debated. Previous research states that patients are more likely to perceive spirituality as religious activity (11). So spiritual definitions and spiritual concepts are needed. Previous studies showed that there was a little evidence base related to spirituality in the nursing care (11) (12). Spiritual care is needed in nursing care practices such as NP (nurse practitioners) and SNs (specialty care nurses). In addition spiritual can make balance relationship between self, others and the environment (12). Spiritual care is needed by clients or patients to improve their quality of life as well as meaning of life. Spiritual is necessary for all ages and all circumstances of the client's condition (13) (14). Spiritual care is also needed to increase mental health, such as decreasing depression level, anxiety as well as stress (15) (16). Lack of spiritual care by health care providers is associated with poor quality of life and dissatisfaction in nursing care as well as low well-being (16) (17). Previous study showed that there were still many clients who reported that spiritual care was not provided by nurses (11).

Methods
This study was a review and conducted for quantitative research. This study following the guideline for Preferred Reporting Items for Systematic Review and Meta-Analyzes (PRISMA) (19) and using previous study for guiding the review (20). This study using CINAHL database for searching spiritual care original study. CINAHL is used because the articles focus on nursing topics. The keywords used were "Spirituality" OR "Spiritual care" OR "Spiritual" AND "Nurse". The inclusion criteria for the article were English language and published from 2019-2021, for adult range between 18-44 years old. Exclusion criteria were article not in English language, not full paper article, not in human and not in psychometric study also master thesis. The data extraction process showed in figure 1. In this review we got 64 articles through CINAHL database. Then, we removed duplicated articles, screening on tittle and abstract. The final records included 19 articles. These articles were focused on the function of spiritual care among patients, nurses, and care giver as well as both of patients and caregivers. Tables were used to assist overview the spiritual care study.

Patients
The review showed that 10 articles focused on the spiritual care among patients (table 1). The studies come from Iran (2 articles), USA (2 articles), Netherlands (1 article), Indonesia (1 article), ROC (1 article), Portugal (1 article), Thailand (1 article), and Australia (1 article). The majority of studies were conducted at hospital (7 articles). In addition the majority of articles focus on patients with cancer who conducted palliative care (5 articles) and using qualitative design (7 articles). The studies focus on the function of spiritual care for patients. Spiritual could increase spiritual well-being, quality of life, self-acceptance and meaning of life. Furthermore, spiritual could be used to increase mental health especially for decreasing depression. Spiritual also could increase maternal fetal attachment among pregnant woman. Spiritual care also related to health behavior. However, some studies still showed that nurse did not provide spiritual care for the patients.

Nurses and Care Giver
The review showed that 7 articles focuses on spiritual care that used by nurses and family caregiver ( Table 2). The studies come from Iran (1 article), Australia (1 article), Thailand (1 article), India (1 article), USA (1 article), and Brazil (1 article). The majority of study setting in this review in intensive care unit (ICU and PICU) (3 articles). The predominant of the design of the studies in this review used qualitative study (5 articles). The studies focused on the evaluation of spiritual care that was conducted by nurses or family care givers for caring the patients or the families. The result of the review showed that spiritual care was the source of the coping and resilience for patients, so nurses were expected to give the spiritual care among the patients or care givers. Furthermore spiritual care was needed for care giver to make decision for their family who undergoing treatment. In addition, spiritual also being a constructed of well-being.

Patients and care giver
The review showed that two articles focused on patients and caregivers. The setting of the studies were hospital and community setting. The studies come from Iran and Canada. The result of the studies were obtained from the patients or care giver's reports. The studies showed that spiritual care was needed in caring patients with cancer. Also spiritual care should be inserted into nursing curriculum or education.

Discussion
The aim of this study was to review the papers related to spiritual care, so it can be used as a guideline for nursing, nursing practice and achieve a holistic care. In this study, we included 19 papers. The results of the study showed that clients or patients who receive spiritual care could enhance quality of life as well as meaning of life. Further, the clients or patients can take lessons from their illnesses, and also more accepting of their life conditions (self-acceptance). The results of the review showed that spiritual care is needed in the nursing care for patients as well as for nurses and caregivers to improve the quality of nursing and achieve physical and mental health. In addition, spiritual care can also be used as coping when facing stressors. However, on the other hand, several studies still report that spiritual care was not provided and delivered by nurses.
The results of this review were in line with previous systematic review which mentioned that spiritual and spiritual care were needed for implementing holistic nursing care to achieve quality of life (37). The paper showed that spiritual care was related to the patient's spiritual well-being (18). One of the results of the papers also showed that well-being is developed by the spiritual domain (34). In addition spiritual influenced the quality of life (19), related to meaning of life (20) self-acceptance (26), and healthy behavior (38,27) (table 1, table 3). Based on these papers, it can be concluded that spiritual care is needed by patients, so it was needed to depict clear definition of spiritual care.
Spiritual care was also needed by patients with mental illness. The result of the review showed that spiritual care was needed to reduce the level of depression among patients diagnosed with depressive disorders (25). Spiritual care is necessary not only for physical health but also for patients with mental illness The review showed that spirituality is needed for nurses and caregivers who take care their families for increasing coping and resilience (table 2, table 3). Furthermore, spiritual care can be used by nurses or caregivers for developing their coping when dealing with patients, because spirituality can control their psychological when facing occupational stress (32,34). Spiritual care could also be used by caregivers to decide the treatment related to patients (31). The results of this review also in line with previous research which mentioned that the importance of spiritual care in the nursing care (39). So it can be concluded that spiritual care was not only needed by the patients but also it had a positive effect among nurse or caregiver to increase their hope.
The results of the review were also predominant by paper which mentioned that spiritual care was needed by patients with chronic and high mortality prevalence disease, such as cancer (18 ,40, 41,35, 42), HIV (43), and congenital heart disease (44). Spiritual care can also be used in patients with new types of diseases such as COVID-19 (45). Further, it very necessary for palliative care (46). Spiritual and spiritual care were the power to struggle and survive from the illness.
Based on the review, spiritual care in providing holistic nursing care was an important aspect, so spiritual care should be provided by nurses and included in the curriculum in nursing education (35). However, the results of the review mentioned that there were still many nurses who do not provide spiritual care (40,47). We assume that there are still many nurses who have not updated or they did not know the definition of spiritual as well spiritual care.
The studies in this review came from the European continent (Netherlands and Portugal), America (USA, Brazil and Canada), Australia, and it were dominated by Asia (Indonesia, Thailand, India, Iran, and China). Many studies was conducted in Iran. We still did not find the evidence why the spiritual studies came from Iran. However, the majority of Iran's population is Muslim (48). We assume that they conducted religious rituals and do not separate religious activities in their daily activities. Religious activity is a part of the spiritual (6). The results of the review also showed that Indonesia had one evidence related to spiritual care. We assume that Indonesia actually has many spiritual care studies however it was not in English language (49)).
This review used one data base (CINAHL database) which focus on nursing science. However, this review covered papers related to spiritual care from various countries in the world. In addition the papers also mentioned that the importance of spiritual care for mental health, physical health, well-being, quality of life, and also increasing expectations to recovery among patients, nurses or caregivers. Further research should be able to focus on the definition and concept of spiritual care in accordance with the culture of each country.

Conclusion
This review provides a new insight related to the importance of spiritual care in nursing care practices. Spiritual care could increase physical and mental health, well-being, meaning of life as well as quality of life among patients, nurses and care givers. Further, spiritual care could develop a new hope for terminal patients also being a coping for nurses and caregivers. Therefore, spiritual care is needed when conducting nursing care to gain the holistic care.