What was the research design? 2. Was the sampling method an

Citation: Košanski, T.; Neuberg, M.

Proficiency and Practices of Nursing

Professionals in Meeting Patients’

Spiritual Needs within Palliative Care

Services: A Nationwide,

Cross-Sectional Study. Healthcare 2024,

12, 725. https://doi.org/10.3390/

healthcare12070725

Academic Editor: Silvio Cavuto

Received: 12 February 2024

Revised: 20 March 2024

Accepted: 25 March 2024

Published: 26 March 2024

Copyright: © 2024 by the authors.

Licensee MDPI, Basel, Switzerland.

This article is an open access article

distributed under the terms and

conditions of the Creative Commons

Attribution (CC BY) license (https://

creativecommons.org/licenses/by/

4.0/).

healthcare

Article

Proficiency and Practices of Nursing Professionals in Meeting Patients’ Spiritual Needs within Palliative Care Services: A Nationwide, Cross-Sectional Study Tina Košanski 1,2,* and Marijana Neuberg 1,2

1 Faculty of Health Sciences, University of Novo mesto, 8000 Novo Mesto, Slovenia; [email protected] 2 Department of Nursing, University North, 42000 Varaždin, Croatia * Correspondence: [email protected]

Abstract: Spirituality and spiritual needs are integral parts of the human experience, but they are often particularly important for palliative care patients. Spirituality has numerous positive effects, especially for those dealing with serious illness. Nevertheless, the spiritual dimension is sometimes overlooked in patient care. This study aims to determine the frequency of addressing the spiritual needs of palliative care patients in Croatia and to investigate the self-perceived confidence of caregivers in this task. A quantitative cross-sectional study was conducted involving 194 nurses in specialised palliative care services across Croatia. A specially developed and validated questionnaire was used for this study. The most common intervention undertaken by respondents was “promoting hope and optimism in patients” (88.4%), while the least common intervention was “reading books and other publications to patients” (13.9%). No statistically significant differences were found in the frequency of spiritual care in relation to the respondent’s level of education, professional experience and nursing environment. Approximately two-thirds of the surveyed nurses stated that they “often” or “always” provided some kind of spiritual care to palliative care patients. However, study participants who indicated that they had received sufficient formal instruction in addressing spiritual needs and spiritual care interventions demonstrated a statistically significant tendency to engage in these practices, as well as greater confidence in their knowledge and skills in this area compared to those who lacked such training. The study suggests that there is a need to identify existing barriers to the provision of spiritual care and to develop strategies to overcome them. By placing emphasis on the spiritual needs and preferences of patients, nursing professionals and other healthcare providers have the opportunity to elevate the standard of holistic care and foster a sense of comfort and dignity among patients.

Keywords: spirituality; spiritual needs; palliative care; nurses

1. Introduction

Due to the ageing of the population and the associated increase in chronic, i.e., non- communicable diseases, the need for palliative care continues to grow, drawing attention to the importance of this area of biomedicine and healthcare. Studies indicate that 69–82% of people in high-income countries require palliative care [1]. Currently, the annual number of people needing palliative care is estimated at 56.8 million [2], with projections suggesting a 25.0% to 42.4% relative increase by 2040 (primarily driven by the ageing population) [3]. These statistics emphasise the importance of investing in the further development of pallia- tive care, improving its quality and determining its current status in individual countries.

Palliative care is established in Croatia and is implemented on three levels:

• At the first level, referred to as the “palliative approach”, palliative methods and procedures are integrated into settings that are not primarily focused on palliative care. Healthcare professionals at this level have basic knowledge of palliative care.

Healthcare 2024, 12, 725. https://doi.org/10.3390/healthcare12070725 https://www.mdpi.com/journal/healthcare

Healthcare 2024, 12, 725 2 of 14

• The second level includes “general palliative care”, which is provided by healthcare professionals who frequently deal with patients requiring palliative care, even if this is not their primary area of responsibility, such as in oncology and neurology departments.

The third level comprises “specialised palliative care”, which deals with the complex needs of palliative care patients and entails advanced training, dedicated staff, and other resources. Specialised palliative care requires a collaborative interdisciplinary approach and a multiprofessional team [4,5]. In addition, all members of the specialised palliative care teams should have additional training in palliative care [6].

The forms of specialised palliative care in Croatia include various services, such as palliative care coordination centres, mobile palliative care teams, palliative care facilities (hospices), palliative care units, palliative care beds, palliative day hospitals, palliative care clinics, palliative care hospital teams, equipment rentals, volunteers, and civil society organisations [6].

All three levels of palliative care are available in the Croatian healthcare system, namely in primary healthcare (e.g., mobile palliative care teams, GP practices, community nursing services, home care, social welfare centres, and inpatient clinics in health centres), secondary healthcare (e.g., general and county hospital), and tertiary healthcare (e.g., clinics, clinical hospitals, and clinical hospital centres) [7].

An important concern identified both in the literature and in practice is that the care provided to palliative care patients is incomplete as it ignores their diverse and numerous needs and often does not take into account all dimensions of the individual [8–10]. More specifically, despite palliative care’s focus on providing holistic support—including physical, emotional, and social aspects—the spiritual dimension is frequently overlooked.

Spiritual needs in palliative care can be defined as an individual’s sense of peace, purpose, connection to others, and beliefs about the meaning of life [11,12]. The challenges related to spiritual well-being, saying goodbye to loved ones, maintaining hope and other end-of-life concerns are often poorly understood and not sufficiently integrated into patients’ overall care plans [11]. As a result, spiritual care and support (which is not necessarily synonymous with religion) are often labelled as the most overlooked dimension of patient care [12].

This study aims to determine the frequency of interventions performed by nurses in Croatia (such as active listening, engaging in discussions, compassionate presence, promoting spiritual reflection and reading, to name a few) in order to address the spiritual needs of palliative care patients and their self-perceived confidence in this task.

2. Materials and Methods 2.1. Research Design and Methodology of Data Collection

To collect the research data, a quantitative cross-sectional survey was conducted in Croatia from January to June 2023. The research was carried out as part of work towards a doctoral thesis to obtain relevant knowledge about the implementation of the holistic approach in palliative care, and the presented results are an integral part of the dissertation.

2.2. Measuring Instrument

A questionnaire was created for this study based on the relevant academic and profes- sional literature [13–18].

The questionnaire consisted of several parts: In the first part, socio-demographic data were collected (gender, age, years of profes-

sional experience in healthcare, years of professional experience in palliative care, level of education, and work setting).

The second part of the questionnaire collected data on the frequency of addressing patients’ spiritual needs, specifically the frequency of undertaking selected interventions. Participants were asked to indicate the frequency of performing each intervention on a 5-point Likert scale, where 1—never; 2—rarely; 3—sometimes; 4—often; 5—always.

Healthcare 2024, 12, 725 3 of 14

In the third part of the questionnaire, respondents were asked to self-assess their confidence in the stated interventions on a 5-point Likert scale: 1—poor; 2—fair; 3—good; 4—very good; 5—excellent.

The fourth section of the questionnaire dealt with the importance of holistic care in the formal education of nurses. Participants were asked to indicate their level of agreement with the statements about the importance given to the spiritual dimension in nursing care during their education, i.e., whether they felt that patients’ spiritual needs were adequately addressed. Responses were rated on a 5-point Likert scale: 1—I strongly disagree; 2—I disagree; 3—I neither agree nor disagree; 4—I agree; 5—I strongly agree.

2.3. Sample

The sample is a random sample. As accurate records of nurses in specialised palliative care services were not available, the authors contacted all services with palliative care beds at the secondary and tertiary healthcare levels and healthcare centres in all counties in Croatia to determine the number of nurses in roles such as palliative care coordinators and members of mobile palliative care team, as well as those working in inpatient clinics with palliative care beds in health centres at the primary healthcare level. According to the available information, 313 nurses with different levels of education were working in specialised palliative care services throughout Croatia during the study period (personal communication, unpublished).

Our total sample included 194 nurses with different levels of education working in specialised palliative care services in Croatia (palliative care coordinators, members of mobile palliative care teams, nurses in inpatient clinics at health centres, nurses in palliative care facilities, and nurses in palliative care units). In Croatia, only nurses in specialised palliative care services exclusively care for patients needing palliative care, while nurses at other levels also care for other patients.

The criteria for inclusion in the study were as follows:

• Participants were general care nurses holding a bachelor’s, master’s, or doctorate degree in nursing.

• At the time of the survey, participants were working in specialised palliative care services in roles such as palliative care coordinators, members of mobile palliative care teams, nursing staff in inpatient clinics in health centres with palliative care beds, nurs- ing staff in palliative care units, or nursing staff in palliative care facilities (hospices).

• Only palliative care coordinators who were also working in mobile palliative care teams (as stand-ins or because the team was understaffed) at the time of the survey were eligible for participation.

A total of 286 questionnaires were distributed in the workplace of nursing profession- als, of which 194 correctly completed questionnaires (67.8%) and 1 incorrectly completed questionnaire were returned.

2.4. Ethical Considerations

General ethical approval for the research was obtained from the University of Novo mesto (FZV-282/2021). The ethics committees of all primary, secondary, and tertiary healthcare institutions in Croatia that provide specialised palliative care were sent research application forms. Of the total of 40 institutions that provide specialised palliative care (28 institutions at the primary, 11 institutions at the secondary, and 1 institution at the tertiary level of healthcare), consent was obtained from 33 institutions (23 institutions at the primary level of healthcare, 9 institutions at the secondary level of healthcare, and 1 institution at the tertiary level of healthcare). Before completing the survey, participants were informed about the purpose of the study, the use of the data, the assurance of anonymity, risk-free participation, and the possibility of voluntary withdrawal, which they confirmed by signing the consent form.

Healthcare 2024, 12, 725 4 of 14

2.5. Statistical Analysis of the Data

The data obtained from the questionnaire were presented descriptively and in tab- ular form. The descriptions and tables were created using Microsoft Office Word, while IBM SPSS Statistics Version 29.0.1 was used for the statistical analysis. Numerical data were tested for normal distribution using the Smirnov–Kolmogorov test, and appropriate parametric statistical tests were applied depending on the results.

Quantitative data were presented as means, standard deviations, and 95% confidence intervals, while categorical data were presented as absolute frequencies and proportions or 95% confidence intervals.

The correlation between the work setting and the frequency of interventions by nurses/technicians in specialised palliative care services was analysed using the one-way ANOVA. Pearson’s correlation coefficient (r) was used to analyse the relationship between frequency of interventions, confidence level, years of experience, level of education, and inclusion of holistic care in nursing education among nurses/technicians in specialised palliative care services.

A p-value of less than 0.05 was considered statistically significant (two-tailed).

3. Results 3.1. Socio-Demographic Categorical and Quantitative Variables

Table 1 shows the descriptive statistics of the socio-demographic categorical variables for the entire sample (N = 194). The majority of the sample analysed are women (177, or 91.20%). Most of the respondents, 96 of them (49.5%), have completed training for general care nurses. Regarding the organisation of working hours, 12 h tours were the most common (94 or 48.5% of respondents), followed by early shift work (85 or 29.90% of respondents). For almost half of the respondents (92 or 47.40%), the functional model of healthcare organisation was the predominant model. In terms of the work setting, most respondents (109 or 56.20%) worked in a palliative care facility/unit, while 38 respondents (19.60%) were members of mobile palliative care teams. In terms of patient categorisation, 138 (71.10%) of the respondents most commonly cared for patients who fell into category IV.

Table 1. Descriptive statistics of socio-demographic categorical variables for the entire sample (N = 194).

N % 95% CI

Gender Male 17 8.80% 5.40% 13.40%

Female 177 91.20% 86.60% 94.60%

Level of education

General care nurse/technician 96 49.50% 42.50% 56.50% Undergraduate professional/university study in nursing 62 32.00% 25.70% 38.80%

Graduate professional/university study in nursing 33 17.00% 12.20% 22.80% Doctoral study programme 3 1.50% 0.40% 4.10%

Organisation of working hours

Early shift 58 29.90% 23.80% 36.60% Early and afternoon shifts 17 8.80% 5.40% 13.40%

Early, afternoon and night shifts 24 12.40% 8.30% 17.60% 12 h tours 94 48.50% 41.50% 55.50%

Shift work with on-call duty 1 0.50% 0.10% 2.40%

Organisational model Functional 92 47.40% 40.50% 54.40%

Team 61 31.40% 25.20% 38.20% Primary 41 21.10% 15.80% 27.30%

Work setting

Member of a mobile palliative care team 38 19.60% 14.50% 25.60% Palliative care coordinator 15 7.70% 4.60% 12.10%

Nurse/technician in an inpatient clinic at the health centre 23 11.90% 7.90% 17.00% Nurse/technician in a palliative care facility/unit 109 56.20% 49.20% 63.00%

Nurse/technician in a hospice 9 4.60% 2.30% 8.30%

Table 2 shows the descriptive statistics of the socio-demographic quantitative variables for the entire sample. The mean age (SD) of the respondents is 38.55 (12.08) years. The average professional experience in healthcare is 16.84 (11.79) years, while the average professional experience in palliative care is 5.24 (4.71) years.

Healthcare 2024, 12, 725 5 of 14

Table 2. Descriptive statistics of the socio-demographic quantitative variables for the entire sample (N = 194).

Arithmetic Mean

SD Min Max Centile

25 Median 75

Age 38.55 12.08 20.00 65.00 29.00 37.50 47.25 Years of experience in healthcare 16.84 11.79 1.00 45.00 7.00 15.00 25.00

Years of experience in palliative care 5.24 4.71 0.20 39.00 2.00 4.00 7.00

3.2. Internal Consistency Analysis for the Subscale “Frequency of Addressing Patients’ Spiritual Needs” and the Subscale “Confidence in Addressing Patients’ Spiritual Needs”

Table 3 shows the analysis of the internal consistency of spiritual care interventions. The Cronbach’s alpha coefficient for the indicated subscale is 0.777.

Table 3. Analysis of the internal consistency of spiritual care interventions.

Cronbach’s Alpha Coefficient Number of Items

0.777 7

Arithmetic mean SD I promote hope and optimism in patients. 4.49 0.707

I pray with patients if needed. 2.86 1.315 I make sure that patients have the opportunity to attend religious services. 3.56 1.213 I read books, newspapers, and other publications to patients when needed. 2.44 1.128

I involve a member of clergy in patient care. 3.48 1.26 I engage in discussions with patients about the meaning of life and their past

accomplishments. 3.85 0.964

I talk to patients about their imminent death if they feel the need to do so. 3.67 1.055

Corrected item correlation-total

score

Cronbach’s alpha coefficient if item

deleted I promote hope and optimism in patients. 0.384 0.772

I pray with patients if needed. 0.559 0.738 I make sure that patients have the opportunity to attend religious services. 0.57 0.735 I read books, newspapers, and other publications to patients when needed. 0.556 0.738

I involve a member of clergy in patient care. 0.595 0.729 I engage in discussions with patients about the meaning of life and their past

accomplishments. 0.404 0.767

I talk to patients about their imminent death if they feel the need to do so. 0.444 0.76

Table 4 shows an analysis of the internal consistency of the statements on the partici- pants’ confidence in the spiritual care interventions listed. The Cronbach’s alpha coefficient for the indicated subscale is 0.832. The indicated subscale demonstrates a high level of internal consistency, suggesting that the items within this subscale reliably measure participants’ confidence.

Table 4. Analysis of the internal consistency of the statements on confidence in spiritual care interventions.

Cronbach’s Alpha Coefficient Number of Items

0.832 7

Arithmetic mean SD Promoting hope and optimism in patients. 4.18 0.823

Praying with patients. 3.32 1.148 Making sure that patients have the opportunity to attend religious services. 3.46 1.097

Reading books, newspapers, and other publications to patients. 3.26 1.095 Involving a member of clergy in patient care. 3.68 1.116

Engaging in discussions with patients about the meaning of life and their past accomplishments. 3.94 0.894 Talking to patients about their impending death. 3.72 1

Healthcare 2024, 12, 725 6 of 14

Table 4. Cont.

Cronbach’s Alpha Coefficient Number of Items

Corrected item correlation—

total score

Cronbach’s alfa coefficient if item deleted

Promoting hope and optimism in patients. 0.487 0.823 Praying with patients. 0.657 0.796

Making sure that patients have the opportunity to attend religious services. 0.699 0.789 Reading books, newspapers and other publications to patients. 0.562 0.813

Involving a member of clergy in patient care. 0.569 0.811 Engaging in discussions with patients about the meaning of life and their past accomplishments. 0.577 0.811

Talking to patients about their impending death. 0.518 0.819

3.3. Descriptive Data on the Frequency of Spiritual Care Interventions

Table 5 shows the respondents’ answers regarding the frequency with which the stated interventions were carried out. In total, 60.80% of respondents reported “always” promoting hope and optimism in patients. Only 15.50% said they “always” prayed with patients, and only 30.90% “always” ensured that patients had the opportunity to attend religious services. Reading books or other publications to patients is the least frequently performed intervention—22.70% of respondents “never” did so, while as many as 32.00% “rarely” did so.

Table 5. Frequency of responses regarding the frequency of the indicated spiritual care interventions (N = 194).

Intervention N % 95% CI

I promote hope and optimism in patients.

Never 0 0.00% Rarely 1 0.50% 0.10% 2.40%

Sometimes 21 10.80% 7.00% 15.80% Very often 54 27.80% 21.90% 34.40%

Always 118 60.80% 53.80% 67.50%

I pray with patients if needed.

Never 37 19.10% 14.00% 25.00% Rarely 42 21.60% 16.30% 27.80%

Sometimes 57 29.40% 23.30% 36.10% Very often 28 14.40% 10.00% 19.90%

Always 30 15.50% 10.90% 21.00%

I make sure that patients have the opportunity to attend

religious services.

Never 8 4.10% 2.00% 7.60% Rarely 34 17.50% 12.70% 23.30%

Sometimes 54 27.80% 21.90% 34.40% Very often 38 19.60% 14.50% 25.60%

Always 60 30.90% 24.70% 37.70%

I read books, newspapers and other publications to patients when needed.

Never 44 22.70% 17.20% 28.90% Rarely 62 32.00% 25.70% 38.80%

Sometimes 61 31.40% 25.20% 38.20% Very often 13 6.70% 3.80% 10.90%

Always 14 7.20% 4.20% 11.50%

I involve a member of clergy in patient care.

Never 19 9.80% 6.20% 14.60% Rarely 23 11.90% 7.90% 17.00%

Sometimes 47 24.20% 18.60% 30.60% Very often 56 28.90% 22.80% 35.50%

Always 49 25.30% 19.50% 31.70%

Healthcare 2024, 12, 725 7 of 14

Table 5. Cont.

Intervention N % 95% CI

I engage in discussions with patients about the meaning of life and their

past accomplishments.

Never 3 1.50% 0.40% 4.10% Rarely 10 5.20% 2.70% 9.00%

Sometimes 59 30.40% 24.30% 37.10% Very often 64 33.00% 26.70% 39.80%

Always 58 29.90% 23.80% 36.60%

I talk to patients about their impending death if they feel the need

to do so.

Never 5 2.60% 1.00% 5.60% Rarely 16 8.20% 5.00% 12.70%

Sometimes 72 37.10% 30.50% 44.10% Very often 46 23.70% 18.10% 30.10%

Always 55 28.40% 22.40% 35.00%

3.4. Descriptive Data on Confidence Level in Spiritual Care Interventions

Table 6 shows the respondents’ self-reported level of confidence in the spiritual care in- terventions listed. In total, 41.20% of respondents indicated that their confidence in promoting hope and optimism in patients was “excellent”. In total, 34.00% stated that their confidence in praying with patients was “good”. The majority of respondents, 35.10%, considered their confidence in making sure that patients had the opportunity to attend religious services to be “good”. Similarly, the majority of respondents, 40.20%, rated their confidence in reading books and other publications as “good”. In total, 35.10% of respondents rated their confidence in talking to patients about their impending death as “very good”.

Table 6. Frequency of responses on the self-reported confidence level in the listed spiritual care interventions (N = 194).

Confidence Level in the Following Areas N % 95% CI

Promoting hope and optimism in patients

Poor 1 0.50% 0.10% 2.40% Fair 3 1.50% 0.40% 4.10%

Good 36 18.60% 13.60% 24.50% Very good 74 38.10% 31.50% 45.10% Excellent 80 41.20% 34.50% 48.30%

Praying with patients

Poor 17 8.80% 5.40% 13.40% Fair 23 11.90% 7.90% 17.00%

Good 66 34.00% 27.60% 40.90% Very good 56 28.90% 22.80% 35.50% Excellent 32 16.50% 11.80% 22.20%

Making sure that patients have the opportunity to attend religious services

Poor 11 5.70% 3.00% 9.60% Fair 21 10.80% 7.00% 15.80%

Good 68 35.10% 28.60% 41.90% Very good 56 28.90% 22.80% 35.50% Excellent 38 19.60% 14.50% 25.60%

Reading books, newspapers, and other publications to patients

Poor 14 7.20% 4.20% 11.50% Fair 26 13.40% 9.20% 18.70%

Good 78 40.20% 33.50% 47.20% Very good 47 24.20% 18.60% 30.60% Excellent 29 14.90% 10.50% 20.50%

Involving a member of clergy in patient care

Poor 8 4.10% 2.00% 7.60% Fair 24 12.40% 8.30% 17.60%

Good 41 21.10% 15.80% 27.30% Very good 70 36.10% 29.60% 43.00% Excellent 51 26.30% 20.50% 32.80%

Engaging in discussions with patients about the meaning of life and their past accomplishments

Poor 1 0.50% 0.10% 2.40% Fair 11 5.70% 3.00% 9.60%

Good 44 22.70% 17.20% 28.90% Very good 80 41.20% 34.50% 48.30% Excellent 58 29.90% 23.80% 36.60%

Healthcare 2024, 12, 725 8 of 14

Table 6. Cont.

Confidence Level in the Following Areas N % 95% CI

Talking to patients about their impending death

Poor 2 1.00% 0.20% 3.30% Fair 22 11.30% 7.50% 16.40%

Good 53 27.30% 21.40% 33.90% Very good 68 35.10% 28.60% 41.90% Excellent 49 25.30% 19.50% 31.70%

3.5. Correlation between Work Setting, Professional Experience, and Level of Education and the Frequency of Providing Spiritual Care and the Level of Confidence in Spiritual Care Interventions

The correlation between work setting and the frequency of spiritual care delivery and confidence in delivering these interventions among nurses/technicians in specialised pal- liative care services is shown in Tables 7 and 8. ANOVA showed no significant differences.

Table 7. Correlation between work setting and the frequency of spiritual care and the level of confidence in spiritual care interventions

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