Hrev_master Healthcare in Low-resource Settings 2024; volume 12:13013 Phenomenology study: the nurse perception of experience in providing spiritual nursing care in the cardiovascular unit Safri,1,2 Elly Nurachmah,1 Budhi Setianto,3 Jahja Umar,4 Sri Yona1 1Faculty of Nursing, Universitas Indonesia, Depok, West Jawa; 2Faculty of Nursing, Universitas Riau, Pekanbaru, Riau; 3Faculty of Medicine, Universitas Indonesia, Jakarta; 4Faculty of Psychology UIN Syarif Hidayatullah, Jakarta, Indonesia Abstract Nurses who provide nursing care are urgently required to assess the patient’s spiritual needs so a correct nursing interven- tion can be given to the patient. Unfortunately, up to present, few instruments are available to specifically focus on patient’s spiritu- al needs. The aim of this study was to identify the perception of experience of nurses in providing spiritual nursing care to patients in cardiovascular wards as a foundation to develop a specific spir- itual nursing care assessment tool. A sample of six nurses partici- pated in this qualitative study. Data collection was conducted through in-depth interviews to nurses used thematic analysis. There were five themes identified: i) spiritual care meaning for nurses; ii) nurse’s current belief in providing spiritual care; iii) barriers in conducting spiritual nursing care; iv) expected solution to eliminate the barriers; v) efforts to improve spiritual nursing care. This study suggest to have a spritual care assessment instru- ments in order to make it easier for nurses to establish a spiritual nursing diagnosis, so that existing nursing care interventions can be carried out on target according to the client’s priority problems. Introduction Patients with cardiovascular health problems assume that they are experiencing a crisis situation that significantly impacts their psycho-spiritual dimension. One of the crisis situations is caused by anxiety, especially towards death. Anxiety can increase the risk of complications because physiological anxiety leads to uninten- tional activities within the body, which are part of the self-defense process.1 In nursing, clients are individuals, families, or communi- ties who have health problems and require assistance to maintain, preserve, and enhance their health under optimal conditions.2 Awareness of understanding the spiritual needs of patients can improve the belief in nursing that the provision of care should be comprehensive or holistic, addressing not only the physical, psy- chological, social, and cultural needs but also the spiritual needs of clients. The spiritual dimension consists of two elements: belief and behavioral dimension, as it is through these two components that the nurse’s relationship with the client (horizontal) and the nurse’s relationship with the divine (vertical) can be felt. Without these elements, spiritual nursing care will not have a positive impact on improving the quality of services. This spiritual nursing care should be applied to all patients with various health problems, including those with cardiovascular disorders. For example, a per- son’s belief in the existence of God and demonstrates through acts of charity or worship is what becomes the patient’s spirit to heal, believing that the illness comes from God and making efforts for treatment to regain health.3 Research at Banda Aceh Hospital dalam Estetika and Jannah shows that spiritual nursing care is still less than optimal.4 Based on the results of this research, it was found that the implementa- tion of spiritual nursing care was 59.7% poor, of which 69.4% was not perfect, namely lifting a spiritual nursing diagnosis 69.4%. Satisfaction with the application of spiritual nursing care at the Sultan Agung Hospital in Semarang, it is known that there is an influence between the application of spiritual care on patient sat- Correspondence: Elly Nurachmah, Department of Medical Surgical, Faculty of Nursing, Universitas Indonesia, Depok, West Java, Indonesia. E-mail: elly08@yahoo.co.id Key word: assessment, cardiovascular, nursing, phenomenology study, spiritual. Contribution: Conceptualization: S,EN, BS; Data curation: S, JU, SY; Methodology: S,BS, JU; Supervision: EN, BS,SY; Validation: EN, BS, JU; Writing Original draft: S, EN, SY. All authors have read and agreed to the published version of the manuscript. Ethical approval: the ethical committee approval (protocol number) was obtained from Universitas Indonesia, No: KET-033/UN2.F12. D1.2.1/PPM.00.02/2023. Availability of data and material: the participants of this study did not give written consent for their data to be shared publicly, so due to the sen- sitive nature of the research supporting data is not available. Conflict of interest: the researchers declare that this research is free from conflicts of interest of individuals and organizations. The researchers would like to thank all those who have supported to carry out this research. Funding: this study received funding from Universitas Indonesia, Grant for International publication 2023 with contract number NKB- 064/UN2.RST/HKP.05.00/2023. Conference presentation: this work was presented at the 3rd International Nursing Scholar Congress 2023, Faculty of Nursing, Universitas Indonesia, Depok, Indonesia. Acknowledgement: we thank all participants for their participation in this study, especially the Universitas Indonesia, Universitas Riau and Arifin Achmad regional general hospital. Received: 4 September 2024. Accepted: 4 September 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; 12:13013 doi:10.4081/hls.2024.13013 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. [page 729] [Healthcare in Low-resource Settings 2024;12:13013] Non -co mmerc ial us e o nly isfaction with a p value of 0.000.5 From the results of a preliminary study of observations and in-depth interviews with 3 CVCU nurses at Arifin Achmad Regional Hospital in May 2021, it is known that spiritual assessment instruments and documentation of spiritual nursing care have not yet been obtained. Materials and Methods This study is a qualitative research using a phenomenological approach. Data collection was conducted through in-depth inter- views with six participants who met the inclusion criteria of being nurses in the cardiovascular care unit Arifin Achmad Hospital Pekanbaru. Prior to the interviews, all participants were given explanations and those who agreed to be respondents signed a con- sent form. Thematic analysis was used to analyze the themes. Results The characteristics of the 6 participants in the study were as fol- lows: the range of age is 32 to 42 years. In terms of educational back- ground, three participants have diploma in nursing and three partici- pants with a Bachelor’s degree in Nursing (S1) and Professional Nursing Certification. The work experience of participants in the car- diovascular care unit ranges from six to 18 years (Table 1). After the process of thematic analyses, the research findings, revealed five main themes supported by 13 categories (Figure 1). Theme 1: The meaning in spiritual nursing care Almost all nurses expressed their feelings to explain their understanding on the meaning in spiritual care in nursing. Their perceived that conducting religion obligation perfectly is the most important thing in muslim’s life. Therefore, it was founded that in this first theme, the nurses’ experience consists of four categories, namely providing facilities, patient response, frequently performed interventions, and involving families. Providing facilites Nurses are the frontliners to provide comprehensive care to patients. The experience of nurses in providing spiritual nursing care has been in line with the perceptions and knowledge of the nurses themselves. For nurses, spiritual care means allowing patients to do their religious custom based on the religious law as stated in the Quran or Sunnah. It includes what facility a person Article Table 1. Characteristics of the participants. Characteristics P1 P2 P3 P4 P5 P6 Age 32 yo 40 yo 38 yo 42 yo 42 yo 42 yo Education D3 Nurse S1 Nurse D3 Nurse S1 Nurse S1 Nurse D3 Nurse Gender Male Female Female Female Female Female Years of service 6 years 15 years 10 years 18 years 18 years 18 years Training ECG ECG ECG ECG ECG ECG BTCLS BTCLS BTCLS BTCLS BTCLS BTCLS basic cardiology basic cardiology basic cardiology basic cardiology basic cardiology basic cardiology Figure 1. Themes. [Healthcare in Low-resource Settings 2024;12:13013] [page 730] Non -co mmerc ial us e o nly needs to be provided, as expressed by the participants, among others: “... Section for providing prayer garments that assist us ...” (P2,P4) “...But for non-Muslims, I’ve also had an experience where they brought a pastor here, and we allowed them to pray like that....” (P1, P2, P3) “...Usually, we do this for patients who experience a decrease in consciousness.” (P3,P6) Response of patient In providing care to patients, nurses always attempt to fulfil the patient’ needs including spiritual need. The nurses involve in clar- ifying how to pray in certain patient’s condition, as for Moslem need to do five times a day. However, for certain patients who is unable to pray using a normal method, the nurses also need to assist patients to prepare for praying or guide them to pray. The nurse perceived that not all patients have an intention to pray while lying in the bed, but many of them response positively toward the nurse’s reminder on praying; as shown in their statements: “...sometimes we still teach them, but sometimes they don’t want to, well, that’s how it is, we can’t force them, right sir...” (P2) “...we are also happy when the response is positive....” (P2,P5) “....to perform ablution with the things around them....” (P1,P3) “....requesting this, requesting what’s it called, requesting tayammum....” (P1,P3) Frequently performed intervention In addition to the tradition of commencing praying during hos- pitalized, it was discovered from the interviews, that nurses usually were involved directly in supporting the patients and families espe- cially those during serious condition such as patient in pain or have trouble in breathing. The following statements have been raised. “...Most often, it’s for patients experiencing pain and shortness of breath, so we usually advise them to recite istighfar (seek for- giveness from God). Sometimes, we also provide deep breathing therapy, along with istighfar. Istighfar, istighfar...” (P1, P2, P3) The theme also comprises of involving the family as demon- strated as follow “....So, we facilitate by usually encouraging the family to recite Qur’an....” (P1,P2) “....We typically summon the family to offer comfort. If the patient is already asleep, then the family can go home....” (P1,P2) The intervention has been displayed as a routine intervention of nurses following the time to pray. The nurse will offer a thing related to the vertical communication with God that required by the patient or family. Theme 2: Current beliefs of nurses in providing spiritual nursing care This theme constructed through two categories, namely nurses’ ability of assesment and diagnosis, and nurses’ ability of intervention. Nurses’ ability of assesment and diagnosis Understanding the importance of providing spiritual nursing care emerged as a determining factor in delivering comprehensive care. Findings from the participants indicated that nurses have been implementing spiritual nursing care, but there is still a lack of knowledge and the use of appropriate instruments. They perceived that spiritual care is depended upon the belief of nurses on how to convey themselves to be closer to God as the highest authority for life. The findings of the interviews shown that they are still unable to internalized the meaning of religion to get the life meaning. They expressed this situation into two categories, as follows. Ability in assessing and establishing nursing diagnoses The category reflects the unability of nurses to explore deeply on what is the meaning of spirituality to patients which lead to unability to assess and diagnose the patient’s spirituality problem as stated in the following statements. “....the assessment of the spiritual aspect is somewhat lacking, actually....” (P1,P3,P5) “....if it comes to spirituality, there is a lack of understand- ing....” (P2, P4) “....lack of understanding in establishing a diagnosis for spiri- tuality....” (P1,P2) “....For the assessment, we first observe why the patient is feel- ing restless and listen to their concerns....” (P2) Ability to provide interventions The category emerged to represent that the only way to solve the spirituality problems of the patients is to call a spiritual expert, as can be observed through the following statements. “...Bringing in a spiritual counselor 1-2 times a week, especial- ly to guide in prayer before undergoing surgery...” (P2) “...Now, when dealing with emotionally distressed patients, we need to call them in and ask what’s bothering them and if there’s anything they need to address in their thoughts...” (P2,P5) “...if I were to say it generally, it’s because my colleagues rarely do things like asking for patient assessments, that’s why it’s not running perfectly... and also, we never document the assess- ments...” (P2,P6) “...and then, for the assessment, we never write it down...” (P3, P4) Theme 3: Barriers in providing spiritual nursing care Nurse sometimes becomes a leader for patients and patients’ families. They initiate and facilitate care according to the patients needs including spiritual needs. However, even they were succed- ed to identify the problems and planned some actions, but in the real situation, not every single action can be delivered based on the standardized procedure. Further, the nurses have a belief that everything happens for a reason include the obstacle of providing spiritual care to patients. Nurse’s belief to allow patients to pray was to facilitate the patients with the needs so the pray can be con- ducted as clean as possible and fulfil the requirements. The obsta- cles were perceived from patient, hospital, and nurse perspectives. These can be shown from the following statements. Barier from patient’s perspective This category is identified based on the following statements. “.... Maghrib prayer, the call to prayer for Isha, because he/she doesn’t know it since our room is closed. So, I told him/her, ‘Sir/Madam, this is the call to prayer for Asr.’ If he/she wants to pray, then we assist, but if he/she doesn’t, then we don’t assist....” (P2,P4) “....Usually, the patient is worried about the condition of their Article [page 731] [Healthcare in Low-resource Settings 2024;12:13013] Non -co mmerc ial us e o nly child and husband, especially when their child is still young. So, it becomes a burden or a topic of discussion for the patient to confide in the nurse....” (P2) “....Sometimes they don’t want us to change their diapers with us....”(P2,P4) “....Sometimes patients have different personalities, sir. There are those who calm down when we show them kindness, but there are also those whose emotions get carried away....”(P2,P3) Barier from hospital’s perspective The category was constructed through the following state- ments of the informen. “....There is no specific place for tayammum (ritual purifica- tion without water)....”(P1, P2) “....If a patient wants to listen to Murottal (recitation of the Quran) or recite the Quran, we call their family and ask them to bring a mobile phone and give it to the patient....”(P2,P5) “....If the patient wants to use a prayer gown (mukena), we don’t provide it. They have to request it from their family....”(P2,P3,P6) “....Visiting hours vary for each patient....”(P2,P6) Barier from nurse’s perspective The last category of the theme was synthesized based on the statements, which some of them was written here: “....The gender of nurses who work on each shift varies....” (P2,P6) “....And maybe this is also because not all nurses have the knowledge or understanding of the importance of religious prac- tices. Yes, one of them is the importance of spirituality for patients who are in a sick condition. On average, they have limited knowl- edge about it. They prioritize their work over the spiritual aspect.....”(P4) Theme 4: The expected solution in overcoming obstacles The fourth theme was built from two categories, includes solu- tion for the hospital and solution for nurses. In the hospitals, every nurse has a good intention to their patients. They always want to deliver the care in a good quality and timely. They attempt to always consider the patient’s preferences which sometime make them unable to fulfil the patient’s wish. This also happened when they tried to deliver the spiritual care optimally. They become aware of the situation where they are unable to facilitate patients to conduct praying. Therefore, in providing optimal spiritual nursing care, solutions and plans are needed, as expressed by the partici- pants’ expectations. Solution for the hospital The category was identified through these following state- ments: “....Facilities for performing ritual cleansing (tayammum), reminder speakers, Qur’an availability, dedicated rooms ....”(P1,P2) “....One of the obstacles to implementing spiritual care is the availability of clean facilities....”. (P3,P5) “.... One possible solution is to ensure the provision of neces- sary facilities. However, it may be challenging to provide clean facilities like lake water due to the time-consuming management planning. From my perspective, providing mukena (prayer gar- ment) specifically for women can be considered. The availability of lake water depends on factors like laundry facilities....” (P4) Solution for the nurse This category was developed after analysing the statements which lead to the perception of nurses to find a way out toward their problems, as follows. “....Suggesting patients who have trouble sleeping to read the Qur’an....”(P1,P2) “....Usually, when reminded, they are willing to, God will- ing....”(P3) “....For patients nearing the end of life, it is common for family members to be called in to provide guidance and support ....”(P3) “....Yes, occasionally we provide guidance when there are no family members available...” (P3,P5) “....Perhaps there should be efforts to provide knowledge and raise awareness among nurses regarding the spiritual needs of patients.....”(P4) Theme 5: The efforts need to be taken The last theme was identified according to the two categories focus on the effort to improve the spiritual care. Those are improv- ing nurse’s knowledge and maximize the facility to conduct reli- gion onligation for the patients. Improving nurse’s knowledge Praying is an important religion customary that every muslim needs to conduct five times in a day. The schedule of praying is fixed according position of the sun. However, the difficulty will be encountered by people who are hospitalized. In a certain situation physically and mentally may lead to the limitation to conduct praying. Moreover, if there is no communication with nurses on such situation, the patient will be unable to pay their religion obligation appropriately. Therefore, in addition to maintain a fluent communication with the patients, the nurses need to identify the effort to improve their communication to know deeper what the patient’s need in conducting their obliga- tion. Some efforts to improve spiritual nursing care can be made by nurses through various strategies. The results of the interview with the participants indicate that the hospital has made efforts to provide knowledge and under- standing of spirituality. However, there is still a limitation in terms of the spiritual values within the nurses themselves, like the expression below: “....Every Friday at the prayer room at the hospital he holds recitations ....”(P2,P6) “....Yes, we don’t even ask for a change, we change it if we get blood on it ....”(P3,P5,P6) Maximize fasilities The second category was encountered due to the limitation of patient to conduct praying. They have no facility to do it during lying on the bed. Therefore, nurses of hospital management need to offer more facilities to allow patients to pay for their religion obligation, as we may learn from the following statements. “....Yes, they sometimes ask like this, ‘Sister, is it prayer time already?’ Oh yes, it is, sir.’ That’s an example....” (P4,P5) “....And then, usually I offer, like, ‘Ma’am, it’s prayer time. Would you like to pray?’ We change it with something clean if the lake gets dirty, and we also change and clean the diaper. After cleaning, we provide a blanket until...for men, I have done it before....” (P4,P5) “....Sometimes I offer, and there have been cases where I saw Article [Healthcare in Low-resource Settings 2024;12:13013] [page 732] Non -co mmerc ial us e o nly patients performing tayammum.....”(P2,P3,P4) “....There are already prayer call reminders for Muslims....”(P2,P3,P4) Discussion The implementation of spiritual nursing care is influenced by the perceptions and knowledge of the nurses themselves. With their perceptions and knowledge, nurses can provide spiritual nurs- ing care and have their own experiences. In this study, the percep- tions of nurses’ experiences in providing spiritual nursing care include providing facilities for religious practices, responding to patients’ requests for facilitation in worship, involving families in the care process, and providing patient education regarding spiritu- al matters. In this study, nurses provide spiritual nursing care based solely on their own habits and spiritual values. As a result, there are several barriers in implementing it, such as nurses not establishing spiritual nursing diagnoses due to a lack of guidance in assessing spiritual care. There are six spiritual nursing diagnoses: spiritual distress, risk for spiritual distress, impaired religiosity, risk for impaired religiosity, readiness for enhanced religiosity, and readi- ness for enhanced spiritual well-being.6 The Indonesian Nursing Diagnosis Standards also include spiritual nursing diagnoses, such as spiritual distress, risk for spiritual distress, health promotion, and anxiety.7 Nurses have provided spiritual nursing interventions such as engaging patients in reciting prayers, reminding them of prayer times, facilitating ritual cleansing, and having spiritual counselors available in the hospital. However, these interventions have not been structured based on established diagnoses, and there is a lack of documentation for their implementation. As a result, the impact is that the evaluation of spiritual nursing care cannot be conducted effectively without proper documentation. In addition to the perceptions and understanding of nurses, the suboptimal provision of spiritual nursing care can also be influ- enced by the available facilities in the hospital. Facilities such as ablution areas (for performing wudu or tayammum), clean prayer mats, prayer garments (mukenah), copies of the Quran or other sacred texts, prayer time reminders, and others play a crucial role in supporting and facilitating spiritual practices for patients. The findings align with the research conducted by Tunny et al., which revealed that most nurses have a positive perception of spir- itual care.8 However, there are also identified barriers, including a lack of knowledge, inadequate skills and competencies, insuffi- cient training or education, limited time due to staffing shortages, and minimal support from hospital management. Despite the challenges mentioned earlier, it is true that nurses are aware of the importance of meeting the spiritual needs of patients. They make efforts to find solutions and overcome limita- tions to provide therapeutic spiritual nursing care. Their aim is to minimize patients’ spiritual suffering and assist them in finding meaning and purpose in their lives. One of the reasons why spiri- tual nursing care is not fulfilled is because it does not begin with an assessment of the patient’s spiritual needs. There is no research on developing spiritual assessment instruments for patients with cardiovascular disorders, especially in Indonesia. The results of a review of spiritual assessment instruments by Yodang and Nuridah regarding several spiritual assessment methods that can be used with palliative patients, namely the Faith Importance and Influence Community Addressing spiritual concern method, Faith Application Influence Talk Help, Spiritual Personal Integration Ritualized Implication Terminal, Explanation Treatment Healers Negotiate Intervention Collaborate (Spiritual), Hope Organized Personal Effect, and Ars Moriendi Model.9 From these results, Yodang and Nuridah said that the majority of spiritual assessment instruments were developed in countries with populations other than Islam, so these assessment instruments need to be adapted to the conditions of Indonesia, where the majority of the population is Muslim, so that these instruments can be applied especially in the area of palliative care.9 For this reason, spiritual assessments can also be prepared and developed for patients with cardiovascu- lar disorders. Conclusions The findings of this research provide an overview of nurses’ experiences in providing spiritual nursing care, which are identi- fied through five main themes: nurses’ perceptions, understanding, barriers, solutions, and efforts to enhance spiritual nursing care. One important aspect highlighted in this study is the lack of imple- mentation of nursing care as a systematic and scientific process used by nurses to meet the clients’ needs in achieving or maintain- ing optimal biological, psychological, social, and spiritual well- being. The nursing care as a systematic and scientific process begins with nursing assessment, identification of nursing diag- noses, planning of nursing interventions, implementation of nurs- ing actions, and evaluation of results. To ensure the effective implementation of spiritual nursing care, it is important to develop various instruments for each step of the nursing process, starting with the assessment of spiritual care. 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