Hrev_master Healthcare in Low-resource Settings 2024; volume 12:12340 Spiritual services needed by the elderly in nursing homes Iskim Luthfa,1,2 Ah. Yusuf,1 Rizki Fitryasari,1 Nopi Nur Khasanah,2 Indah Sri Wahyuningsih,1,2 Israfil1 1Faculty of Nursing, Universitas Airlangga, Surabaya; 2Faculty of Nursing, Universitas Islam Sultan Agung, Semarang, Indonesia Abstract Older adults are a group vulnerable to health problems, and cases continue to increase. One of the reasons is living in a nursing home. So far, efforts have been made to improve older adults’ care services for their Quality of Life (QoL). However, one thing that is forgotten is spiritual services for older adults. This research aims to find relevant aspects between care and spiritual services to improve the QoL for older adult people living in nursing homes. This was a cross-sectional study. The sample size was 131 older adult people living in nursing homes. Samples were taken through simple random sampling with the criteria of being able to commu- nicate and having a good cognitive function. Care services were measured using the Services Assessment Scale (SVAS) question- naire, spiritual services were measured using the Spiritual Assessment Scale (SAS) questionnaire, and QoL was measured using the World Health Organization Quality of Life Older (WHOQOL-OLD) questionnaire. Data analysis used the gamma test. Respondents in this study were mostly women (55.5%), aged 60-74 years (62.6%), who had an elementary school graduation education (56.5%). Most respondents received low care services (74.0%), low spiritual services (84.0%), and most of them had low QoL (82.4%). The results showed a significant correlation between care services and QoL (p=0.000 and r=0.623), and between spiritual services and QoL (p=0.000 and r=0.755). Older adults in nursing homes need spiritual services and care services to improve their QoL. Introduction The World Health Organization (WHO) stated that in 2020, the Southeast Asia region had an older adult population of 9.77%, or 24 million of the total population. Indonesia is currently facing a transition period from a young society to an older adult society, and will be for the next 20 to 30 years.1 In 2020, there were 80,000,000 people aged 60 years and over, representing 9.6% of the population. This percentage is predicted to increase to 20% by 2040.2 Significant changes in older adults present challenges and opportunities. The challenge is that they experience a degenerative process that decreases their physical, psychological, and social functioning. They become a vulnerable group to health problems, and reduce their Quality of Life (QoL). This condition will increase the demand for long-term healthcare provision.3 The opportunity is to provide comprehensive primary health care for older adults and access to long-term care. Nursing homes are an appropriate model of care for the older adults in need. Care services in nursing homes include daily care and health services. Care services in nursing homes are carried out intensively to meet physical, psychological, and social needs. The hope is to be able to support the health of older adults and improve their QoL. But in reality, older adults who live in nursing homes have a lower QoL than those who live at home with their families.4,5 Nursing homes in the city of Semarang, Indonesia, currently still provide care services focused on the medical aspect, namely administering medication to sick older adult people. Meanwhile, promotive, pre- ventive, and rehabilitative aspects have not been provided opti- mally. Care services are aimed at overcoming physical, psycho- logical, and social disease problems, such as physical health care, anticipating anxiety and stress, as well as communication between older adults. Meanwhile, spiritual services are not provided opti- mally. Nursing homes in the city of Semarang, Indonesia, answer the need for religious practices, such as places of worship and tools for healthy elderly people. However, for older adult people who are dependent, there are no facilities to practice worship, so their spiritual needs cannot be fulfilled. We know that humans Correspondence: Nopi Nur Khasanah, Faculty of Nursing, Universitas Islam Sultan Agung, Semarang, Indonesia. Tel. +6285640256378- E-mail: nopi.khasanah@unissula.ac.id Key words: geriatric care, nursing, Quality of Life, spiritual. Contributions: all the authors made a substantive intellectual contribu- tion. All the authors have read and approved the final version of the man- uscript and agreed to be held accountable for all aspects of the work. Conflict of interest: the authors declare no potential conflict of interest. Funding: none. Ethics approval and consent to participate: this study was approved by The Health Research Ethics Committee at the Nursing Faculty, Sultan Agung Islamic University (Unissula) Semarang, Indonesia, with the number 772/A.1-S1/FIK-SA/X/2021. Informed consents were obtained from all the subjects after they were given an explanation about the study. Acknowledgments: the researchers would like to thank the Nursing Homes of Central Java, Indonesia, for permitting this study and the par- ticipants who participated in it. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Received: 1 February 2024. Accepted: 12 April 2024. Early access: 7 May 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12:12340 doi:10.4081/hls.2024.12340 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2024;12:12340] [page 339] Non -co mmerc ial us e o nly have holistic needs, including physical, psychological, social, and spiritual. Spiritual needs are the highest aspect in older adults.6 The spiritual aspect has a function as a source of strength for older adults when facing illness and affects health care.7 Spiritual services are very important for older adults living in nursing homes. The spiritual services provided include personal beliefs, spiritual satisfaction, and religious practices.8 Spiritual ser- vices can improve spiritual well-being, which includes personal, communal, environmental, and transcendental. In the end, spiritual services will be able to improve the QoL for older adults in nursing homes.9 So far, the spiritual needs of older adults living in nursing homes have not been widely considered as an issue that must be addressed. Sometimes, nurses forget that the spiritual aspect is a lifelong necessity. Even when older adults are dying, spiritual sup- port is something that can help them die peacefully.10 Therefore, it is crucial to comprehend the spiritual and care services offered and their correlation with the QoL of older adults in nursing homes. Materials and Methods Ethical considerations This study was approved by the health research ethics commit- tee at the Nursing Faculty, Sultan Agung Islamic University (Unissula) Semarang, Indonesia, with the number 772/A.1- S1/FIK-SA/X/2021. Informed consents were obtained from all the subjects after they were given an explanation about the study. Study design, setting and period Between January and March 2022, a cross-sectional study design was conducted in Semarang City, Indonesia. Sample size and sampling technique The research population was 200 older adult people living in nursing homes in Semarang City, Indonesia. The samples in the study were taken using the Slovin formula with a margin of error of 5%, 131 samples were obtained, taken randomly using a simple random sampling technique. The sample inclusion criteria includ- ed older adults people aged 60 years and over, living in nursing homes in Semarang City, Indonesia, able to communicate and hav- ing good cognitive function based on the results of examinations using the Short Portable Mental Status Questionnaire (SPMSQ) instrument. The SPMSQ instrument is standard; the validity test results show that all question items obtained a calculated r value greater than the r table based on a significant test of 0.05 (0.421- 0.755), and the reliability test results obtained a Cronbach alpha value of 0.88. The SPMSQ measurement results are categorized as intact intellectual function with a score of 0-2, mild intellectual damage with a score of 3-4, moderate intellectual damage with a score of 5-7 and severe intellectual damage with a score of 8-10. The exclusion criteria are that older adults have severe intellectual impairment. Data collection tool and procedure Data collection was carried out after the older adults were given an explanation of the purpose of the research and agreed to informed consent. The questionnaire was directly given to the older adults to read and fill out. While filling out the questionnaire, the researcher accompanied the older adults to ensure they did not experience any problems. Completing the questionnaire takes approximately 30 minutes. After the questionnaire was filled in, the researcher confirmed its completeness. Instruments The instrument used to measure care services is the Services Assessment Scale (SVAS) questionnaire. This questionnaire was developed by the researchers themselves and has been tested for validity and reliability. The validity test results show that all ques- tion items obtained a calculated r value greater than the r table based on a significant test of 0.05 (0.410-0.989), and the reliability test results obtained a Cronbach alpha value of 0.986. The SVAS questionnaire consists of 12 question items on a Likert scale with five rating options from never to always (1-5). The resulting cate- gories are low maintenance services with a score of 12-27, medium with a score of 28-43, and high with a score of 44-60. The instrument for measuring spirituality is the Spiritual Assessment Scale (SAS) questionnaire.8 The SAS instrument is standard and valid, with the results of all question items obtaining a calculated r value greater than the r table based on a significant test of 0.05 (0.30-0.70) and the reliability test results obtained a Cronbach alpha value of 0.92. SAS consists of 21 Likert scale question items with five answer options. The resulting category was low spiritual, with a score of 21-48, medium 49-76, and high 77-105. The instrument used to measure QoL is the World Health Organization Quality of Life Older (WHOQOL-OLD) question- naire. This instrument is standard and valid, with the results of all question items obtaining a calculated r value greater than the r table based on a significant test of 0.05 (0.97), and the results of the reliability test obtained a Cronbach alpha value of 0.75. WHO- QOL-OLD consists of 24 questions divided into six facets. The raw score lies between the lowest and highest possible values (ranging from 4 to 20). The total score (QoL score) lies from 24 to 120. The higher the score, the higher the QoL is. Data analysis Univariate analysis used descriptive analysis to determine the description of spiritual services, care services, and QoL for older adults. Bivariate analysis used the Gamma test to determine the relationship between the independent variable and the dependent variable, as well as show the close relationship between the two. If the sig value is >0.05 then there is a relationship between the inde- pendent and dependent variables. The correlation coefficient ranges from no relationship (0.00), less significant relationship (0.01-0.09), weak relationship (0.10-029), moderate relationship (0.30-0.49), strong relationship (0.50-0.69), very strong relation- ship (0.70-0.89) and the relationship is close to perfect (>0.90). Results Demographic characteristics of respondents Most of the respondents in this study were women, 72 respon- dents (55.5%), most were aged 60-74 years, 82 respondents (62.6%), most had elementary school graduation education, 74 respondents (56.5%). Most received low care services, 97 respon- dents (74.0%), most received low spiritual services, 110 respon- dents (84.0%), and most had low QoL, 108 respondents (82.4%). The relationship of care and spiritual services to Quality of Life The results of the Gamma test obtained a p-value of 0.000 and an r-value of 0.623, meaning that there is a relationship between care services and QoL in older adults living in nursing homes with Article [page 340] [Healthcare in Low-resource Settings 2024;12:12340] Non -co mmerc ial us e o nly a strong level of relationship strength. The results of the Gamma test obtained a p-value of 0.000 and an r-value of 0.755, meaning that there is a relationship between spiritual services and QoL in older adults living in nursing homes with a very strong level of relationship strength. Discussion The relationship of care services with Quality of Life Table 1 shows that the majority of respondents, 97 respondents (74%), received care services at nursing homes in the low category. Nursing homes are currently an alternative choice of residence for older adults, especially those who do not get care at home. Various health and nursing services provided will help make it easier for older adults to live their daily lives and enjoy their old age.11 The results of the Gamma test in Table 2 show that there is a relationship between care services and QoL with the strength level of the strong relationship. The better the care services, the higher the quality of life of the older adults. The results of this study are in line with research that has been conducted.12 They stated that there is a relationship between care services and the QoL of older adults in nursing homes. Care services at the Nursing Home are tailored to the health problems experienced by each older adult. These services are dif- ferentiated into short-term and long-term. Short-term services are intended for older adults who need shelter and temporary care, such as rehabilitative services and palliative care. Long-term ser- vices are provided to older adults who are unable to carry out self- care, such as those with dementia.13 The quality of services provided in nursing homes is very important to pay attention to, in order to ensure that older adults feel comfortable and get good care.13 Things to note are: first, the availability of caregivers who provide care every day. The compar- ison of the number of caregivers and older adults deserves special attention, especially for the older adult groups who experience total dependence. Caregivers will experience severe fatigue due to having to provide daily care to many older adults.14,15 Second, there are health workers who provide regular care. Nursing homes need to provide staff to monitor activities and serve the older adults 24 hours a day. Medical personnel, such as nurses or doctors, need to make regular visits to check the health of older adults.16 The older adults expect staff in nursing homes to care about their needs, understand what they need, be accompanied, and listen to all their problems.16 Third, a safe environment for older adults. Physical environ- mental facilities in nursing homes need to be designed to be safe and comfortable to prevent the risk of falling injuries to older adults.17,18 In addition to physical environment settings, older adults need mental and social services to adapt.19 Mental services aim to reduce serious mental illness problems that occur in older adults, including schizophrenia, bipolar disorder, major depressive disorder, obsessive-compulsive disorder, and others.20 Social guid- ance services aim to increase interaction, socialization, and moti- vation together to reduce loneliness.21 Based on the policy in Indonesian older adult nursing homes, the implementation of health services in nursing homes aims to strengthen physical, mental, and social services in order to create comfort and welfare, so the QoL of the older adults has to increase. The relationship of spiritual service to Quality of Life Table 1 shows that the majority of respondents received spiri- tual services at nursing homes in the low category, 110 respondents (84%). Over time, older adults who live in nursing homes for longer periods of time will be attracted to religious and spiritual programs.22 Conversely, Choi et al. believe that declining body functions, inability to carry out activities independently, and expe- riencing severe dependence will cause the spiritual health of older adults to gradually decline.23 Living in a nursing home causes older adults to lose social contact with relatives and friends; social sta- Article Table 1. Profile of the patients (n=131). Variable N % Sex Male 59 45.0 Female 72 55.0 Age 60-74 82 62.6 75-90 47 35.9 >90 2 1.5 Education Elementary school 74 56,5 Junior high school 42 32.1 Senior high school 15 11.4 Care services Low 97 74.0 Medium 25 19.1 High 9 6.9 Spiritual services Low 110 84.0 Medium 16 12.2 High 5 3.8 Quality of Life Low 108 82.4 Medium 14 10.7 High 9 6.9 Table 2. The relationship of care and spiritual services with Quality of Life (n=131). Variable Low Medium High rp n (%) n (%) n (%) Care services Low 84 (64.1) 7 (5.34) 1 (0.8) 0.623 0.000 Medium 18 (13.7) 7 (5.34) 4 (3.1) High 5 (3.8) 0 (0) 5 (3.8) Spiritual services Low 79 (60.3) 4 (3.1) 2 (1.5) 0.755 0.000 Medium 26 (19.8) 10 (7.6) 5 (3.8) High 2 (1.5) 0 (0) 3 (2.3) [Healthcare in Low-resource Settings 2024;12:12340] [page 341] Non -co mmerc ial us e o nly tus, self-esteem, and confidence in themselves will be reduced.24 This condition causes the older adults to experience helpless- ness, thus preventing the older adults from finding spiritual mean- ing from the experience of illness, reduced belief in religious val- ues, and feeling that they have no purpose in life.6 Spirituality is a basic need for every human being. A frequent problem with the ful- fillment of spiritual needs is spiritual distress. The spiritual aspect influences the fulfillment of life’s needs, such as social, mental, and other aspects of life.9 The Gamma test results in Table 2 show that there is a relation- ship between spiritual services and QoL which has a very strong relationship strength. The better the spiritual service, the higher the QoL for older adults. The results of this research are in line with research conducted by Lima et al., (2020) that spirituality has a correlation with QoL. Spirituality is the highest need in older adults and will increase with age.25 Spirituality is the most important source of strength in older adults in facing the challenges of illness,26 as a coping strat- egy to increase the meaning of life and death, and exerts a signifi- cant influence on health care.27 Spirituality is considered an impor- tant source of adaptation in the face of stressful life events.28 Spirituality is the highest power and gives older adults confidence in what is to come. Spiritual will motivate older adults to be enthu- siastic about maintaining their health by maintaining a healthy lifestyle.29 The spiritual aspect can be increased through spiritual experiences and spiritual activities that older adults carry out daily. Spiritual activities can increase spirituality in older adults by believing in God. Mature spiritual development will help older adults face reality, play an active role in life, and seek the meaning of life, the purpose of life, and the highest transcendence (divinity).30 Older adults with low spiritual levels will show poor purpose in life, a sense of worthlessness, a feeling of being unloved, and fear of death. On the contrary, older adults with a good spiritual level are not afraid of death and are better able to accept life.28 If the spiritual needs of older adults are well met, then the QoL will also improve. Fulfillment of spiritual needs through activities that can get closer to the creator, namely by worshiping, praying, and reading scriptures. In addition, spiritual needs are also met by establishing good relationships with fellow humans and the environment, and finding the meaning of peace in life. The envi- ronment and nursing services have a relationship with QoL.9 Families and health workers in nursing homes should ensure that the spiritual needs of the older adults can be met, so as to improve their QoL.31 Spiritual understanding helps older adults achieve their poten- tial and improve their QoL. The spiritual health of older adults is said to be good if it has fulfilled several spiritual characteristics, namely: the relationship with oneself, namely who he is, what he does, and attitudes that involve belief in oneself; a harmonious relationship with nature; a harmonious relationship with others; and a relationship with God, which includes praying and partici- pating in worship activities.8 Conclusions The conclusion of this study is that care services and spiritual services have a relationship with improving the QoL in older adults in nursing homes in Central Java Province, Indonesia. The treat- ment services provided include physical services, mental services, and social services. The spiritual services provided aim to increase confidence in oneself and maintain harmonious relationships with others and nature, as well as relationships with God. 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