Clients and Patients’ Spiritual Nursing Diagnosis of the Sound Heart Model

Aim: Holistic nursing provide postural care by assessing clients and patients’ bio-psycho-socio-spiritual reactions, which could harm spiritual health due to interruption in communications with God, self, people and nature. The purpose of this study is designing and validating clients and patients’ spiritual nursing diagnosis of the Sound Heart Model. Methods: This is a “developmental research” with Sound Heart Model approach, which was done on students at the faculty of nursing and hospitalized patients of Baqiyatallah in 2016. The inductive propositions were extracted by using conventional content analysis, through interviews with clients and patients, their families and clinical nurses. Two focus group were used, besides the individual interviews to approve the validity of data. The religious evidence, were investigated systematically and deductively. The spiritual diagnosis based on religious evidence were compared with propositions stated by the participants, the list of nursing diagnosis of NANDA, and spiritual health assessment questionnaire (25 cases). 76 spiritual diagnosis were classified into four communicational domains. Applicability was assessed through two focused group discussions with the comments of 20 experienced nurses. Results: safety from divine wisdom, neglecting and forgetfulness of God in healthy clients, and the frustration of God's mercy with fear, suspicion, future anxiety, sadness of losing health in patients, were the most important spiritual nursing diagnoses. Disruption of communication with God causes disturbance in other person's communication. Conclusion: The Sound Heart Nursing Care Model provide postural care at all levels of prevention. Failure to pay attention to the spiritual problems affects physical, mental, and social health.


Introduction
Holistic nursing is responsible for caring of clients and patients, throughout their life, from birth to death, at all levels of prevention [1], by diagnosing, treating and taking care of the bio-psycho-sociospiritual reactions to actual and potential health problems [2]. The professional performance of nursing is based on its theoretical knowledge, through nursing care models, which is influenced by the philosophical perspective of theorists, who define how to take care of clients and patients [3,4]. The effect of philosophy (ontology), on people's culture and lifestyle, mood, behaviors, health habits, meaning of events, perception of health and sickness, selecting treatment and care models is different in every culture and society [5][6][7], that represents: people of every society, have their own spiritual responses to stress or diseases, based on their philosophical attitudes toward the world [8]. Reaction to disease varies from person to person, such as: an unfair event from God that causes dissatisfaction with fate, a challenge that has a solution, a factor for future anxiety or sadness of losing health, the reason for creating a sense of revenge from the cause of disease with frustration, or vice versa: time for rest and care with the hope to spend the course of disease, easily [9]. Distinctive differences in the response of different patients to the disease emphasize the necessity of community-oriented care [10]. The WHO emphasizes the consideration of clients and patients' values and beliefs [11]. An essential element of holistic nursing is assessing client and patients' bio-psycho-social-spiritual reactions ( Figure 1) [12]. The uncertainty of life events and incidence of diseases, create spiritual needs that necessitate spiritual care [5]. The Sound Heart model is a spiritual care model from Abrahamic religions viewpoint, which accepts the spirit in human beings as the default and define the soul (heart) as the "spiritual, gentle, divine, identifier, wise and mighty essence that is assigned by God, is the place of emotions which perceives the surrounding environment, is addressed by God for His reward and punishment [13]. The soul gives existence to human and has capable of perceiving, feeling, moving, reasoning, and determining [14,15]. The Holy Quran attributes three items of perceptions, emotions, and acts to the heart, which result from one another; as perceptions cause emotions which result in acts. Among these three dimensions, perception is the essential component, emotion and action originate from perception. Some hadiths have interpreted the heart as wisdom [16,17]. Unfortunately, the global care models have ignored clients and patients' soul [18]. Although the spiritual distress as a nursing diagnosis was accepted of NANDA in 1988 [19] and the parish nurses with respect the entire human being, is being practiced in various communities in the U.S.A with regard spirituality as" a key aspect" of health and treatment [20] but because of the inductive epistemological method [21], theories and models of nursing care could not assess the immaterial (spiritual) dimension of the human [22] for this reason, spiritual diagnosis have been neglected. Regarding the necessity of using revelation epistemology to recognize human's divine soul, belonging to the unseen world, besides examining clients and patients' spiritual responses to stress and illness, the purpose of this study is designing and validating clients and patients' spiritual nursing diagnosis of the Sound Heart Model.

Materials and Methods
First, Vienna's Psychotherapy perspectives, systemic theory and homeostasis, quantum theory and the rules of physics, humans' needs and characteristics of a perfect human in psychology as assumptions of nursing care models, and over 35 nursing care models from the development of these models up to 2015 were analyzed [23] as follows: • Seven global care models were analyzed based on total ratio analysis that can be compared with perceptual analysis and communication analysis of Carly (1992) in nursing [18]. • Metaparadigmatic concepts of the model (human, health, environment, disease, care) were defined. The concept of soul was derived from paradigm of Abrahamic religions, and the concept of sound heart (spiritual health) was derived from Quran and hadiths based on Walker Avant's adoption of the concept method [24]. • The Sound Heart model was developed regarding the core concept by using grounded theory method [25]. • To examine the concept of sound heart in real situations and define experimental parameters and themes of the concept, inductive propositions were extracted by using the conventional content analysis [26]. The data collection instruments included an in-depth semi-structured interview containing open-ended questions and the focus group discussion.

The individual interview
After obtaining the informed written consent and approval of the university ethics committee, by protecting the privacy of the participants, they were selected through targeted sampling and invited for individual in-depth semi-structured interviews. Demographic information, including age, marital status, social support systems, and comorbidities were collected from participants. The researcher ran a pilot study to familiarize with the potential unpredicted problems and to develop the questions. Some of the questions for beginning the interview were as follows: • Please talk about your feelings and emotions about your current disease or stressors.
• What are the emotions caused by the situation? How do you cope with the emotions? • When do you feel emotionally relaxed and secure? • Has the situation caused adverse emotions and feelings in you?
Why have such emotions and feelings happened?
The focus group discussion Two focus group were used, besides the individual interviews to complete and approve the validity of data. The focus group comprised a certain number of students and patients who were not interviewed individually for the purpose of increasing the rigor and strength of the study and accuracy and comprehensiveness of the data.
Item analysis: The conventional qualitative content analysis was used to collect and analyze the data. In this analysis, the categories were determined during the item analysis. The analysis was performed through constant comparative analysis, which is a method for determining the reliability and validity of data. All participants 'statements and expressions were transcribed verbatim, and item analysis was conducted. The three-phase coding was performed to determine scales, subscales, and items.
The spiritual diagnosis induced from religious evidence, propositions stated by the participants, the list of nursing diagnosis of NANDA, spiritual health assessment questionnaire (25 cases) were compared, reviewed, and classified. The content validity was assessed through the Delphi method by obtaining the opinions of 10 faculty members of different Universities. Applicability was assessed through focused group discussions with the comments of 10 experienced professors

Results
Spiritual diagnosis can be classified into two groups as follows: • Spiritual diagnosis relevant to patients and their family • Spiritual diagnosis relevant to clients Although NANDA has provided the following nursing diagnosis: anxiety, death anxiety, fatigue, fear, predicted sorrow, chronic sorrow, ineffective social adaptation, social isolation, disappointment, loneliness, vulnerability, self-care inability, ineffective rejection, being offensive to self or others, disturbed protection, disturbed identity, disturbed role playing, disturbed self-confidence, disturbed selfperception, and spiritual distress, a number of religious evidence based diagnosis have been ignored in science. To perform the spiritual care by nursing process, nurses or spiritual advisors, should firstly examine clients and patients' spiritual responses in three areas: thoughts and beliefs, moralities and emotions, and verbal and non-verbal behaviors, then detect disorders in communications with God, themselves, people, and nature. They should practice, based on evidence-based instructions and spiritual health model for reaching a sound heart [44,45].
The results of this study revealed the following diagnoses in the four domains of communication (Table 1).

The patients' disturbed relationship with God included:
1-feeling of insecurity: arising from distrust in God's power, wisdom and mercy 2-Hidden polytheism: considering the physician as a healer, because of lack trust in God and fail to delegate the treatment to God

Discussions
To fulfill pastoral care, nurses should increase their knowledge about spirituality and the influence of clients and patients' spiritual beliefs on lifestyle, responses to stress and diseases, choice of care and treatment [46]. The spiritual care generally depends on understanding clients and patients' spiritual beliefs and needs [47] such as: communicating with God, need to a meaningful and purposeful life, receiving and giving love, hopefulness, creativity, forgiveness and honest communication with themselves and others [48]. The spiritual evaluation addresses individuals' perception of God or divinity, the source of power and hopefulness, the importance of religious practices, and the relationship between their personal beliefs and health status [49]. Results of other studies have shown four areas of spirituality that normally evaluated in patients as follows: fear of medical practices, sources of patients' internal power, feeling of hopefulness, religious practices related to the surgery, but integrity, as a dimension of spiritual evaluation, has been less reported by nurses [50]. Although the goal of nursing care, is to promote health, prevent of diseases, maintain health, and relieve patients' pain and suffering, and the spiritual care is influential in reaching these goals [51] by reducing patients' stresses during their hospitalization through focusing on optimism and hope to the mercy of God, but there are still few nurses providing spiritual care [5]. Over 50% of nurses do not try to provide spiritual care to patients in practice and feel that, they are not competent enough in this regard [46]. Nurses may also feel that spiritual issues are not related to their profession but is related to clergymen [52]. For nurses interested in pastoral care, most nursing books lack, enough training materials on spiritual care practice [53,54]. Those books emphasize patients' physical and mental needs rather than their spiritual needs [47] and do not contain much scientific materials on the spiritual dimension of nursing care [55]. None of the courses of Iranian nurses' academic education, discusses the manner and necessity of providing spiritual care to patients or clients, and this important matter is ignored. The spiritual care teaching process in Iran, which involves the concept of patient-oriented care, is a dynamic and unsystematic process hidden in social interactions and is developed often clinically under the influence of religious, spiritual, and cultural knowledge of students, through modeling the behavior and personality of professors/trainers, and under the influence of the educational ruling atmosphere, informally without planning. The students' clinical modeling and informal learning, occur through choosing popular individuals with spiritual attributes and good interactions.
Although Pullen introduce reasons of nurses' failure to consider spirituality as: nurses' low levels of spiritual consciousness, fear of affecting patients by their own beliefs, time limitations, lack of training on interventions related to spirituality in nursing. Yardley explains challenges of implementing the spiritual care as: the difficulty with determining patients' spiritual needs, determining the person responsible for providing the spiritual care, and determining the degree of trust in accuracy of spiritual interventions. Although nursing care providers try to provide holistic care services, the evaluation of the provided care, shows patients' dissatisfaction and neglect of their spiritual needs, which damage the patients and nursing profession irreversibly. However, the paradigm of Abrahamic religions, introduces bio-psycho-social-spiritual needs for the clients and patients and the efficient strategy of faith therapy for achieving sound heart (a peaceful soul that is confident with God, full of security and trust, love, happiness, hopefulness, satisfaction). Deep faith in God and worship, directed humans' communications with themselves, people, and nature to sake of Allah. Religion shows the way to reach the truth, that is, closeness to God, and modifies thoughts and beliefs, moralities and emotions, and verbal and non-verbal behaviors. Religion not only determines characteristics, which are equal to morals, for a perfect human (God's caliph) but also introduces spiritual diagnosis (humans' responses to various difficulties). The review of existing nursing diagnoses showed that, there is no comprehensive list that can check all four individual's communication. The use of religious spirituality and divine epistemology and its rich resources can fill the gap in this regard.

Conclusion
The analysis of clients and patients' spiritual nursing diagnosis is necessary for providing pastoral care. These are different in different cultures, based on the attitude toward health and sickness. Culture influenced by people's philosophical attitude that results from epistemological methods, thus the analysis of clients and patients' spiritual responses has a philosophical basis. Therefore, diagnosis of spiritual problems and pastoral care in followers of monotheistic