Spiritual Care Café on the Level of Spiritual Care Competence among Nurses of a Selected Tertiary Hospitals

Spiritual Care Café on the Level of Spiritual Care Competence among Nurses of a Selected Tertiary Hospitals

Neilan John R. Acaso and Daisy R. Palompon

Tallahassee Memorial Hospital, United States of America

DOI: https://doi.org/10.51244/IJRSI.2024.1109018

Received: 23 August 2024; Accepted: 05 September 2024; Published: 28 September 2024

INTRODUCTION

Several studies (DeKoninck, Hawkins, Fyke, Neal, & Currier, 2016; Tornoe, Danbolt, Kvigne, & Sorlie, 2015) recommended that a spiritual training or specific bedside intervention program need to be undertaken by hospitals and hospice care institutions to enhance the nurses competency and practice in providing spiritual care to their patients. These study findings were further exemplified in the experience of the researcher in the ward where it was observed that there was limited advocacy on the provision of spiritual care of nurses. Most common reason why spiritual care assistance is provided with reservation is due to the discomfort in the expression of such aspect or the cultural taboo misinterpreting it as a care provided for critically ill or near death conditions of the patients.

There is no documented information regarding the integration of spiritual care interventions in the Philippine setting considering that the country is oriented and focused in the religious aspect from which each dilemma a citizen calls out to the higher entity. As far as skills enhancement is concern, the researcher, having a background as a Training Officer in his designated institution, observed that spiritual care is not integrated in the training for nurses. Based on the premise cited above, the researcher took the initiative of exploring the possibility of developing a spiritual enhancement program for nurses to develop spiritual care competency but most of all capacitate and empower them to practice spiritual care to their patients. The researcher conceptualized a protocol in relation to the enhancement or stabilization of spiritual care competency of the registered nurses considering the concepts of spirituality and the roles of nurses in providing spiritual care to the patients.  From the literature reviewed and per interview from religious practitioners, the researcher developed the Spiritual Care Café (SCC) as the study intervention. The SCC was developed with consideration to the learning styles and approach appropriate for adults in the millennial learning environment.

METHODS

Study design

The research design that was used is the one group pretest-posttest quasi-experimental design. The design has only one experimental group who went through the Spiritual Care Café. This research design was utilized to test causal hypothesis wherein, like experimental design, the café was viewed as an “intervention” which was considered as the treatment and tested for how it achieved the objectives, as measured by a pre-specified set of indicators, however, it lacked random assignment. The dependent variable was the spiritual care competency of the nurses which was measured before and after the intervention based on the use of a standardized tool. The findings were further validated using the patients’ feedback mechanism particularly on the changes in the spiritual care dealings of the nurse to the patient before and after the Spiritual Care Café.

Sample/Participants

Selection of the sample size of the study was based on the established inclusion and exclusion criteria of the study. In the implementation of the study, selection of the research participants included the following: (a) those licensed nurses under the Professional Regulations Commission, (b) assigned in the clinical and special services that includes, but not limited to, (1) the medical ward, (2) the surgical ward, (3) hemodialysis unit, (4) intensive critical care unit and (5) private rooms with medical and surgical cases in the selected tertiary hospitals under the management of one corporation as the locale of the study, (c) must have been working as full-time staff nurse for at least one year and (d) nurses who have rated 3.9 and below. Nurses who are not licensed, with a result of the spiritual care competency of 4.0 and are not working in the locale of the study will be excluded from the study. Nurses who have a result of 4.0 and above that are working in the locale will be allowed to join the Spiritual Care Café to avoid stigmatization of those that have low scores.

In the absence of information on the effect size, it was suggested that for t-test as statistical method, d = 80% was described as having a large effect in the area of behavioral sciences. Thus, a sample of at least fifteen (15) nurses per group was determined using R software for comparison of means to be able to detect an effect size of 80% or larger with 80% certainty and no more than a 5% chance of erroneously concluding that a difference exists when, in fact, it didn’t.

Instrument

The research tool was a questionnaire adapted from van Leeuwen et al. (2009) “Spiritual Care Competence Scale”. It has twenty-seven (27) items with six (6) dimensions as: (1) Assessment and implementation of spiritual care (Cronbachs’ α 0.82); (2) Professionalization and improving the quality of spiritual care (Cronbachs’ α 0.82); (3) Personal support and patient counseling (Cronbachs’ α 0.81); (4) Referral to professionals (Cronbachs’ α 0.79); (5) Attitude towards the patient’s spirituality (Cronbachs’ α 0.56); and (6) Communication (Cronbachs’ α 0.71). The spiritual care competence scale can be used to assess the areas in which nurses need to receive training and whether they have developed competencies in providing such care. It was used to guide in developing the spiritual care competence of nurses for them to engage in thorough patient care.

Each dimension of spiritual care competence was rated as follows: 5 for Strongly Agree, 4 for Agree, 3 for Neither Agree or Disagree, 2 for Disagree and 1 for Strongly Disagree. A mean score below 3.5 is considered not competent; a mean score of 3.5 – 4.0 is competent while the mean score above 4.0 is highly competent.  

Permission to use the tool was made through electronic mail (email) with the address r.vanleeuwen@viaa.nl on August 28, 2018 to the author and permission was granted for use of the tool. The author sent the literature involving the test for the validity and reliability of the instrument in the assessment of nursing competencies in spiritual care wherein it stated that the spiritual care competence scale can be used to assess the areas in which nurses need to receive training in spiritual care and can be used to assess whether nurses have developed competencies in providing spiritual care.

Research Intervention Protocol – Spiritual Care Café

An Informed Consent Form was distributed by the researcher to the nurses with full disclosure of the study thoroughly explained as well as all questions and classifications are entertained and answered by the researcher. After they consented to answer the Spiritual Care Competence Scale, they were given a choice, without any discrimination of the result, to join the research intervention which was the Spiritual Care Café.  The Spiritual Care Café was developed and modified to meet the dimensions based from Rene van Leeuwen’s principal component, as approved for application from consultation by multiple spiritual leaders who validated the tool, following the five components comprising the basic model: The setting was based on the structure of the venue which was creating a café-oriented environment with tables covered with Manila paper and crayons provided for each table together with five chairs.

The SCC started with a Welcome and Introduction.  Each participant was made to sit in a table comfortable to them composed of five participants each. The expert began with a warm welcome and an introduction to the Spiritual Care Café process, setting the context, sharing the Café etiquette and putting participants at ease in Small Group Rounds.

The process began with the first thirty-minute rounds of interaction for the small group seated around the table. Prior to the beginning of the process, each table must designate a “table host” to gather inputs regarding ideas and concepts given by the group. Each table must discuss an answer to a question provided by the expert in relation to the domains of spiritual care competency which includes (1) assessment and implementation of spiritual care, (2) professionalization and improving the quality of spiritual care, (3) personal support and patient counseling, (4) referral to professionals, (5) attitude towards patient spirituality and (6) communication. During their discussion, they were encouraged to write, scribble or provide ideas in the Manila paper for each table in their own creative and comfortable way. After the allotted time was given, the “table host” was left in the table to welcome another group and discuss the harvested ideas provided by the previous group. As for the other members, they went to another table to answer the other questions that was provided by the expert in relation to the domains of spiritual care competency. Once another group arrives in a certain table, the group must designate another “table host” to gather the inputs and to give chance to the previous “table host” to exchange ideas to another table once they finish their discussion for a certain question provided by the expert. Once the expert has provided all the questions, each table must discuss the gathered inputs formulated from the ideas exhausted by the participants in the Manila paper in front of all the participants to develop a sense of self-awareness on the said topic. After all groups have made the rounds based on the questions asked, the table hosts were requested to report the summary of the discussions made in their table. The expert gave a summary of the reports and concludes the Spiritual Care Café.

Data collection

Upon approval to conduct the study, the researcher met with the Corporate Director of Nursing Services (situated in Cebu Doctors’ University Hospital) asking for collaboration and coordination in gathering the data intended for screening of qualified participants of the intervention. Same procedure was done with the selected affiliated hospitals with their corresponding Chief Nurses (Mactan Doctors Hospital and Cebu South General Hospital). Permission was sought to use the conference room in Cebu Doctors’ University Hospital, being the corporate institution, to centralize the intervention involved. An Informed Consent Form was distributed by the researcher to the nurses with full disclosure of the study thoroughly explained as well as all questions and classifications are entertained and answered by the researcher. After they consented to answer the Spiritual Care Competence Scale, they were given a choice, through purposive sampling and without any discrimination of the result, to join the research intervention which is the Spiritual Care Café.

The data was collated until every nurse in the unit gets to answer the scale. All the data that was gathered was statistically measured, analyzed and interpreted. From this data, we are able to screen the qualified participants based from the inclusion criteria and include those that have higher scores to avoid discrimination regarding low scores of spiritual care competency.

The qualified participants were recruited to attend the said intervention on the fixed date. The Spiritual Care Café was filed for a Continuing Professional Development (CPD) accreditation for the participants to gain the necessary points for the enhancement of their professional standing and can be utilized for the renewal of their licenses through CPD points. This was also a means of recruitment among the qualified participants. To facilitate the Spiritual Care Café, an expert on its conduct was hired.

An evaluation was done after the intervention has been provided among the participants who attended. The researcher then interviewed patients to validate the effectiveness of the intervention. Patients, that have consented and provided with full disclosure as well as questions answered, who was interviewed and recorded, through a sound recorder, are those that are cared by the nurses who attended the intervention, responsive, conscious and no impairment in terms of communication as well as those who comprehend the universal language, which is English. The names of the patients were kept confidential as the only thing that are needed to be gathered are their responses from the conduit of the care provided, more specifically on the spiritual care. The main gauge of the responses of the patients was based on the saturation point collected which aid in the evaluation for the effectiveness of the SCC. The data collected was stored in a lock-and-key cabinet where only the researcher has the access to such information. After the research study, the result was disposed and shredded by the researcher himself.

Data analysis

Data processing and analysis were carried out with the aid of IBM SPSS version 22. Results were summarized as mean with standard deviation of the subject’s scores before and after the Spiritual Care Café in terms of the following: (1) assessment and implementation, (2) professionalism and improving the quality of spiritual care, (3) personal support and patient counseling, (4) referral to professionals, (5) attitude towards patient spirituality and (6) communication. Paired t-test was used to determine the significant mean score difference between the before and after the implementation of the Spiritual Care Café domain scores in terms of the following: (1) professionalism and improving the quality of spiritual care, (2) personal support and patient counseling, (3) referral to professionals,  and (4) attitude towards patient spirituality. Kolmogorov-Smirnov (KS) tests revealed that the score differences before and after the implementation of the Spiritual Care Café domain mentioned were normally distributed, D = 0.186, p = 0.174, D = 0.219, p = 0.052, D = 0.138, p = 0.200 and D = 0.146, p = 0.200, respectively. On the other hand, Wilcoxon signed ranks test was used to determine the significant median score difference between the before and after the Spiritual Care Café in terms of (1) communication and (2) assessment and implementation of spiritual care. KS tests revealed that the score differences on before and after the Spiritual Care Café of these domains were not normally distributed, D = 0.332, p = 0.000 and D = 0.243, p = 0.017, respectively. Hypotheses were tested at 0.05 level of significance. All results were presented using tables.

Ethical consideration

A letter of request was written to inform and seek approval for the conduct of the study. These were addressed to the different hospital administrators of different and selected institutions under the Cebu Doctors Group of Hospitals. Approval from the dean of the Graduate School was sought to allow conduct of the study. The manuscript was then submitted to Cebu Doctors’ University – Institutional Ethics Review Committee (IERC) for review then approval was given.

RESULTS

Level of Spiritual Care Competence of the Nurses Before and After the Spiritual Care

There is an elevation of level of all domains, from which all nurses who joined the Spiritual Care Café started as not competent in terms of the delivery of spiritual care. Two domains, which include; (1) assessment and implementation of spiritual care and (2) communication resulted to a competent level after joining the Spiritual Care Café. While the other four domains, which includes; (1) professionalization and improving the quality of spiritual care, (2) personal support and patient counseling, (3) referral to professionals and (4) attitude towards patient spirituality scores was reported as highly competent after the interventions.

Based on the Spiritual Care Café conducted, there were a lot of ideas and concepts harvested in relation to the dimensions illustrated in the table that are of great concern in the workplace. It was discovered that some practices based on the spiritual care competencies are founded by the idea that interaction with different disciplinary team and affirmation of colleagues regarding the care provided can ignite the impression of the provision of spiritual care. Each nurse have diverse and creative outlets in terms of expressing the spiritual care conducive to the patient’s spiritual needs. The only limitation that they may have during its provision is the assertion of the premise that it can be done because there is no agreed definition of what it meant to provide “spiritual care” moreover, there are few guidelines for spiritual care in the nursing practice. There is also that hesitancy in the nurses’ side that resulted to an awkward predisposition thus refutes the implementation of the holistic care which includes the concept of spiritual care itself.

There is that gap in the professionalization and improvement of spiritual care as nurses do not feel that their voice was be heard by the management in terms of providing nursing care. One factor could be the confusion of the available resources and the proper channeling of concerns. With that said, it could influence the dimension on communication which is beneficial in the patient interaction. Addressing these issues could provide self-awareness to the nurses and enhance their capacity to advocate for patients’ needs in attaining holistic care from physical to spiritual aspect during their stay in the institution. With the spiritual care competency enhanced, it can benefit the nurses to grasp the philosophy of nursing care in the workplace.

Significant Difference in the Spiritual Care Competency of Nurses Before and After the Spiritual Care Café in terms of Assessment and Implementation of Spiritual Care

Assessment and implementation of spiritual care score was significantly higher after the Spiritual Care Café (Mdn = 4.00) was done before it was implemented (Mdn = 1.83), z = -3.418, p = <0.05, r = 0.88. The effect size for this analysis (r=0.88) was found to exceed the convention for a large effect. In this domain, sub-topics were assessed oral nursing reports on the spiritual functioning of the patient, written nursing reports on the spiritual functioning of the patient, documenting the nurse’s contribution to spiritual care in the patient’s care plan, coordinating spiritual care in multidisciplinary consultation, coordinating spiritual care in dialogue with the patient and oral and written reporting of the spiritual needs with the patient.

It was discussed during the Spiritual Care Café that nurses can tailor care to for patient’s spiritual needs in consultation with the multidisciplinary team and in coordination with the patient. They can construct a care plan based from the subjective and objective cues that they have gathered and collated from the patient but with the affirmation and collaboration with the healthcare team, most of which are with their colleagues and immediate superiors and seldom with the physician. Some nurses who have been with their respective institution for more than a year have familiarize different personalities with corresponding diseases and disorders from different adult population. They mentioned that they can tailor this care but felt some awkwardness in implementing it. They have diverse and creative outlets to do so but with the demand of time from different population and cases, they don’t see it as a priority in terms of its application and focused more on the physical and biological care.

One of the difficult procedures that can be implemented by the nurses, based on their discussion in the Spiritual Care Café, was reporting and recording the patient’s spiritual functioning. One of the barriers that they see in terms of its implementation is the demand of time and fast-paced movement in the nursing units. Some have considered recording the spiritual functioning of the patient during their clinical exposure in their respective institution but some of their colleagues tend to ignore their documentation. Some may see it as not essential and practical to be applied in their hospitals as it is deemed subjective as well as some of their colleagues have difficulty understanding the philosophy of recording the patient’s well-being that is focused on holistic care, including the spiritual aspect of the patient.

Significant Difference in the Spiritual Care Competency of Nurses Before and After the Spiritual Care Café in terms of Professionalization and Improving the Quality of Spiritual Care

Professionalization and improving the quality of spiritual care score was significantly higher after the Spiritual Care Café (M = 4.14, SE = 0.14) was done before it was implemented (M = 1.56, SE = 0.08), t (14) = 14.747, p = <0.05, r = 0.97. The effect size for this analysis (r = 0.97) was found to exceed the convention for a large effect. In this domain, sub-topics were assessed such as policy recommendations to management regarding the spiritual care, contributing to professionalism and expertise in spiritual care, coaching healthcare workers in providing spiritual care, implementing quality improvement projects in spiritual care, contributing to quality of care regarding spiritual care and addressing work-related problems in relation to spiritual care.

It was noted during the discussion in the Spiritual Care Café that the nursing participants do not see themselves as contributors of ideas in their nursing units of their respective hospitals. They have difficulty voicing out their concerns regarding the provision of holistic care because of high ratio of patients that they cater, how much more on the spiritual care aspect of their nursing care? They do not feel that the management is listening to them and the institution is focused on income generation rather than the quality of care that they can cater to the patients. In some instances, certain results of incidences in their hospitals tend to be perceived as one-sided because it has been seen as punitive rather than corrective. But some nurses who have been with the institution for a long period of time, who participated in the Spiritual Care Café, made their colleagues understand that the existing policy is more on corrective measures as the corporate company follows the progressive discipline program from verbal warning, written reprimand to suspension based on the allotted days mandated in the company manual.

Significant Difference in the Spiritual Care Competency of Nurses Before and After the Spiritual Care Café in terms of Personal Support and Patient Counseling

Personal support and patient counseling score was significantly higher after the Spiritual Care Café (M = 4.14, SE = 0.12) was done before it was implemented (M = 2.02, SE = 0.08), t (14) = 16.573, p = <0.05, r = 0.96. The effect size for this analysis (r = 0.96) was found to exceed convention for a large effect. In this domain, sub-topics were assessed such as helping the patient to continue his or her daily spiritual customs and rituals, providing spiritual care to the patient, providing information to the patient regarding facilities for spirituality and spiritual care in the healthcare institution, addressing questions regarding spirituality during daily care and evaluating spiritual care with the patient and the team.

From the very start of the Spiritual Care Café, the nursing participants felt that they are competent enough to refer members of the patient’s family to a spiritual advisor if, and only if, the family express spiritual needs. It was discussed that this is merely an option rather than a routine because of the awkward position of communicating this human vulnerability as present in the family setting of the patient. Some nurses who joined the Spiritual Care Café was not well aware that they have been providing spiritual care towards their patients by simple application of routine nursing care as it is seen by some of the patients as God’s extension and instrument. Not until they joined the Spiritual Care Café that they realized that can provide such application and cater to the psychological and spiritual needs of the patients. Some of the nurses, prior to the intervention, have no idea on the spiritual care resources existing in their institution even though it was part of their orientation, as mentioned by the nurses who have been in the institution for a long period of time. Through small group discussion, they were able to gain how to do provide personal support and deliver patient counseling in terms of spiritual care. Selected nurses may have gained the ideas on the provision of spiritual care but still has that hesitancy and self-doubt in the provision of spiritual care.

Significant Difference in the Spiritual Care Competency of Nurses Before and After the Spiritual Care Café in terms of Referral to Professionals

Referral to professionals score was significantly higher after the Spiritual Care Café (M = 4.02, SE = 0.16) was done before it was implemented (M = 2.51, SE = 0.21), t (14) = 7.261, p = <0.05, r = 0.89. The effect size for this analysis (r = 0.89) was found to exceed convention for a large effect.

In this domain, sub-topics were assessed such as referring the patient with spiritual needs adequately to another health care worker, assigning spiritual care adequately and knowing when to consult the chaplaincy. Pastoral care describes the interventions carried out by religious ministers in response to the spiritual or religious needs of others. The activities of the pastoral caregiver, “including sacramental and social ministries, can be as informal as conversational encounters and as formal as highly structured ritual events” (Studzinski, 1993, as cited in O’Brien, 2011). Chaplains within the hospital setting must often rely on professionals in other disciplines to make them aware of the spiritual needs and concerns of patients (Handzo & Koenig, 2004). However, chaplains’ professional relationships with those in other disciplines tend to vary with each discipline’s perspectives about religion and spirituality. Many nurses, for example, view spiritual care as an essential component to holistic treatment (Narayanasamy & Owens, 2001).

During the Spiritual Care Café, there was an inquiry on regarding the scope and limitation between the nurses and the chaplaincy in the provision of spiritual care. It was furthered discussed that effective assignment of patient’s spiritual needs to another care provider is based on the confidence of the staff nurse that catered to the patient’s holistic being. Experience was seen as a factor due to more exposure on the different personalities of diverse population and cases. They seem to realize that timely and effective referral to spiritual professionals is a challenge as trust among these professionals are deemed questionable by some participants because of human vulnerability and rigid interactions of the personality of the existing spiritual professionals in their institution. They may have gain an idea on when to consult a spiritual advisor but there is hesitancy and doubt in terms of the capability and the capacity of the spiritual professional that they referred to their patients.

Significant Difference in the Spiritual Care Competency of Nurses Before and After the Spiritual Care Café in terms of Attitude towards Patient Spirituality

Attitude towards patient spirituality score was significantly higher after the Spiritual Care Café (M = 4.55, SE = 0.11) was done before it was implemented (M = 2.83, SE = 0.19), t (14) = 7.422, p = <0.05, r = 0.89. The effect size for this analysis (r = 0.89) was found to exceed convention for a large effect.

In this domain, sub-topics were assessed such as being open to (other) spiritual beliefs in patients, not forcing personal spirituality upon patients, showing respect for the patient’s spiritual beliefs and recognizing personal limitations in spiritual care.  Koenig, King & Carson (2012, as cited in O’Brien, 2011) mentioned that one’s spirituality is an important human dimension that is integral to a person’s well-being, healing, values and reactions to life experiences. Having meaning and purpose in life, a sense of belonging to a source of sublime, hope in God’s help in stressful situation in life, and benefit from social and spiritual support are all methods that enable religious people to deal with stressful events of life. Many nurse scholars posit that nurses must gain a degree of awareness about their own spirituality to be effective as spiritual caregivers. Everyone experiences some degree of pain, whether the breakup of a romantic relationship, an unkind remark from a parent or friend, the loss of someone or something, or the experience of any unexpected or difficult transition. Even though a nurse may not have been diagnosed with physical or mental disease, he or she can on some level identify with the client’s experience (Taylor, 2002).

Significant Difference in the Spiritual Care Competency of Nurses Before and After the Spiritual Care Café in terms of Communication

Communication scores was significantly higher after the Spiritual Care Café (Mdn = 4.00) was done before it was implemented (Mdn = 2.00), z = -3.453, p <0.05, r = 0.89. The effect size for this analysis (r = 0.89) was found to exceed convention for a large effect. In this domain, sub-topics were assessed such as the following: (1) listening actively to the patient’s “life story” and (2) showing an accepting attitude towards the patient’s spirituality. According to Riley (2000), communication is a life-long learning process for the nurse. She stated that nurses make the intimate journey with the client and family from the miracle of birth to the mystery of death. Nurses build assertive communication for this journey. Nurses communicate with people under stress: clients, family and colleagues. Nurses deal with anger and depression, with dementia and psychosis, with joy and despair. Nurses serve as client advocates and as members of interdisciplinary teams who may have different ideas about priorities of care.

Participants in the Spiritual Care Café discussed that communication can be a healing medium or instrument in terms of the provision of spiritual care. They mentioned that patient interaction involving accepting attitude that involves presentation of concern, sympathy, trust, empathy, sensitivity, sincerity and personal touch is a skill set that can’t be learned in a classroom setting but on a well-versed related learning experience and further hospital exposure which provides accountability to the professional nurses. They shared that they can practice this kind of patient engagement if they attained the confidence and inspiration to do so. The awkwardness in its application would still be there but during their small group sharing they were able to arrive to an idea that it can be seen as an opportunity rather than a barrier. With this positive outlook on communication, creative outlet can be designed in accordance to the patient’s spiritual needs.

Another discussion that they have provided in the table is involvement of active listening to the patient’s “life story” in relation to the consequences or result of his or her medical and/or surgical condition. With the high demand of nurse’s time, inadequacy and scarcity of nursing personnel as well as increasing patient load, there is a limited time for the provision of patient interaction and communication. Some nurses are only limited to general rounds and has seldom do their periodic rounds because of time constraints and increasing nursing procedures provided to a certain patient. The nursing participants of the Spiritual Care Café voiced out their willingness to participate in active listening as this has two benefits which includes a therapeutic relationship with the patient and at the same time a learning opportunity for the nurses. They have come up with different alternatives to apply such idealistic approach but due to the challenges that they face, they have no assurance that such principle would be applicable in the nursing practice.

DISCUSSION

Based on the findings of the study, the Spiritual Care Café was seen as an effective approach in the enhancement of the spiritual care competency by exploring the nurses’ ideas and understanding on spiritual care thereby providing self-awareness and an acceptable environment for holistic care in the different institution of Cebu Doctors Group (CDG) of Hospitals. A Spiritual Nursing Care Protocol was proposed to be utilized by the institution for the nurses to be guided in the delivery of spiritual care.

These were the findings of the study:

1. There were elevations in the level of spiritual care competency of the nurses before and after the implementation of Spiritual Care Café. All of the domains have attained a “Not Competent” score before the Spiritual Care Café but four of the domains (professionalization and improving the quality of spiritual care, personal support and patient counseling, referral to professionals, attitude towards patient spirituality) have attained a “Highly Competent” score while the other two (assessment and implementation of spiritual care, communication) only shows a “Competent” score.
2. There were significant differences in the spiritual care competency of the nurses before and after the Spiritual Care Café in terms of the following domains.

The researcher recommends that future research will be done to evaluate the effectiveness of the said intervention to other healthcare population who engages and interacts with patients and accountable to the care provided with a greater sample size to improve the study’s statistical power as well as multiple time points post-intervention. Furthermore, future research should include measures to control confounding variables, such as training or personal beliefs about spirituality. In addition, the researcher also recommends entertaining a qualitative study in relation to the recipient of the spiritual care given, which are the patients themselves. Moreover, the researcher recommends implementing the said intervention among the different hospitals for the nurses to be guided in the provision of holistic nursing care and include it in the quality assurance monitoring to attain the holistic care provided to the patients. On top of that, the researcher recommends to use the protocol developed in the study for the administration and nurse managers to be guided on spiritual care development among their nursing personnel.

CONCLUSION

To enhance the spiritual care competency of nurses, an intervention that addresses the domains was seen as most effective following the format of the World Café.

REFERENCES

1. Baldacchino, D. (2015) Spiritual Care Education of Health Care Professionals. Religions, 6, 549-613. Retrieved October 13, 2018 from https://doi.org/10.3390/rel6020594
2. Benner, P. (1982). From novice to expert. The American Journal of Nursing, 82 (3), 402-407. Retrieved October 13, 2018 from http://www.jstor.org/stable/3462928
3. Boutell, K.A., & Bozett, F.W. (1990). Nurses’ assessment of patients’ spirituality: Continuing education and implications. Journal of Continuing Education in Nursing, 21 (4), 172-176. Abstract retrieved March 3, 2019 from https://www.ncbi.nlm.nih.gov/pubmed/2116464
4. Bowles, A., & Bowles, N.B. (2000). A comparative study of transformational leadership in nursing development units and conventional clinical settings. Journal of Nursing Management, 8 (2), 69-76. Abstract retrieved March 3, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/11051962
5. Brown, J., Isaacs, D., & Tan, S. (2008). Multi-generational collaboration: Shaping tomorrow, together. Kosmos, 7 (2), 32-33. Retrieved March 9, 2018, from http://www.theworldcafe.com/wp-content/uploads/2015/07/KosmosMulti-GenArticle.pdf
6. Burkhart, L., & Hogan, N. (2008). An experiential theory of spiritual care in nursing Practice [Abstract]. Qualitative Health Research, 18 (7), 928-938. doi: 10.1177/1049732308318027.
7. Burkhart, L., Schmidt, L., & Hogan, N. (2011). Development and psychometric testing of the Spiritual Care Inventory Instrument. Journal of Advanced Nursing, 67 (11), 2463-2472. doi: 10.1111/j.1365-2648.2011.05654.x. Epub 2011 Apr 26.
8. Callister, L.C., Bond, A.E., Matsumura, G., & Mangum, S. (2004). Threading spirituality throughout nursing education. Holistic Nursing Practice, 18 (3), 160-166. Retrieved March 10, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/15222604
9. Castro, M. (2018) Reflections on end-of-life dialysis. Brazilian Journal of Nephrology, 40(3), 1-15. Retrieved October 13, 2018, from http://www.scielo.br/scielo.php?script=sci arttext &pid=S010128002018005010101
10. Chinn, P.L. & Jacobs, M.K. (1987) Theory and nursing: a systematic approach. Research in Nursing & Health, 7 (1), 222. Retrieved March 3, 2019 from https://onlinelibrary.wiley.com/doi/abs/10.1002/nur.4770070111
11. Christie, M., Carey, M., Robertson, A., & Grainger, P. (2015). Putting transformative learning theory into practice. Australian Journal of Adult Learning, 55 (1), 10-22. Retrieved October 14, 2018, from https://files.eric.ed.gov/fulltext/EJ1059138.pdf
12. Clark, C. (2016). Watson’s Human Caring Theory: Pertinent transpersonal and humanities concepts for educators. MDPI Humanities, 5 (2), 21. doi: 10.3390/h5020021
13. Damasceno, M.M., Zanetti, M., Carvalho, E.C., Teixeira, C.R., Araujo, M.F., & Alencar, A.M. (2012). Therapeutic communication between health workers and patients concerning diabetes mellitus care. Rev. Latino-Am. Enfermagem. 20(4), 685-692. Retrieved from: https://pdfs.semanticscholar.org/ee72/f5f475ec43b6bc88d6ebfc753d06dab217b1.pdf
14. DeKoninck, B., Hawkins, L.A., Fyke, J., Neal, T. & Currier, K. (2016). Spiritual care practices of advanced practice nurses: a multinational study. The Journal for Nurse Practitioners, 12 (8), 536-544. Retrieved October 13, 2018, from https://doi.org/10.1016/j.nurpra.2016.05.023
15. Dell’Orfano, S. (2002). The meaning of spiritual care in a pediatric setting. Journal of Pediatric Nursing, 17(5), 380-385. Retrieved March 4, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/12395306
16. Edwards, D., & Burnard, P. (2003). A systematic review of stress and stress management interventions for mental health nurses. Journal of Advanced Nursing, 42 (2), 154. Abstract retrieved March 3, 2019, https://doi.org/10.1046/j.1365-2648.2003.02600.x
17. Fallon, H., & Connaughton, L. (2016). Using a World Café to explore new spaces and new models for front line services: A case study from the Irish University Library Sector. New Review of Academic Librarianship, 22 (1), 43-59. Retrieved March 19, 2019, from https://eric.ed.gov/?id=EJ1091294
18. Finkelstein, F., West, W., Gobin, J., Finkelstein, S., & Wuerth, D. (2007). Spirituality, quality of life and the dialysis patient. Nephrology Dialysis Transplantation. 22, 2432-2434. Retrieved October 30, 2019, from https://academic.oup.com/ndt/article/22/9/2432/1839941
19. Fletcher, J. (2016). Understandings and perceptions of spirituality held by multidisciplinary professionals involved in a community-based palliative care organization: implications for professional practice (Doctoral dissertation, Australian Catholic University). Retrieved March 4, 2019, from https://doi.org/10.4226/66/5a9cbf07b0ba1
20. Galek, K., Flannelly, K., Koenig, H. & Fogg, S. (2007) Referrals to chaplains: The role of religion and spirituality in healthcare settings. Mental Health, Religion & Culture, 10 (4), 363-377. Retrieved March 4, 2019, http://dx.doi.org/10.1080/13674670600757064
21. Gomez-Castillo, B., Hirsch, R., Groninger, H., Baker, K., Cheng, J., Phillips, J., Pollack, … (2015). Increasing the number of outpatients receiving spiritual assessment: A Pain and Palliative Care Service Quality Improvement Project. Journal of Pain and Symptom Management, 50(5), 724-729. Retrieved March 4, 2019, from https://cc.nih.gov/palliativecare/pdf/increasing_number_outpatients.pdf
22. Handzo, G., & Koenig, H. (2004) Spiritual care: Whose job is it anyway? [Abstract] Southern Medical Journal, 97 (12), 1242-1244. doi:10.1097/01.SMJ.0000146490.49723.AE
23. Kalkim, A., Midilli, T.S., & Daghan, S. (2018). Nursing Students’ Perceptions of Spirituality and Spiritual Care and Their Spiritual Care Competencies: A Correlational Research Study [Abstract]. Journal of Hospice & Palliative Nursing. 20(3), 286-295. Retrieved October 19, 2018, from https://insights.ovid.com/crossref?an=00129191-201806000-00015
24. Laschinger, H.K.S., Wong, C., McMahon, L., & Kaufmann, C. (1999). Leader behavior impact on staff nurse empowerment, job tension and work effectiveness. Journal of Nursing Administration, 29 (5), 28-39. Abstract retrieved March 7, 2019 from https://www.ncbi.nlm.nih.gov/pubmed/10333859
25. Lind, B., Sendelbach, S., & Steen, S. (2011). Effects of a spirituality training program for nurses on patients in a progressive care unit. Critical Care Nurse, 31 (3), 87-90. doi: 10.4037/ccn2011372
26. Lundmark, M. (2006). Attitudes to spiritual care among nursing staff in a Swedish oncology clinic. Journal of Clinical Nursing, 15 (7), 863-874. doi: 1111/j.1365-2702.2006.01189.x
27. Marquis, B. & Huston, C. (2006) Leadership Roles and Management Functions in Nursing: Theory and Application (5^th ed). Philadelphia: Lippincott Williams & Wilkins.
28. Mazandarani, H.A., Asadzandi, M., Saffari, M., & Khanghanizadeh, M. (2017). Effects of Spiritual Care Based on Sound-Heart Consulting Model (SHCM) on Spiritual Health of Hemodialysis Patients. Critical Care Nursing. 10(4), 1-5. doi: 10.5812/ccn.16147
29. Mitchell, D.L., Benett, M.J., & Manfrin-Ledet, L. (2006). Spiritual development of nursing students: developing competence to provide spiritual care to patients at the end of life. Journal of Nursing Education, 45(9), 365-370. Retrieved October 30, 2018 from https://www.ncbi.nlm.nih.gov/pubmed/17002083
30. Mok, E., Wong, F. & Wong, D. (2010). The meaning of spirituality and spiritual care among the Hong Kong Chinese terminally ill. Journal of Advanced Nursing, 66 (2), 360-370. doi: 1111/j.1365-2648.2009.05193.x
31. Narayanasamy, A., & Owens, J. (2001). A critical incident study of nurses’ responses to spiritual needs of their patients. Journal of Advanced Nursing, 33 (4), 446-455. Retrieved March 7, 2019 from https://www.ncbi.nlm.nih.gov/pubmed/11251732
32. National Coalition Hospice and Palliative Care. (2018). Clinical practice guidelines. Retrieved October 13, 2018, from http:/www.nationalconsensusproject.org/NCP
33. O’Brien, M.E. (2011). Spirituality in Nursing: Standing on Holy Ground. (4^th). Sudbury: Jones & Bartlett Learning.
34. Perra, B.M. (2001). Leadership: The key to quality outcomes. Journal of Nursing Care Quality, 24 (2), 56-61. Abstract retrieved March 4, 2019 from https://www.ncbi.nlm.nih.gov/pubmed/10765258
35. Pipe, T.B., Kelly, A., LeBrun, G., Schmidt, D., Atherton, P., & Robinson, C. (2008). A prospective descriptive study exploring hope, spiritual well-being and quality of life in hospitalized patients.
36. Medsurg Nursing, 17 (4), 247-253. Abstract retrieved March 7, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/18807859
37. Puchalski, C.M., & Romer, A.L. (2000). Taking a spiritual history allows clinicians to understand patients more fully. Journal of Palliative Medicine, 3(1), 129-137. doi: 1089/jpm.2000.3.129
38. Pullen, L., McGuire, S., Farmer, L., & Dodd, D. (2014). The relevance of spirituality to nursing practice and education. Mental Health Practice, 18 (5), 14-18. doi: 7748/mhp.18.5.14.e916
39. Ramezani, M., Ahmadi, F., Mohammadi, E., & Kazemnejad, A. (2014). Spiritual care in nursing: a concept analysis. International Nursing Review, 61 (2), 211-219. doi: 1111/inr.12099.
40. Riley, J. B. (2000) Communication in Nursing (4^th ed). St. Louis, MO: Mosby.
41. Sawatzky, R., & Pesut, B. (2005). Attributes of Spiritual Care in Nursing Practice. Journal of Holistic Nursing [Abstract], 23(1), 19-33. doi: 10.1177/0898010104272010
42. Sternberg, E.M. (2009). Healing spaces: The science of place and well-being. Cambridge, MA: Harvard University Press.
43. Strang, S., Strang, P., & Ternestedt, B.M. (2002). Spiritual needs as defined by Swedish nursing staff. Journal of Clinical Nursing, 11(1), 48-57. doi: 10.1046/j.1365-2701.2002.00569.
44. Taylor, E.J. (2002) Spiritual Care: Nursing Theory, Research and Practice. Upper Saddle River, New Jersey: Prentice-Hall.
45. Tornoe, K., Danbolt, L.J., Kvigne, K., & Sorlie, V. (2015). A mobile hospice nurse teaching team’s experience: training care workers in spiritual and existential care for the dying – a qualitative study. BMC Palliative Care, 18 (14), 43. doi: 10.1186/s12904-015-0042-y
46. Vance, D.L. (2001) Nurses’ attitudes towards spirituality and patient care. MEDSURG Nursing, 10, 264-268. Retrieved October 13, 2018 from https://www.researchgate.net/publication/284229411 Nurses’ attitudes towards spirituality and patient care
47. van Leeuwen, R., & Cusveller, B. (2004). Nursing competencies for spiritual care [Abstract]. Journal for Advanced Nursing, 48 (3), 234-246. doi: 1111/j.1365-2648.2004. 03192. x
48. van Leeuwen, R. & Schep-Akkerman, A. (2015) Nurses’ Perceptions of Spirituality and Spiritual Care in Different Health Care Settings in the Netherlands. Religions, 6 (4), 1346-1357. doi: 10.3390/rel6041346
49. van Leeuwen, R., Tiesinga, L., Middel, B., Post, D. & Jochemsen, H. (2009) The validity and reliability of an instrument to assess nursing competencies in spiritual care. Issues in Nurse Education. Journal of Clinical Nursing, 18 (20), 2857-2869. doi: 1111/j.1365-2702.2008.02594. x. Epub 2009 Jan 30.
50. Veloza-Gomez, M., de Rodriguez, L.M., Guevara-Armenta, C., & Mesa-Rodriguez (2017). The Importance of Spiritual Care in Nursing Practice. Journal of Holistic Nursing, 35 (2), 118-131. doi: 1177/0898010115626777
51. Weaver, A.J., Koenig, H.G., & Flannelly, L.T. (2008). Nurses and healthcare chaplains: Natural allies. Journal of Health Care Chaplaincy, 14 (2), 91-98. doi: 1080/08854720802129042
52. Williams, E. (2008). Holistic Medical Care – The Role of Chaplains in a Multi-Disciplinary Team. Scottish Journal of Healthcare Chaplaincy. 11(1), 9-14. Retrieved October 30, 2019, from http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.519.9287&rep=rep1&type=pdf
53. Yilmaz, M., & Gurler, H. (2014). The efficacy of integrating spirituality into undergraduate nursing curricula [Abstract]. Nursing Ethics, 21 (8), 929-945. doi: 10.1177/0969733014521096.
54. Yong, J., Kim, J., Park, J., Imsun, S., & Swinton, J. (2011). Effects of a Spirituality Training Program on the Spiritual and Psychosocial Well-Being of Hospital Middle Manager Nurses in Korea. The Journal of Continuing Education in Nursing, 42(6), 280-288. doi: 10.3928/00220124-20101201-04
55. Zehtab, S., & Adib-Hajbaghery, M. (2014). The Importance of Spiritual Care in Nursing. Nursing and Midwifery Studies, 3 (3). Retrieved March 1, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4332997/