1. Background
Spiritual care is a growing topic of interest in health care across the world (Cockell & McSherry 2012; Ronaldson et al. 2012), and the spiritual dimension is regarded as an important and ethical obligation in holistic care (Chung, Wong & Chan 2007). Spirituality as a universal human experience, which includes sense of connection to the higher power being, involves search for meaning, hope, and purpose in life and death (Wynne 2013). Spirituality is a prominent factor in achieving balance in life that maintains health and well-being (Potter & Perry 2008; Ruder 2013). 
According to the holistic paradigm, body, mind, and spirit are intertwined, so holistic health care mandates attention to the spirit as well as to other aspects (Aziz Dhamani, Paul & Kaye Olson 2011). Provision of spiritual care has been an integral feature of holistic nursing care (Chan et al. 2006; Ronaldson et al. 2012; Cooper et al. 2013). In other words, it is important for health care providers to include physical, psychological, sociocultural, and spiritual dimensions in their interventions (Abu-El-Noor 2012). The International Council of Nurses (ICN) recognizes the spiritual aspect of nursing care as a required duty of nursing discipline (Baldacchino 2008; Wu, Tseng & Liao 2016).
Although most nurses believe that spiritual care is an integral component of quality and holistic nursing care, they rarely address spiritual issues (Kaur, Sambasivan & Kumar 2015). Literature review suggests various reasons for this neglect such as lack of time, preparation and or education in this area as well as nurses’ feeling of incompetency to deliver spiritual care (Baldacchino 2008; Lind, Sendelbach & Steen 2011; Ruder 2013). Recent studies indicate that nurses’ perception of their own spirituality influences how to identify the clients’ spiritual needs, plan the care, and implement the proper intervention (Wu & Lin 2011; Chiang et al. 2016). 
Nurses should have spiritual self-awareness before observing and emphasizing patients’ spiritual needs. Moreover, researchers recognized that nurses’ individual spiritual perspectives, experience and education affect the delivery of their spiritual care and influence their abilities to practice it (Mitchell, Bennett & Manfrin Ledet 2006; Cooper et al, 2013). There are few studies on nurses’ attitudes towards spiritual care, and spiritual care practices in Iran. Therefore, more knowledge should be obtained about the attitudes regarding spiritual care, and its practice. This information is necessary, not only to evaluate the existing situation of spiritual care, but also to draw the attention of authorities in health care system toward this issue and for conducting broader studies. This study aimed to examine nurses’ attitudes towards spiritual care and spiritual care practices.

2. Materials and Methods
This is a descriptive cross-sectional study conducted in 2011. In this study, 166 nurses were recruited from hospitals affiliated to Iran University of Medical Sciences (IUMS) through stratified randomized sampling (proportion to size).
The relevant data were collected through a two-part questionnaire. The first part assessed demographic data. The second part included the Nursing Spiritual Care Perspective Scale (NSCPS) developed by Taylor et al. that has two parts. Part 1 measures spiritual care practices and contains 12 statements of spiritual interventions rated on a 4-point Likert-type scale. The scores for each answer are sum up and averaged for each item. The total score is between one and four. Part 2 consists of 13 phrases that assesses the attitude of the participants toward providing spiritual care. Participants should rank their responses to each item from 1 to 5 according to their agreement with the items. To calculate the total score that ranges from 1 to 5, the average score for each item is tabulated. 
Mean scores above 3 were considered favourable responses toward providing spiritual care to patients (Hubbell et al. 2006). In this study, the second part of NSCPS was modified (With permission to use only part of the tool or to modify the tool as needed) (Farahaninia 2006). The alpha coefficient value for attitudes about providing spiritual care was between 0.78 and 0.82 for spiritual practice. The obtained data were analyzed by descriptive statistics, including frequency, mean, and standard deviation using SPSS V. 16. 

3. Results
In this study, 166 questionnaires were completed. Demographic data of the participants are presented in Table 1. Findings revealed that the total Mean±SD score of nurses’ attitudes toward providing spiritual care was 3.67±0.51. Mean score of responses to 9 out of 11 items were above 3 indicating more positive attitudes toward providing spiritual care. The statements that scored the highest were “Spiritual care is a significant part of advanced nursing practice” (item 1) and “Only clergy people should not help patients with specific religious activities” (item 10). The statement that scored the lowest was “Atheists and agnostic are spiritually healthy” (Table 2).
The total Mean±SD of nurse’s intervention was 1.93±0.48. The most frequently practiced spiritual intervention were “offering to pray with a patient” (item 2) and “encouraging a patient to pray” (item 3). The least frequently practiced spiritual intervention was “referring my patient to a hospital chaplain” (item 8) and “referring my patient to his/her clergy or religious leader” (item 7) (Table 3).

4. Discussion
 Recent studies have emphasised that spiritual care can be helpful (Deal 2010; Cetinkaya, Azak & Altundag Dundar 2013). In spite of agreement of many nurses on the issue that spiritual care is a nursing duty, discrepancy between believing in spiritual care and its actual practice is prominent (Deal 2010; Vlasblom et al. 2011). 
Our finding indicated that the Mean±SD score of NSCPS (Part 2) was 3.67±0.51. Mean scores above 3 were considered favourable responses toward providing spiritual care. A number of studies obtained the same results. According to these studies, nurses believe that spiritual care is an important part of nursing practice (Hubbell et al. 2006; Farahaninia et al. 2006; Mazaheri et al. 2008; Deal 2010; Vlasblom et al. 2011). 

 

 

 

 

 

The total mean score of nurse’s intervention was 1.93 with standard deviation of 0.48. Stranhan concluded that more than half of the nurses did spiritual care rarely or never and nearly half of them were unable to offer spiritual care (Chan 2009). In Vance’s study, nurses perceived themselves as highly spiritual, but a quarter of the subjects provided adequate spiritual care for their patients. In this study, time restrictions and lack of education were reported as the most common barriers for nurses to provide spiritual care (Chan 2009). In Hubbell et al. study, although most of the participants’ had a positive attitude toward spiritual care, few reported spiritual care practices (Hubbell et al. 2006). Similar results were also obtained in Chen et al. study (Chan et al. 2006).
With respect to part one of NSCP tool, the most common reported interventions (3 of 12 items) were “I offered to pray with a patient”, “I encouraged a patient to pray”, “I prayed privately with a patient”, that showed nurses need to strengthen their abilities to provide spiritual care for their patients. The least common intervention reported by nurses was “I referred my patient to a hospital chaplain”. In Hubbell et al. study, the most common reported item of spiritual care practice items were “referring the patient to their religious leader”, “encouraging patients to pray”, and “talking with patients about spiritual topics”, in the descending order (Hubbell et al. 2006). Meanwhile according to Stranhan’s study, the most frequent interventions were “Praying privately for a patient” and “Referring a patient to clergy or religious leaders” (Chan et al. 2006). Praying with patients or encouraging them to pray is a common intervention in all studies in different religions and cultures. It is indicated that pray is emphasized in all religions but the type and form of pray is different according to the specific religion or culture. 
Referring to clergy or chaplain was reported in other studies, the results which was not consistent with the present study results. The discrepancy in results could be that in Iran hospitals, multidisciplinary team working in spirituality care is a new approach that includes clergy or religion experts as a member and most of health care team are not familiar with this team and its related tasks. Although this study did not examine the reasons for not doing spiritual care, probably one of the common reasons could be lack of its training throughout the educational course (Farahaninia et al. 2006; Hubbell et al. 2006; Van Leeuwen et al. 2008; Lind, Sendelbach & Steen 2011).
 Studies suggest that role preparation in nursing for spiritual care is poor (Hubbell et al. 2006; Van Leeuwen et al. 2008). Evidence implies that the nurse’s lack of knowledge regarding spiritual care results in failing to provide holistic care (Wong & Yau 2010; Wu, Tseng & Liao 2016). Increasing self-awareness in nurses is effective and nurses must initially perceive their own inner spirituality in order to offer spiritual care more efficiently (Chan 2009). Based on studies, internal spirituality and desire for spiritual care are interrelated, but there is less emphasis on spiritual nursing care (Cockell & Mcsherry 2012). 
Spiritual care education increases nurses’ awareness with respect to the importance of this aspect of care (Melhem et al. 2016). It is necessary to include the concept of spirituality, spiritual care, and its practice in the educational curriculum to draw more attention to spirituality and spiritual care (Cockell & Mcsherry 2012). Qualitative and quantitative approaches must be implemented in defining spirituality in nursing field and the best teaching strategies must be used for training spiritual merits and increasing students’ capability in facing with spiritual needs and offering spiritual care. Spiritual eligibility is achieved through individual and professional growth in nursing students (Mitchell, Bennett & Manfrin Ledet 2006). One potential limitation of this study was sample size (n=166), which is relatively low for descriptive studies.
Nurses’ attitude toward spiritual care is positive, but their spiritual care interventions were insufficient. Lack of training in spiritual care may be a barrier for the competence on spiritual care giving. In this regard, establishment of inter-professional training, workshop, and in-service education are suggested. In addition, appropriate approach for teaching spiritual merits and increasing nurses’ abilities for providing spiritual care seems to be necessary.

Ethical Considerations
Compliance with ethical guidelines
The research Ethics Committee of Iran University of Medical Sciences granted the permission to conduct the study. Before the study, the research objectives were described to the participants, and they were assured that the collected data would be kept confidential. Next, all participants gave their written informed consent before completion of the questionnaires.

Funding
This manuscript was a part of the research project of first & corresponding author (Grant No: 671) that was approved  by Iran University of Medical Sciences Research Deputy. 

Authors contributions
The authors contributions is as follows: Conceptualization: Marhamat Farahaninia and Mojgan Abasi; Methodology: Marhamat Farahaninia, Mojgan Abasi and Hamid Haghani; Investigation: Marhamat Farahaninia and Ezzat Jafar Jalal; Writing-original draft: Marhamat Farahaninia and Mojgan Abasi; Writing–review & editing: Marhamat Farahaninia and Naimeh Seyedfatemi; and Supervision: Marhamat Farahaninia.

Conflict of interest
The authors declare no conflict of interest.

Acknowledgements
The authors thank Fahimeh Rahimiha who helped to modify project, Dr Martha Highfield who allowed us to use her instrument and Special thanks to the nurses who participated in this study.




References