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Spiritual care competencies among nursing students in the middle East and Asia: a systematic review

BMC Nursing volume 24, Article number: 401 (2025) Cite this article

Abstract

Spiritual care is recognized as a crucial component of holistic nursing education, significantly enhancing patient well-being, health outcomes, and decision-making. However, a systematic evaluation of spiritual care education programs in the Middle East and Asia remains limited. This systematic review aims to assess the effectiveness of spiritual care education programs in enhancing undergraduate nursing students’ competencies in these regions. Following PRISMA-P guidelines and registered on PROSPERO (CRD42024552137), the study employed the PICOS framework for selection criteria: Participants (undergraduate nursing students), Intervention (spiritual nursing education programs), Comparison (education without spiritual content), Outcomes (spiritual care competencies), and Study design (RCT or quasi-experiment). Searches were conducted in Cochrane, Medline, PubMed, Sage, and Scopus from April to May 2024. Multiple reviewers independently performed data extraction and quality assessment using ROB 2 and ROBIN-I tools. A narrative synthesis approach explored data relationships and theoretical applications. Out of 1,350 reviewed articles, 10 studies involving 749 nursing students from Iran, Taiwan, and Turkey met the inclusion criteria. The interventions spanned from one month to a full semester and combined theoretical learning with clinical practice. The findings indicate that education in spiritual care significantly enhances students’ self-awareness, knowledge, attitudes, and practical skills. The study emphasizes the importance of incorporating spirituality into nursing curricula to promote a holistic approach to patient care. Limitations of the study include differences in study designs, selection bias, variability among participants, and reliance on self-reported data. Future research should aim for longitudinal studies to evaluate long-term effects and create culturally sensitive assessment tools for measuring spiritual competencies.

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Introduction

Spirituality is fundamental to holistic, patient-centered care, providing individuals with meaning, direction, and a connection to what is considered sacred. It extends beyond religious beliefs, encompassing personal values and a deeper sense of purpose in life. While religion refers to an organized system of beliefs and practices, spirituality is a broader concept that may or may not involve religious affiliation [1,2,3,4]. In healthcare, particularly nursing, integrating spiritual care enhances patient well-being, decision-making, and coping strategies. Many individuals turn to their faith during challenging times, especially when facing serious illness. Recognizing faith as a source of support helps healthcare providers identify patients’ spiritual needs and address them appropriately [5, 6]. By incorporating spiritual care into nursing education, professionals develop the competencies to provide holistic, patient-centered services. This integration ultimately improves healthcare quality by ensuring that patients’ spiritual and emotional well-being are considered alongside their physical health [2].

Holistic patient care can be achieved by providing structure to experiences, attributing meaning to them, and offering comfort, well-being, security, and a sense of belonging [7]. Spiritual care plays a fundamental role in this approach, as it addresses patients’ emotional and existential needs alongside their physical health. As an integral part of healthcare, spiritual care often requires interdisciplinary collaboration among health professionals. It is particularly important in rehabilitation, palliative care, and general practice, where patients may seek deeper meaning and support during critical moments [8, 9]. Given its significance, nurse educators are increasingly encouraged to incorporate spirituality into nursing curricula and clinical practice [10,11,12]. A systematic review is essential to guide this integration effectively. Understanding and embracing spirituality equips healthcare professionals and nursing students with the skills to improve patient outcomes, enhance quality of life, and support informed decision-making [13, 14].

Existing systematic reviews have identified several methodological constraints that limit the robustness of their conclusions. Paal et al. [15] highlighted the absence of control groups in research studies and the importance of examining the validity of tools utilized to evaluate spirituality. Moreover, concerns related to biases like social desirability and questionnaire fatigue were also addressed. Mthembu et al. [16] pointed out the lack of preparedness among instructors and methodological shortcomings in integrating spirituality into health sciences education. Jones et al. [17] noted the challenges in capturing the abstract nature of spirituality and the need for diverse search terms, which could lead to the omission of relevant studies. Addressing these methodological limitations is crucial to ensure the reliability and validity of future research outcomes.

Furthermore, previous systematic reviews by Paal et al. [15] Jones et al. [17], and Crozier et al. [18] have primarily focused on North America and Europe, with limited representation from Middle Eastern and Asian contexts. Since spirituality is interpreted and practiced differently across cultures, findings from Western studies may not be fully applicable to these regions. The existing regional gap in research restricts its applicability to diverse cultural and religious backgrounds. Rykkje et al. noted that most studies on spiritual education are conducted in Western nations, highlighting the need for research in non-Western contexts. Moreover, the differing definitions of spirituality across cultures complicate the interpretation of findings [12]. A systematic review focusing on Middle Eastern and Asian contexts could foster the development of culturally relevant educational interventions, ultimately enhancing nursing students’ ability to provide holistic, patient-centered care.

This systematic review aims to assess the effectiveness of spiritual care education programs in enhancing the competencies of undergraduate nursing students in the Middle East and Asia. By identifying effective educational strategies, evaluating their impact, and addressing gaps in current research, this study provides insights into improving spiritual care training in culturally diverse settings.

The findings will contribute to developing evidence-based recommendations for integrating spiritual care into nursing curricula in these regions, particularly for those working in multicultural and multi-faith communities, where understanding diverse spiritual perspectives is critical to holistic care.

Materials and methods

Study design

This review aims to address the following questions:

  1. 1.

    What are the characteristics and effectiveness of spiritual care education programs for nursing students in the Middle East and Asia?

  2. 2.

    How do these programs affect students’ competencies in delivering spiritual care?

A systematic review was developed in compliance with PRISMA-P guidelines and registered on PROSPERO with registration number CRD42024552137.

Eligibility criteria

The PICOS framework was used to structure the research inquiry to identify the key terms and create an appropriate research strategy for the study’s aim.

  • P: Undergraduate nursing students or nursing college students.

  • I: Spiritual nursing education program.

  • C: Education program without spiritual content.

  • O: Spiritual care competencies (knowledge, attitude, and skill).

  • S: RCT or quasi-experiment.

Search strategies

Electronic databases were used for research, reviewing, and reference lists. Cochrane, Medline, PubMed, Sage, Directory of Open Access Journals, Science-Direct, Pro-quest, Google Scholar, and Scopus databases were queried to access the primary studies. The exploration of databases commenced in April 2024, with the final search conducted in May 2024.

The Boolean operator OR, while terms associated with distinct components were conjoined using the AND operator. Examples of keywords in Google Scholar were: ((“Spiritual Nursing” OR “Spiritual Care in Nursing” OR “Spirituality in Nursing” OR “Spiritual Health in Nursing”) AND (“Education Program” OR “Educational Program” OR “Training Program” OR “Instructional Program” OR “Curriculum” OR “Educational Intervention”) AND (“Nursing Students” OR “Student Nurses” OR “Nursing Undergraduates” OR “Nursing Trainees” OR “Nursing Education” OR “Nursing Learners”)) AND (“spiritual care competencies”)). The detailed search methodology for exploring the keywords in databases is delineated in Appendix 1.

Rayyan Software was used to aggregate, organize, and compare retrieved papers. A team member independently did initial exploration and screening tasks, assessing titles and abstracts and eliminating duplicates. Two team members evaluated the eligibility of full texts of relevant papers (IPD and HH). Disagreements are resolved through discussion or with the assistance of another reviewer (TP, HR, NA, PK).

Data extraction and analysis

The data extracted independently by three reviewers (IPD, HR, and PK) are depicted in authors, years, participants’ characteristics, location of study, study design, sample size, intervention, and outcomes. Data items were collected in an Excel spreadsheet. Any disagreements with the reviewer are resolved through discussion or with the help of an additional reviewer.

A third reviewer was selected based on expertise in nursing education and systematic review methodologies to ensure a rigorous review process. This reviewer was crucial in resolving discrepancies during data extraction and quality assessment. A structured reassessment process was followed, in which the third reviewer independently evaluated any inconsistencies in study inclusion, risk of bias assessment, and data synthesis. This approach helped to minimize subjectivity and enhance the reliability of the findings.

The population under study is comprised of students enrolled in an academic undergraduate nursing program. The intervention is a spiritual care learning program course or training. The educational content encompasses spirituality, spiritual nursing, personal awareness, spiritual suffering, communication skills, comparative religious studies, and the ethics of spiritual nursing. Instructional methods include lectures, online learning, simulations, role-playing, videos, group discussions, and practical exercises. The comparison is education without any content of spirituality.

The participants demonstrated improved competencies in spiritual care, including increased self-awareness, knowledge, attitudes, and practical skills, leading to better integration of spirituality in clinical practice. Studies using randomized control trials and quasi-experimental methods.

Three reviewers (IPD, HR, PK) independently evaluated the study quality using specific tools. The ROB 2 tool was utilized to conduct randomized control trials. Overall bias judgment can be low, high, or with some concern [19].

Quasi-experimental studies were evaluated using the ROBIN-I Tool. Bias judgment can be critical, serious, moderate, or low-risk [20]. The studies for the systematic review were analyzed through a narrative synthesis. Investigations on nursing sciences education regarding spirituality and spiritual care were explained.

The reviews included learning objectives, content, topic knowledge, teaching methodologies related to spirituality and spiritual care, and research summaries by country. The narrative synthesis process comprises four primary components: developing a theoretical framework, conducting an initial synthesis, examining data connections, and evaluating the robustness of the synthesis. The evaluation focuses on data that supports inferences about effects across various contexts and demographics [18].

Results

Characteristics of included studies

1350 articles were recorded from databases and search engines, with duplicate records removed from 39 articles. 1218 articles were removed for not being relevant, and 93 full-text were selected for country of origin. 22 articles came from other than the Middle East and Asia, so the selection of articles for eligibility was 71. Ten studies were included in this systematic review. Search results are recorded in a PRISMA flowchart (Fig. 1).

Fig. 1
figure 1

Prisma flow diagram

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Table 1 presents the attributes of the studies included in our analysis. The origin countries of the studies are Iran [22,23,24,25] and Turkey [26,27,28]. Two study designs for RCT [24, 25] and eight quasi-experiments [22, 23, 26,27,28,29,30,31]. The studies involved 749 participants, with sample sizes ranging from 30 to 72 nursing students in each study. All participants were nursing students in their third to final semester of undergraduate university courses.

Table 1 Summary of findings in included studies
Full size table

Intervention in spiritual education was provided for varying durations, ranging from one month to a whole semester (16 weeks), covering materials, content, and learning outcomes. Only four of the ten studies integrated theoretical learning with clinical practice in hospitals [23, 25, 29, 30] while the rest solely took place in a classroom setting. One study described incorporating Buddhist religious beliefs into spiritual courses [29] while the other studies did not explicitly address the integration of the predominant religion in the area.

Spiritual education intervention was compared with face-to-face lessons or regular education without spiritual content in eight studies using a traditional course model. Two studies did not have a control group for comparison.

All ten studies assess the competencies encompassing attitudes, knowledge, and abilities resulting from spiritual care education. The outcomes evaluated include spiritual care abilities, self-efficacy, moral sensitivity, attitudes toward spiritual care, caring actions, and spiritual health. Additionally, the research examines students’ perceived support for spiritual care, commitment to the profession, and spiritual well-being. All studies reported significant values ranging from less than 0.001 to 0.004, indicating that spiritual care instruction positively impacted the assessed outcomes.

Quality assessment

The primary risk of biased findings from RCT studies indicates some concern about bias due to missing outcome data in the studies by Momennasab et al. [24] and Sharifi et al. [25]. Additionally, participants in the survey by Sharifi et al. were not blinded to treatment assignment, as they were aware of whether they were participating in group reflection sessions or attending a lecture, refer to Fig. 2.

Fig. 2
figure 2

Risk of bias randomized control trial

Full size image

Eight research articles were assessed for bias risk using seven categories: confounding bias, participant selection, intervention classification, deviations from intended interventions, missing data, outcome measurement, and selection of reported results. The articles were evaluated and rated as critical, serious, moderate, low, or without information, refer to Fig. 3.

Fig. 3
figure 3

Risk of bias quasi-experimental

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The findings revealed a varying degree of bias among the studies. Three articles exhibited a serious risk of bias overall, highlighting significant concerns in multiple categories. Specifically, studies by Chiang et al. [29], Frouzandeh et al. [23], and Hsiao et al. [30] each had serious biases, mainly due to confounding and selection of participants. Another study by Özveren et al. [27] also showed a serious overall risk, with moderate biases consistently across most categories.

Studies by Ekramifar et al. [22], and Yilmaz et al. [28] determined a critical risk of bias, the highest concern level. The study was critically biased due to confounding, while other studies had critical and serious biases, indicating substantial methodological flaws that could compromise the validity of their findings. Two articles demonstrated a moderate risk of bias. Although the study by Karaca et al. [26] lacked some information with some moderate biases, Tsai et al. [31] was more robust than the others but still had limitations that needed careful consideration. Overall, the analysis highlights that most articles have notable biases that could impact their reliability, emphasizing the need for a cautious interpretation of their findings.

Synthesis of the results

Narrative synthesis allows for describing patterns, exploring data relationships, and applying theory to the findings. It involves referencing original studies when summarizing and explaining the findings to enhance credibility. Spiritual education programs are developed by defining learning outcomes and creating study materials to achieve these competencies. It is essential to choose appropriate learning strategies, as illustrated in Fig. 4.

Fig. 4
figure 4

Linking learning outcomes, assessment tools and teaching/learning activities in spiritual care education

Full size image

The diagram presents a comprehensive framework for spiritual care education, encompassing learning outcomes, assessment tools, learning models, and teaching strategies. The theoretical framework integrates knowledge, attitudes, and skills necessary for spiritual care, forming the foundation for educational objectives. A preliminary synthesis highlights diverse assessment tools, such as scales for attitudes, behaviors, professional commitment, and spiritual health, ensuring a thorough evaluation of competencies.

Investigating data connections reveals that theoretical and practical activities are intertwined to enhance learning. Theoretical methods include traditional lectures, experiential learning, and case-based discussions, while practical activities emphasize mindfulness, self-reflection, and bedside teaching, ensuring a balanced approach. These connections demonstrate how theoretical knowledge is applied in practical settings, reinforcing learning.

Assessing the robustness of this synthesis involves evaluating the evidence supporting the framework’s effectiveness across various populations and contexts. The comprehensive nature of the framework, covering multiple dimensions of spiritual care, suggests it is adaptable and applicable in diverse healthcare settings, thereby enhancing the overall quality of spiritual care education.

Discussion

Effectiveness of spiritual care education

Spiritual care programs significantly improved nursing students’ competencies, particularly in developing self-awareness, empathy, and communication skills, as shown in Table 1. The reviewed studies indicate that students who received structured spiritual education demonstrated a better understanding and implementation of spiritual care in clinical settings [15, 17]. As Figure Four illustrates, combining theoretical knowledge with practical application is crucial for enhancing learning outcomes. Students engaged in experiential learning activities—such as case studies, role-playing, and clinical exposure—reported greater confidence and competence in addressing patients’ spiritual needs [10, 12, 32]. The Spiritual Care Competence Scale (SCCS) and the Spirituality & Spiritual Care Rating Scale (SSCRS) are frequently used to assess outcomes related to spiritual care competence, indicating their reliability and validity in educational settings [33].

Additionally, research suggests that incorporating reflection-based learning, such as Gibbs’ Reflective Cycle, can further enhance students’ ability to integrate spirituality into nursing practice [24]. This structured approach allows students to critically assess their experiences and better understand patients’ spiritual needs [25]. Experiential learning through direct patient interaction is emphasized as a crucial component, allowing students to apply spiritual care theories in real-world settings, which leads to greater confidence in their skills [30].

Cultural and contextual considerations

The effectiveness of spiritual care education is shaped by cultural and religious contexts. In Taiwan, programs incorporated Buddhist teachings [29], while those in Iran and Turkey were aligned with Islamic principles [26, 27]. The remaining seven studies on spiritual care learning content did not affiliate with any specific religion. Understanding these variations is essential for designing culturally relevant spiritual education programs. The findings indicate that educators should modify course content to align with local beliefs, ensuring that students can deliver patient-centered spiritual care in their respective environments.

While religious teachings often inform spiritual care education, it is important to distinguish between spirituality and religion. Spiritual care addresses patients’ existential needs, values, and sources of meaning, whereas religious care involves faith-specific practices, rituals, and doctrines. These variations emphasize the importance of culturally relevant education that aligns with local beliefs and practices. Differences in curriculum structure were also observed, with some programs integrating spirituality into broader nursing education while others offered it as a standalone module. Findings suggest that structured and standardized spiritual care curricula lead to better competency outcomes, underscoring the need for consistency in educational frameworks [11, 16].

The review also emphasizes the differences in the structure of spiritual care education across various countries. Some programs incorporated spirituality into broader nursing curricula, while others offered it as a separate module. In countries with a more organized approach to spiritual care education, students demonstrated greater improvements in competency. This highlights the necessity for standardizing curricula in this area [16, 34]. Incorporating interfaith perspectives in spiritual care training is beneficial, as it enables students to develop an inclusive approach when interacting with patients from diverse religious backgrounds [35].

Study bias and quality assessment

The reliability of findings in this review is influenced by study biases, including selection bias, lack of blinding, and missing data. Selection bias was evident in studies that did not use random sampling, which may limit the generalizability of results. The lack of blinding in several studies, where participants were aware of their intervention status, could introduce response bias, leading to inflated self-reported improvements in spiritual care competencies [24, 25]. Additionally, missing data in follow-up assessments raises concerns about the long-term sustainability of observed effects [17].

Despite these limitations, studies that employed rigorous methodological approaches, such as randomized controlled trials and validated assessment tools, provide valuable insights into the effectiveness of spiritual care education [31, 35]. Future research should aim to mitigate bias by incorporating double-blind designs, ensuring complete follow-up data, and using mixed-methods approaches to triangulate findings. Recognizing these biases allows for a balanced interpretation of the results, acknowledging both the strengths of well-designed studies and the limitations posed by methodological weaknesses.

Limitations

A key challenge in synthesizing findings from different studies is the significant variability in study designs, intervention durations, and assessment tools. Many studies relied on self-reported measures, introducing potential bias. Moreover, only a few studies incorporated long-term follow-ups to assess the sustainability of competency gains over time. Variability in assessment tools used across different studies also complicates cross-study comparisons and reduces the generalizability of findings.

The study has limitations, as it only includes articles from three countries in the target region: Iran, Turkey, and Taiwan. This scarcity may affect the generalizability of the findings. The limited representation could be due to variations in research focus, the availability of studies, and the emphasis on spiritual care education within those institutions across the region.

Implication for nursing education

The findings emphasize the importance of integrating spiritual care training into nursing curricula. Educators should utilize evidence-based strategies such as experiential learning, role-playing, and interdisciplinary collaborations. Furthermore, developing culturally sensitive teaching models can enhance the effectiveness of this training. By incorporating spiritual care education into core nursing programs, institutions can better prepare students to deliver holistic, patient-centered care.

Additionally, the integration of spiritual care should extend beyond theoretical instruction and be reinforced through clinical practice and mentorship programs. In our increasingly globalized world, equipping nurses to provide culturally and spiritually competent care is essential for improving patient outcomes and ensuring comprehensive healthcare practices.

Future directions

Future research should prioritize the development of standardized, culturally sensitive assessment tools to accurately measure competencies in spiritual care. Additionally, longitudinal studies are necessary to evaluate the long-term effects of spiritual care education on nursing students’ professional development.

Collaborative research efforts among institutions in the Middle East and Asia could further enhance the generalizability of findings and contribute to the creation of robust educational frameworks. More research should also explore the role of technology in spiritual care education, particularly in e-learning and simulation-based training, to expand accessibility and enhance learning experiences.

Conclusion

This review demonstrates that spiritual care education significantly enhances nursing students’ competencies in the Middle East and Asia. However, variability in study design, reliance on self-reported data, and limited regional representation present challenges to broader applicability. Future research should focus on refining methodologies, expanding cultural considerations, and standardizing assessment frameworks.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

PICOS:

Population, Intervention, Comparison, Outcome, and Study Design

PRISMA-P:

Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols

PROSPERO:

International Prospective Register of Systematic Reviews

SCCS:

The Spiritual Care Competence Scale

SSCRS:

The Spirituality & Spiritual Care Rating Scale

RCT:

Randomized Control Trial

ROB 2:

Risk of Bias 2 Tool (for randomized trials)

ROBINS-I:

Risk of Bias In Non-randomized Studies - of Interventions

QE:

Quasi-Experimental

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Acknowledgements

We sincerely thank our colleagues and peers at Padjadjaran University, Indonesia, and Universitas ‘Aisyiyah Bandung, Indonesia, for their continued support, constructive discussions, and encouragement.

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Open access funding provided by University of Padjadjaran

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Authors and Affiliations

  1. Doctoral Nursing Student, Faculty of Medicine, Padjadajaran University, Bandung, West Java, Indonesia

    Inggriane Puspita Dewi

  2. Nursing Department, Faculty of Health Sciences, Universitas’ Aisyiyah, Bandung, West Java, Indonesia

    Inggriane Puspita Dewi

  3. Nursing Department, Faculty of Nursing, Padjadjaran University, Bandung, West Java, Indonesia

    Hartiah Haroen, Hana Rizmadewi Agustina & Tuti Pahria

  4. Public Health Department, Faculty of Medicine, Padjadajaran University, Bandung, West Java, Indonesia

    Nita Arisanti

  5. Department of Nursing, Faculty of Nursing, Prince of Songkhla University, Pattani Campus, Thailand

    Preeya Keawpimon

  6. Faculty of Medicine, Padjadajaran University, Jl. Ir. Soekarno KM 21, Hegarmanah, Jatinangor, Sumedang, West Java, 45363, Indonesia

    Inggriane Puspita Dewi

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  1. Inggriane Puspita Dewi
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Contributions

Study conception and design: IPD Data collection: TP, HR, NA Data analysis and interpretation: IPD, HR, PK Drafting of the article: IPD Critical revision of the article: HH, HR, PK.

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Correspondence to Inggriane Puspita Dewi.

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Dewi, I.P., Haroen, H., Agustina, H.R. et al. Spiritual care competencies among nursing students in the middle East and Asia: a systematic review. BMC Nurs 24, 401 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12912-025-03047-3

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12912-025-03047-3

BMC Nursing

ISSN: 1472-6955

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