Objectives: To assess and compare the dimensions of spiritual wellness as elements of quality care in medical students of private and public medical universities.
Methods: The cross-sectional study was carried out at private and public medical universities in Karachi from November 2013 to January 2015.Students from both genders and all ethnic groups19-23 years of age were included. The responses of spiritual wellness were obtained and evaluated on a four-point Likert's scale; score ranging from 0-3. Data was analysed using Predictive Analysis Software version 18.
Results: Out of 736 students, 286 (38.9%) were from public medical universities and 450 (61.1%) were from private-sector institutions. Students of both types of universities were aware of the concept of spiritual wellness but the level of awareness needed scaling up. Public-sector students had a stronger will, were more physically and mentally alert, more compassionate, empathetic and enthusiastic about their relationship with patients than their private-sector counterparts (p<0.05). They used spiritual wellness as a coping strategy to deal with difficult situations through religious activities. Though attentive listening was a predominant feature in both groups, the use of communication skills required particular attention to improve the element of compassionate care.
Conclusion: Empowerment of spiritual wellness is more likely to enable medical students to be more compassionate towards their patients and strengthen doctor-patient relationship.
Keywords: Spiritual wellness, Spirituality, Compassionate care, Medical Students, Pakistan. (JPMA 67: 187; 2017).
Wellness has a strong impact on performance and academics of healthcare providers.1 Growing interest in holistic care has included spiritual care in health, interrelating spiritual essentials with biological, psychological, and social needs. Spirituality, spiritual wellness (SpW) and religion are all interlinked to give a unique meaning to each individual and realise the importance of the issues of spirituality and SpW to improve the quality of medical care, promote internal control and facilitate coping mechanisms in stressful situations.2
Spirituality may affect lifestyles and health behaviour and helps clinicians to offer compassionate services to their patients.3 Spiritual or compassionate care (an attribute of the healthcare provider) is a spiritual activity that serves the whole person - the physical, emotional, social, and spiritual. Compassion means "to suffer with" and compassionate care requires physicians to be empathic, non-judgmental, understanding and congruent with the patient through any stage of morbidity, coping or recovery.
Seeman et al. have shown convincing evidence that spirituality endorses hope and optimism, and inhibits depression, anxiety, mental health problems and substance abuse.4 It is therefore important to assess the healthcare provider's basic values and personal perspectives to ascertain that he is providing patient-centred or high quality care.
According to Culliford, the West has taken the lead in addressing the philosophy of SpW by relating it to health professions and students.5 Medical students from Pakistan graduate from both public and private medical universities. Public universities are subsidised and grant admission to students strictly on a merit basis. Private universities are expensive and most of their students belong to well-off families. Irrespective of the type of university, the element of compassionate care is a necessity for all medical graduates and undergraduates to enable them to provide high-quality care. Medical students are exposed to a specialised system of education and a change in educational environment with increased academic demands that can also affect their behaviour, health, learning capabilities, interpersonal relationships and even their academic performance.1,6 The teaching of spirituality in relation to health is negligible in the curricula of both sets of medical universities (MUs) in the country, emphasising the need to introduce this concept for the mental and emotional wellbeing of the students as better care-givers.
The current study was planned to assess and compare dimensions of SpW in undergraduates of both public and private medical universities.
Subjects and Methods
The cross-sectional study was carried out in private and public-sector MUs in Karachi from November 2013 to January 2015. Five private and 3 public MUs were selected for ease of access to students. To exclude any selection bias, the questionnaire was distributed among all students who were 19-23 years of age in both types of universities irrespective of gender or ethnic background.
Planned in continuation of Vander Bilt University, Wellness Resource Centre "Wellness Wheel Studies",7 the current study was approved by Ethical Review Board of Bahria University Medical and Dental College, Karachi. The questionnaire was pretested and verified for error on a group of 50 students. The reliability of the questionnaire was determined by measuring the related Cronbach's alpha which was 81%, indicating good consistency in the responses from study participants. All variables were judged on the basis of four-point Likert type scale (never, sometimes, mostly, and always) and the score ranged from 0-3, from the lowest to the highest ranks. All respondents were informed about the purpose of the survey.
Data was analysed using Predictive Analysis Software (PASW) version 18. The total scores were expressed as mean ± standard deviation (SD). Score of individual item of SpW was expressed as frequencies and percentages. Shapiro Wilk's test showed SpW scores were non-normally distributed. Therefore, Mann Whitney U Test was used to compare SpW scores between public and private MU students. P<0.05 was considered significant.
Overall, 790 questionnaires were distributed; 472(59.7%) in private MUs, and 318(40.2%) in public-sector MUs. Completely filled questionnaires were received 736(93%) students; 450(61.1%) from private, and 286(38.9%) from public MUs.
Irrespective of the type of university, 536(73%) students reported to be peaceful, calm, balanced and satisfied in life (p=0.002). Helping others, being useful, empathy and love for nature was a positive attribute of 244(85%)public students and 363(81%)private students (p>0.05). A significant difference was observed when 268(94%) of public students reported to have a strong will with physical and mental alertness compared to 330(73%) private students (p=0.001). A significant difference was observed within each group of students (p=0.001) when comparing alertness and health. Overall, 275(96%)public MU students were aware of the reason of their being and were clear about their purpose of life and had a positive attitude towards it compared to 400(89%) private MU students (p=0.001). Overall, 676(92%) students said they were religious and God-fearing (p=0.001), and 681(92.5%) were clear about their values and beliefs (p>0.05) (Table-1).
Overall, there was no significant difference between the two sets of students in stating that they fulfilled the essential quality of being honest to their profession and also implemented the criterion of delivering high-quality care by being trustworthy and reliable in the eyes of their patients(p=0.034). The responses related to the elements of compassionate care were further analysed (Table-2).
Growing interest in holistic care has included spiritual care in holistic health, interrelating spiritual needs with biological, psychological, and social needs. Spirituality is a universal phenomenon that addresses humanity and gives an insight into the phenomenon of interdependence between the healthcare provider and the patient as well as within the mind and body of the patient. The medical profession is realising the importance of the issues of spirituality and SpW to improve the quality of medical care. According to the Association of American Medical Colleges (AAMC), physicians must be compassionate and empathetic towards patients.8 Kelm et al. suggested that our future healers should be trained to provide adequate SpW, compassionate care and manage associated behavioural aspects of patient management.9 Research supports that a deeper understanding of SpW though demanding and time-dependent contributes to the development of responsibility, discipline, focus in life and stronger interpersonal relationship. Peacefulness, calmness and satisfaction point towards positive emotions and only three-fourths of our undergraduates reported to display such emotions.
Habib addressed this element in Pakistani nursing profession a sympathy and the feeling of being good to others paves the way to compassionate care.10 The aggregate scores of empathy in the study students were good, but not sufficient for appropriate performance of healthcare provider.
Concentration is the king that rules the mind and it is expected of a healthcare provider to show full attentiveness in a doctor-patient relationship. For definitive performance both physical and mental alertness with ample sleep are needed. Physical alertness improves the power of concentration by removing lethargy and the body can be made to work towards positive values and desires. Callaghan proposed that mental alertness through the same power of concentration empowers the mind to operate smoothly, reduces anxiety, depression, and improves self-esteem and cognitive functions.11 Nazir & Malik supported the positive association of religious beliefs with good mental health leading to overall positive progress in academic performance of medical students.12 Students from public MUs in the current study reported to be both physically and mentally alert and stated to have a strong will contributing to their performance. Similarly, a greater proportion of public MU students were aware of the reason of their being, revealed positive attitude towards life, and were more clear about the reason of their being.
In a study from Pakistan, medical students used mentorship as a coping strategy to acquire intellectual wellness.6 Recently, Sree et al. concluded that spiritual practice is essential not only for a tension-free life and personality management but also vital to attain competencies and skills.13 It was observed that public MU students enjoyed better SpW compared to private MU students as they were significantly more spiritual and religious than their counterparts from private MUs.
Majority of students of both medical universities understood their values, beliefs and were able to speak on them. The concept of meaning and purpose in life was, however, responded to by public MU students more than private MU ones. In a study, females reported to have more well-defined meaning and purpose of life and connected to the Almighty through modes of prayers of their religions.1 In a similar manner, patients across the globe need to be treated as a whole human being with physical, emotional and spiritual needs. Koenig et al. suggested that awareness of SpW should not be ignored in clinical practice and health-related professions as it teaches students to respect humanity and the beliefs and values of others.14 Public MU students in the present study were more respectful to the beliefs of those around them.
The attribute of attentive and passionate listening without getting emotionally involved with patients should be the decisive aim of our teachings. It was observed that public MU students were tolerant while listening to others, raising the expectation that in clinical practice they would use this tolerance in good listening and counselling.
It is expected that physicians use all knowledge, skills and compassion in patient care. Valenti et al. supported the importance of spiritual values and clinical skills in clinical care. Compassionate care, often in the form of attentive listening, creates a "healing relationship" with patients that favours outcomes, improves diagnosis and patient's adherence with treatment.15 Communication between doctors and patients has been clearly demonstrated to affect many aspects of patient care, including health outcomes. Compassionate care is thus more likely to develop stronger patient-doctor interpersonal relationships. By re-introducing, compassionate care and role of spirituality in our current health professional education, we would certainly be able to re-introduce the physician's lost hidden touch.
Unfortunately in this materialistic scientific paradigm, mind is inaccurately associated with brain; in fact mind is a dimension and compassion is a relationship issue. The only appropriate way to measure a mind is to compare it with another mind in a live relationship. Various studies suggest that the essential mind-based and relationship-based nature of a mindful healthcare worker promotes faster healing, reduces pain and anxiety and even bouncing back faster from minor ailments.16 Healthcare providers in our study stated that they were compassionate in their relationship with patients. Physician's empathy warmth and genuineness are key elements of effective human caring relationships. Compassion is not the same as empathy or altruism, though the concepts overlap. While empathy enables us to feel the emotions of another person, compassion is an action step with the desire to help. The quality of empathy was observed to be significantly more in public MU students compared to private MU students.
Lejoyeux proposed that in a doctor-patient relationship, the patients voluntarily approach a doctor and become a part of a contract which they adhere to under the doctor's guidance.17 A poor relationship leads to poor compliance, changing doctors repeatedly or even visiting quacks, eventually affecting the quality of healthcare and inability of the patients to cope with their illness. Public MU students in our study were more enthusiastic about their relation to patients compared to private students. The sense of accomplishment, satisfaction and pride after meaningful activities was also significantly more in public MU students and they felt happier after doing well. This is particularly important from the perspective of medical undergraduates as it leads to job satisfaction and prevents burnouts.
Communication has always been the cornerstone of optimal care. Shield et al. proposed integrating communication curriculum to health to improve physicians' interactions with patients and families.18 The practice of communication skills for improved care needed attention in both types of MU students. The AAMC, the World Health Organisation (WHO) and the Joint Commission on Accreditation of Healthcare Organization (JCAHO) advocate spiritual and health education to be addressed as an up-to-the-minute scientific need in clinical care and health education systems.8,19 In this regard, this study is a positive national contribution for our evolving health professional academic needs.
The present study had its limitations. Results were not analysed on the basis of gender and the sample was limited to a single city. The significant bias in reporting of individuals who believed or perceived that they were more religious and trustworthy could not be excluded. The study does not have substantial comparable national and international studies, yet it is expected that results of this study will help scale up the scope of SpW in the medical field.
The concept of SpW and compassionate care should be introduced as part of a new curriculum for healthcare and allied professionals. We also recommend that short courses in these two areas be started and faculty trained as part of faculty development programmes to attain international standards. This will eventually also permit us to get closer to achieving our desired and health-related millennium developmental goals (MDGs) for Pakistan.
Medical students of both types of universities displayed most elements of compassionate care. Irrespective of the type of university, all medical students scored well in the dimensions of SpW contributing to performance. Public MU students scored more in some attributes and used spiritual wellbeing as a coping strategy to face problems and difficulties. Attentive listening was high up, but communication skills needed attention. The notion that stability of financial status can take the students away from spiritual wellbeing is a question yet to be answered.
Declaration of Interest: None.
Source of Funding: None.
1. Rehman R, Syed S, Hussain M, Shaikh S. Health and spirituality 'walk along' in wellness journey of medical students. J Pak Med Assoc 2013; 63: 495-500.
2. Hefti R. Integrating religion and spirituality into mental health care, psychiatry and psychotherapy. Religions 2011; 2: 611-27.
3. Puchalski CM, Guenther M. Restoration and re-creation: spirituality in the lives of healthcare professionals. Curr Opin Support Palliat Care 2012; 6: 254-8.
4. Seeman TE, Dubin LF, Seeman M. Religiosity/spirituality and health. A critical review of the evidence for biological pathways. Am Psychol 2003; 58: 53-63.
5. Culliford L. Teaching spirituality and health care to third?year medical students. Clin Teach 2009; 6: 22-7.
6. Naz AS, Rehman R, Hussain M. Medical students' endeavour to make use of their mental capabilities. J Pak Med Assoc 2013; 63: 568-72.
7. Vanderbilt University. Wellness Wheel. Vanderbilt Recreation & Wellness Center. [Online] January 2016 [cited 2009 November 24]. Available from: URL: http://www.vanderbilt.edu/recreationandwellnesscenter/wellness/wellness-wheel/.
8. Puchalski CM. The role of spirituality in health care. Proc (Bayl Univ Med Cent) 2001; 14: 352-7.
9. Kelm Z, Womer J, Walter JK, Feudtner C. Interventions to cultivate physician empathy: a systematic review. BMC Med Educ 2014; 14: 219.
10. Habib S, Riaz MN, Akram M. Emotional Intelligence as Predictor of Life Satisfaction among Nurses: Mediating Role of Spiritual Wellness. FWU J Soc Sci 2012; 6: 73.
11. Callaghan P. Exercise: a neglected intervention in mental health care? J Psychiatr Ment Health Nurs 2004; 11: 476-83.
12. Nazir S, Malik S. Workplace spirituality as predictor of workplace attitudes among Pakistani doctors. Sci J Psychol 2013; 2013.
13. Sree MS, Mishra S, Jena S, Patnaik S, Begum J, Reddy NSS. Study on Spiritual Dimension of Health among Medical Students in Coastal Andhra Pradesh. Int J Health Sci Res 2014; 4: 16-20.
14. Koenig HG, Hooten EG, Lindsay-Calkins E, Meador KG. Spirituality in medical school curricula: findings from a national survey. Int J Psychiatry Med 2010; 40: 391-8.
15. Valente VE, Quitério RJ, Barnabe V, Ferreira LL, Abreu LC. Spirituality/religiosity and cardiovascular system. OA Alternative Med 2014; 2: 2.
16. Seager M. Bad Science and Good Mental Health, Therapy Today. Br Assoc Counseling Psychother 2012; 23: 7.
17. Lejoyeux M. [The doctor-patient relationship: new psychological models]. Bull Acad Natl Med 2011; 195: 1477-88; discussion 88-90.
18. Shield RR, Tong I, Tomas M, Besdine RW. Teaching communication and compassionate care skills: an innovative curriculum for pre-clerkship medical students. Med Teach 2011; 33: e408-e16.
19. Hodge DR. A template for spiritual assessment: a review of the JCAHO requirements and guidelines for implementation. Soc Work 2006; 51: 317-26.
This journal is a member of and subscribes to the principles of the Committee on Publication Ethics.