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Background: The spiritual part of life is important to health, well-being and quality of life. Spiritual care is expected of nurses/midwives, but it is not clear how students can achieve competency in spiritual care at point of registration as required by regulatory bodies., Aim: To explore factors contributing to undergraduate nurses'/midwives' perceived competency in giving spiritual care., Design: A pilot cross-sectional, multinational, correlational survey design., Method: Questionnaires were completed by 86% (n=531) of a convenience sample of 618 undergraduate nurses/midwives from six universities in four countries in 2010. Bivariate and multivariate analyses were performed., Results: Differences between groups were small. Two factors were significantly related to perceived spiritual care competency: perception of spirituality/spiritual care and student's personal spirituality. Students reporting higher perceived competency viewed spirituality/spiritual care broadly, not just in religious terms. This association between perceived competency and perception of spirituality is a new finding not previously reported. Further results reinforce findings in the literature that own spirituality was a strong predictor of perceived ability to provide spiritual care, as students reporting higher perceived competency engaged in spiritual activities, were from secular universities and had previous healthcare experience. They were also religious, practised their faith/belief and scored highly on spiritual well-being and spiritual attitude/involvement., Conclusions: The challenge for nurse/midwifery educators is how they might enhance spiritual care competency in students who are not religious and how they might encourage students who hold a narrow view of spirituality/spiritual care to broaden their perspective to include the full range of spiritual concerns that patients/clients may encounter. Statistical models created predicted factors contributing to spiritual care competency to some extent but the picture is complex requiring further investigation involving a bigger and more diverse longitudinal sample., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Purpose: Measuring dental clinic service quality is the first and most important factor in improving care. The quality provided plays an important role in patient satisfaction. The purpose of this paper is to identify factors affecting dental service quality from the patients' viewpoint., Design/methodology/approach: This cross-sectional, descriptive-analytical study was conducted in a dental clinic in Tehran between January and June 2014. A sample of 385 patients was selected from two work shifts using stratified sampling proportional to size and simple random sampling methods. The data were collected, a self-administered questionnaire designed for the purpose of the study, based on the Parasuraman and Zeithaml's model of service quality which consisted of two parts: the patients' demographic characteristics and a 30-item questionnaire to measure the five dimensions of the service quality. The collected data were analysed using SPSS 21.0 and Amos 18.0 through some descriptive statistics such as mean, standard deviation, as well as analytical methods, including confirmatory factor., Findings: Results showed that the correlation coefficients for all dimensions were higher than 0.5. In this model, assurance (regression weight=0.99) and tangibility (regression weight=0.86) had, respectively, the highest and lowest effects on dental service quality., Practical Implications: The Parasuraman and Zeithaml's model is suitable to measure quality in dental services. The variables related to dental services quality have been made according to the model., Originality/value: This is a pioneering study that uses Parasuraman and Zeithaml's model and CFA in a dental setting. This study provides useful insights and guidance for dental service quality assurance.

Background: Spiritual care is expected of nurses, but it is not clear how undergraduates can achieve competency in spiritual care at point of registration as required by nursing/midwifery regulatory bodies., Aims: To describe undergraduate nurses'/midwives' perceptions of spirituality/spiritual care, their perceived competence in delivering spiritual care, and to test out the proposed method and suitability of measures for a larger multinational follow-on study., Design: Cross-sectional, multinational, descriptive survey design., Methods: Author administered questionnaires were completed by 86% of the intended convenience sample of 618 undergraduate nurses/midwives from 6 universities in 4 European countries in 2010., Results: Students held a broad view of spirituality/spiritual care and considered themselves to be marginally more competent than not in spiritual care. They were predominantly Christian and reported high levels of spiritual wellbeing and spiritual attitude and involvement. The proposed method and measures were appropriate and are being used in a follow-on study., Conclusions: The following are worthy of further investigation: whether the pilot study findings hold in student samples from more diverse cultural backgrounds; whether students' perceptions of spirituality can be broadened to include the full range of spiritual needs patients may encounter and whether their competence can be enhanced by education to better equip them to deliver spiritual care; identification of factors contributing to acquisition of spiritual caring skills and spiritual care competency., (© 2013.)

Background and Aims: Career motivation in university educators through efficient ways and appropriate with the educational system, is considered one of the important factors affecting education of students and their competence. This study aimed to determine the relationship between career motivation and spiritual leadership among a university of medical sciences in the west, Iran., Methods: This descriptive, cross-sectional correlation study was conducted among the university educators of medical sciences in the west, Iran in 2012. All of the educators (N=230) were selected and recruited according to census method. The data were collected by two established self-completed questionnaires on spiritual leadership (SL) and career motivation. Data were analyzed statistically by parametric tests: Pearson correlation, independent student t-test and one-way analysis of variance (ANOVA)., Results: The Pearson correlation test identified a significant relationship between educators' career motivation and vision, altruistic love, hope/faith, meaning/calling and membership dimensions of spiritual leadership (p<0.05). The independent t-test detected a significant relationship between the 'hope/faith' (p=0.04) and organizational commitment (p=0.004) dimensions and the gender of educators. ANOVA revealed significant differences in educators' years of work experience and their overall career motivation (p=0.003) and the dimension of 'membership' (p<0.04). A significant relationship was found in 'altruistic love' and 'Hope/faith', and the educators' academic rank place in the university (p=0.03). Also a significant relationship was found in 'vision' (p=0.03) and 'altruistic love' (p=0.002) and 'membership' (p=0.04) dimensions, and the type of faculty., Conclusion: The results indicate that the dimensions of existence of spiritual leadership may have a positive relationship with educators' career motivation.

Spiritual coping, which may or may not contain religiosity, may enhance adaptation of clients with chronic illness. Part 1 of this article (Baldacchino et al, 2013) presented the research methodology of this cross-sectional comparative study, which explored the spiritual coping of clients with chronic illness receiving rehabilitation services in Malta (n=44) (lower limb amputation: n=10, chronic heart disease: n=9, osteoarthritis in an institution: n=10 and in the community: n=15) and Norway (n=16) (post-hip/shoulder surgery: n=5; chronic heart disease: n=5; chronic pain: n=6). Data were collected from seven purposive samples by focus groups. Roy's adaptation model (1984) and Neuman's Systems Model (2010) guided the study. Part2 discusses the findings, which consist of one main spiritual coping theme and three sub-themes: 'adopting religious coping strategies, relationship with God, and time for reflection and counting one's blessings'. Commonalities were found in the findings except in one dimension, which was found only in the Malta group, that is, being supported by others with a similar condition. This difference may be a result of the environment in the rehabilitation centres, cultural, and geographical differences between the two countries. While considering the limitations of this study, recommendations are proposed to the rehabilitation and education sectors and further trans-cultural comparative longitudinal research with mixed method approach on various clients with acute, chronic and life-threatening illness.

Chronic illness is defined as a long-term disease that challenges a person's physical, psychological and spiritual wellbeing. However, individuals may adapt to their condition by adopting spiritual coping strategies that may or may not include religiosity. Part 1 of this article presents the methodology of this cross-sectional comparative study, which explored the spiritual coping of patients with chronic illness receiving rehabilitation services in Malta (n=44: lower limb amputation n=10; chronic heart disease n=9; osteoarthritis-in an institution n=10 and in the community n=15); and in Norway (n=16: post-hip/shoulder surgery n=5; chronic heart disease n=5; chronic pain n=6). Data were collected from seven purposive samples during focus group sessions. Roy's Adaptation Model (1984) and Neuman's Systems Model (2010) guided the study. While acknowledging the limitations of this study, the findings presented in Part 2 identify commonalities in the spiritual coping of patients irrespective of cultural differences between Malta and Norway. A set of recommendations address clinical practice, education and further research.

Finding meaning in illness appears to give individuals purpose in life, which may motivate them to maintain a healthy lifestyle. Research to date has mainly used cross-sectional designs in the acute phase of recovery. This article describes a longitudinal exploratory study which explored patients' search for meaning in life across the first 5 years following myocardial infarction (MI). Interviews were conducted between 2000 and 2007 on patients with first MI (n=70; mean=61.9 years; SD=12.1). The qualitative data underwent thematic analysis guided by the analysis framework of Burnard (1991). Finding meaning appeared to increase patients' awareness of their current holistic state of life, and to provide impetus for making lifestyle changes. In the immediate aftermath of MI, patients restructured and re-evaluated their attitudes towards self, life, religious beliefs and others. However, from the third year onwards, as time passed patients lapsed in their behaviour, tending to become non-compliant with treatment and less aware or concerned about the risk of another heart attack. Further education on the spiritual dimension in care may guide nurses and health professionals in order to promote patients' rehabilitation process and persevere with a long-term healthy lifestyle. Further longitudinal comparative research with mixed method approach on various groups of patients is recommended to support these findings.

This descriptive exploratory study conducted between 2000 and 2007 aimed to explore patients' search for causal meaning of myocardial infarction across the first 5 years of recovery. Qualitative data were collected by audio-taped interviews with 70 patients. This paper discusses patients' interpretations of the cause of their illness guided by Frankl's theory of Logotherapy and Existential Analysis. Research demonstrates that the sudden onset of a life-threatening illness appears to trigger a search for causal meaning, in an attempt to find an answer to the question, 'Why me?' The three themes found across time were determining the cause, finding fate- or faith-related causal meaning for their illness, and understanding the personal significance of illness. These findings corroborate with Frankl's Theory, whereby individuals' beliefs can give meaning to their illness and life. Causal meaning may enable persons to change their attitude to life, including their unavoidable suffering. Recommendations were set in order to increase awareness among nurses and health professionals and bridge the gaps in the current clinical practice in hospitals and community.

The study unit Spirituality for Health Carers was part of the BSc(Hons) nursing/midwifery programme which aimed at providing an innovative clinical placement for students. This placement promoted the delivery of spiritual care to clients in Lourdes. This paper discusses the experiential learning of students based on Gibbs (1988) Framework of Reflection. The scarce research demonstrates that caring for clients in Lourdes enabled students to develop meaningful relationships due to increased carer to clients' ratio, more time available and the presence of role models who were dedicated and compassionate with clients. Qualitative data were collected by a reflective diary, a written reflective assignment and a focus group discussion. The four themes which emerged from the data are team building, holistic care, trustful nurse-client relationship and strengthening personal spirituality. Recommendations were proposed to enhance the delivery of spiritual care and holistic care by further exposure of students to care for the pilgrims in Lourdes.

Background and Aims: Stress amongst nursing students is a global issue. There is an absence of published international comparative studies which investigate this and so this paper sets out to explore the sources of stress among nursing students throughout their course of study and to determine whether they were more stressed by academic or clinical factors across five different countries (Albania, Brunei, the Czech Republic, Malta and Wales). Although each country, within this study, has a unique culture, a cross-cultural comparison can be made in an attempt to better understand stress in the student nursing population., Methods: The study was undertaking using a descriptive quantitative design using the Stress in Nurse Education Questionnaire with 1707 nursing students across the five countries., Results: The mean score for the total sample for all the items on the stress scale was 52.3 (SD 17.1). The sample from Wales had the lowest mean score and those in Brunei had the highest. Students in Brunei and Malta were more stressed by the academic elements of the course than by the clinical elements. Whereas for those students in the Czech Republic For students in Wales and in Albania - Korçe there were no differences in stress experienced between the academic and clinical elements of the course. The results indicated that there were no significant differences in total stress scores by year of study for students in Albania - Tirana, Albania-Korçe, Malta and Wales. In Brunei however, ANOVA revealed that there were significant differences in total stress scores by year of study. Further analysis revealed that students in year 3 scored higher on the overall scale than students in year 1. The individual item on the stress scale with highest mean in the Albania - Korçe and the Albania-Tirana sample was "The death of a patient" whilst the Bruneian sample, Maltese sample and Welsh sample opted for "Revising for and sitting examinations" and the Czech sample chose: "Continuous pressure to meet deadlines for assessments"., Conclusions: This study has succeeded as the first of its kind to compare and contrast levels and sources of stress amongst an international sample. The findings indicate that student nurses worldwide do share much in common while still retaining individual cultural features relating to stress throughout their course of study.

Aims of the Paper: This paper reviews some of the limited nursing research-based literature, orientated towards the use of spiritual coping strategies in illness. This review aims at identifying those spiritual coping strategies used by the believers and nonbelievers followed by implications for holistic nursing care., Literature Search: The CINAHL and MEDLINE CD Rom databases were searched, identifying literature published from 1975 onwards which amounted to 187 articles. The majority of the literature traced were found anecdotal with only few studies investigating directly spiritual coping strategies. Following scrutiny of the available articles, only five research studies explored directly the spiritual coping strategies used in various illness, four of which were conducted in USA and one in UK. Because of the small scale research studies, generalization of the findings of this review is limited to the samples used., Theoretical Background: Research suggests that spiritual coping strategies, involving relationship with self, others, Ultimate other/God or nature were found to help individuals to cope with their ailments. This may be because of finding meaning, purpose and hope, which may nurture individuals in their suffering. Spirituality is oftenly referred by literature as being synonymous with religiosity. Thus the use of spiritual coping strategies is restricted to individuals who hold religious beliefs. However, the definition of spirituality indicates that this concept is broader than religiosity. The theories on stress-coping (Folkman & Lazarus 1984) and the numinous experience (Otto 1950) outline the rationale for the use of these strategies which are applicable to both the believers and nonbelievers., Implications: This review suggests that the onset of illness may render the individual, being a believer or nonbeliever to realize the lack of control over his/her life. However the use of spiritual coping strategies may enhance self-empowerment, leading to finding meaning and purpose in illness. This implies that holistic care incorporates facilitation of various spiritual coping strategies to safeguard the wholeness and integrity of the patients.