The relationship between knowledge, self-efficacy, and nursing spiritual care behaviors in school-age children in pediatric room

Introduction: Spiritual care for children is important in the care provided by nurses so that children do not feel guilty when being treated in the hospital. It is important for nurses to understand that the process of providing nursing care is bio-psycho-social and spiritual based. This study aimed to find out the relationship between knowledge, self-efficacy, and nurse behavior in the provision of spiritual care for school-age children in hospitals. Methods : This study used a cross-sectional approach with a purposive sampling technique followed by 102 nurses who cared for school-age children in a pediatric nursing room. Knowledge was measured using the Spiritual Care-Giving Scale, Self-Efficacy was measured by Burkhart Spiritual Care Inventory (BCI)


Introduction
Approximately 60% to 80% of children hospitalized feel lost, anxious, lack self-confidence, feel guilty, and want to get closer to God and 37 % of school-age children who are hospitalized need spiritual care because when they are treated at the hospital they already understand the meaning of separation and understand the illness they are experiencing (Nascimento et al 2016;Oberholzer 2016).Meanwhile, according to Bull and Gillies (2007), spiritual care is the treatment needed for children to reduce the impact of separation on school-age children.
Research conducted by Mashar and Nurihsan (2017) with school-age children treated at the hospital in Yogyakarta found a child who prays diligently is more able to accept his illness.Nurses' knowledge about spiritual care is important to know to provide the spiritual care needs of hospitalized children.Factors that influence children's nurses in the fulfillment of spiritual care for school-age children are the characteristics of the child, the environment, the http://e-journal.unair.ac.id/JNERS 275 interaction between the child and the nurse and the spiritual intelligence of the nurse herself (Glanz et al., 2015).
Based on the results of research done on nurses in Turkey using the spiritual care giving scale instrument, it was found that 46.7% of nurses did not understand part of spiritual care and 52.8% did not understand the definition of spiritual care and other factors related to the fulfillment of spiritual care by nurses in the understanding of spiritual care and nurses' experience in providing spiritual care (Çoban et al., 2015).The research in Indonesia by Sujana et al. (2017) shows that 84.2 % of nurses have good control over providing spiritual care to children.Even though the nurse's knowledge is in a good category, this treatment has not been carried out properly (Kieft et al., 2014).
Research support conducted by Kurniawati et al. (2019) in several hospitals in Central Java from 2016 to 2017 was found that 50% did not know how to provide spiritual care and lacked cooperation between multidisciplinary services to provide spiritual care.Apart from knowledge, self-efficacy is required to provide spiritual care in children.The research finds that 86.26 % of nurses had poor self-efficacy because the nurses between patients had different beliefs.Lack of this knowledge can affect nurses' behavior in providing spiritual care (Anderson et al., 2019;Frouzandeh et al., 2015).
Behavior is a reaction that arises as a result of knowledge and self-efficacy that comes from the environment or oneself.It is known that only 46.1 % of nurses can provide good spiritual care (Mamier & Taylor, 2015).This is supported by qualitative research by Alvarenga et al. (2017) explaining nurse challenges in spiritual care for children provided in culture, work time, and nurse experiences in dealing with patients' death.Previous research on the role of nurses in spiritual fulfillment in the ward room of Dr. Sardjito Hospital amounted to 63% of nurses sometimes and only 27% stated that they often prepare calm conditions to be able to pray (Nurinto, 2007).The results of the interviews when conducting clinical practice in the pediatric care room of RSUP Dr. Sardjito Yogyakarta found spiritual care is rarely done, usually given if there is a request by parents who have sick school-age children to pray and be brought in by clergy according to the patient's religion.Based on the description above, there has never been a study on spiritual care fulfillment behavior related to the knowledge and self-efficacy of nurses in the childcare room, so researchers are interested in conducting research on the relationship between knowledge and self-efficacy of nurses about spiritual care fulfillment in school-age children treated at Dr. Sardjito Hospital Yogyakarta.This study aimed to determine the relationship between knowledge and self-efficacy in the nurse's behavior in providing spiritual care in a pediatric nursing room.The research can be an additional reference for nursing education in enhancing about spiritual care to increase the knowledge and skill to implementation spiritual care to patients in providing pediatric nurses especially as one the achievements of childcare competencies by nurses.

Research Design
This study was a descriptive correlation analysis with a cross-sectional design approach intended to determine the relationship between the independent variables in this study which were knowledge and selfefficacy by the nurse and the dependent variable was behavior by the nurse providing spiritual care for pediatric patient.

Place, time population and sample
The setting of the study was conducted in May to June 2020 at RSUP Dr. Sardjito Yogyakarta.The study population in this study were 115 nurses who served in the pediatric care unit and intensive care unit.The sampling technique was carried out by purposive sampling, which was selected from each pediatric nursing room and pediatric intensive care room.The inclusion criteria were a nurse who works as a permanent employee in the childcare room for at least three months, agrees to participate in the research and signs the research agreement.The exclusion criteria were nurses working in intensive care for neonates, and perinatal care who are on leave or not on whole duty or are incarcerated during the study.Samples that met the criteria obtained as many as 102 pediatric nurses.

Instrument and data collection
The characteristics of respondents contained questions regarding the name (initial), age, gender, length of work, and the nurse education were then interpreted using distribution table frequency by displaying the frequency and percentage of each data.
Nurse knowledge about spiritual care was measured using the Spiritual Care-Giving Scale (SCGS) of 40 items consisting of five factors about spiritual care, an attribute, perspective, definition, attitude, and value of spiritual care using a Likert scale of SD (Strongly Disagree), D (Disagree), MD (Middle Disagree), MA (Middle Agree), A (Agree), SA (Strongly Agree) with 1 and 6 values the smallest value by 1 x 40 = 40 and the highest by 6 x 40 = 240.In this study, for the SCGS questionnaire researchers did back translation because there are cultural and linguistic differences from previous researchers.In back translation, the first researcher makes an initial translation, and this is given to two translators using the original language to the language for which the questionnaire will be used So that it can be seen I the differences in words that are more ambiguous in than the questionnaire using the original language.Then word selection is carried out then the bad ones are t discussed again with the translator.The second stage is synthesis of the translations and stage involves the original questionnaire version of the first translation (T1) and the translator's second (T2) This translation synthesis was first performed and produced one general translation (T-12), with a written report that carefully documents the synthesis process, every problem handled, and how items are completed.The next steps are completed with the T-12 version of the questionnaire.The third stage is the questionnaire T1 T2 version being translated by translators who do not know the original questionnaire then translate the questionnaire and return it to reflect the original language version.The fourth stage is that an expert committee reviews all translation and reaches consensus on any difference.The last stage of the adaptation process is the pretest.
Field tests of this questionnaire to use the initial version, the subjects or target sample of ideally between 30 and 40 people should be tested.The results strongly agree that interpretation is good knowledge of nurses (Tiew & Creedy, 2012).After that, the researcher did a content validity test use Aiken's V, which for this questionnaire is 0.77 -1.Furthermore, the researcher carried out the research with 30 pediatric nurses in another hospital with Cronbach's alpha 0.911 Nurse self-efficacy was measured with Burkhart Spiritual Inventory Scale Indonesian version to assess the nurse's confidence level for providing spiritual care in the domains of magnitude and strength according to Bandura.This has 16 items using the Likert scale measurement on the original questionnaire by which a score will be assigned to answers that are (4) Very Agree (SS), ( 3) Agree (S), ( 2) Disagree (TS), (1) Strongly Disagree (STS).Self-efficacy scores are compiled using normal distributions with mean and standard deviation with values of 1 and 5 with the smallest value 1 x 17 = 17 and the highest score of 5 x 17 = 85 with the interpretation that more nurses answered strongly in agreement on each item of nurse self-efficacy about spiritual care, with higher nurse's self-efficacy about Spiritual Care for the Fulfillment of Spiritual Care with validity value r = 0.645 -0.697.Cronbach's alpha value > r table = 0.891> 0.333.
The nurse behavior was measured using the Indonesian version of the Nurse Spiritual Care Therapeutic Scale (NSCTS) questionnaire with a total of 16 items measured using a Likert scale with the highest value of 64 and the lowest score of 16.The valid value obtained was r = 0.444 -0.893 and Cronbach's alpha value of s the sample of 33 nurses was 0.909.

Ethical approval
This study began by giving an informed consent form to respondents to respect the principle of autonomy, then researchers guaranteed the confidentiality of information by means of respondents only filling in their initials, not their real names.This study did not provide harm to respondents and as a form of gratitude researchers gave souvenirs.During

Data analysis
The univariate analysis describes data on the dependent, independent, and external variables in the form of a proportion and frequency distribution table.Bivariate analysis is used to determine the relationship between each independent variable (knowledge and self-efficacy), and external variables (age, gender, length of work, education, employment status, and spiritual nursing training).The data uses the Spearman correlation because the independent variable and dependent variable use interval scale and mean Whitney test for categorical variables (gender, education, employment status, and spiritual nursing training) for analysis with the dependent variable of nurse behavior using a numeric scale.
Each variable that uses a numerical scale then determines the type of test to be used; a data normality test is carried out for respondents who are more than 50 using the Kolmogorov Smirnov test.If the data are normally distributed, then the test used is the Pearson correlation test, but if the data are not normally distributed, then the test used is the Spearman correlation test.The normality test results for each variable that uses a numerical scale are p<0.05.

Respondent characteristics
Most of the respondents were women (98.0%) and their average age was 26-35 years old, with an educational level of bachelor nurse (31.4%), and length of work of average of 4-10 years old.All respondents indicated they had never been in spiritual care nursing training (84.3%) and all respondents had a good knowledge about spiritual care (100%), a high selfefficacy of 77% and good behavior for providing spiritual care at pediatric ward (Table 1).
The relationship between knowledge, self-efficacy, characteristics of nurses with nurses' behavior in providing spiritual care in the pediatric nursing room The bivariate analysis showed that each variable was associated with knowledge, self-efficacy, and characteristics of the respondent with nurses' behavior in providing spiritual care in a pediatric nursing room with a value of p > 0.05 using Spearman rank correlation for numeric variables.Categorical to numeric data used the Mann-Whitney (gender, education, length of work, training in spiritual care) against bound nurse behavior.Table 3. Description of Knowledge, Self-efficacy, and Characteristic of Nurses with Nurses Behavior of Respondents (n = 102).

Discussions
Table 1 shows that the majority of the respondents are women (98.0%) and the average pediatric nurse is 26 -36 years old.Koenig also found that females are more likely to have a good knowledge of spiritual care.At age 26 -35 , one has figured out the concepts of right and wrong, using the beliefs, morals, religions, and ethics that were the basis of planning life, evaluating according to trust and values spirituality (Koenig, 2012).Table 3 shows that knowledge variable and behavior have a positive correlation with r value = 0.133 but fall under the correlation category very weak because it ranges from 0 -0.199.This explains that the greater the knowledge score, the nurse's behavior score is also increasing in providing spiritual care.Table 2 shows majority knowledge average score is 86 -100, in contrast to research by Alvarenga et al. (2017b) that spiritual care is not only provided in the near-time premature but hospitalized school-aged children require treatment to provide inner calm during treatment.Research by Hassanian et al. (2014) also says that nurses have the need of developing, and responsibilities on the basis of professionals in applying knowledge in providing spiritual care to the patient. in contrast, long-serving nurses at categories 5-10 years and spiritual nursing training obtained that nurse more than once attended training related to spiritual care due to the basis of Based on the results of statistical analysis of the study, it was found that there was no relationship between knowledge and behavior in 102 pediatric nurse respondents at RSUP Dr. Sardjito Yogyakarta.This is supported by statistical test results using the Spearman correlation test with a p value of 0.181 (p value > 0.05) which means that there is no meaningful relationship between both knowledge variables and behavior variables.Results of the Spearman correlation test coefficient correlation value r and the variables of knowledge and behavior show a positive correlation with the value of R =0.133 but belong to the very weak correlation category because it is in the range 0 -0.199This explains that the greater the knowledge score, the nurse's behavior score is also increasing in giving spiritual care.
These results support Burns et al. (2017) who found that when a child is hospitalized it requires spiritual care because it is important for nurses to have good knowledge and understanding about spiritual care in children (Burns et al., 2017).Based on Table 1, it obtained that 69 respondents (67.6%) have a good degree of knowledge of nurses with an associate degree in nursing and working as managing nurses, 87 respondents (85.3%).This result is supported by O'Shea et al. ( 2019) that the higher level of education is not a factor for a person to have good knowledge.Table 3 explains that there is a significant relationship between the self-efficacy variable and the nurse behavior variable in fulfilling spiritual care for children in the pediatric nursing room with p-value <0.05 and a weak positive correlation.
Even though it has a positive correlation value, the strength of the correlation is weak because of the factors that influence nurses to increase the confidence of nurses to provide spiritual care, namely differences in the beliefs of nurses and patients, and researchers also accidentally meet the patient's parents when outside the room.is found that religious matters are family matters.The pediatric nurse also said this spiritual treatment is usually provided by religious leaders from the patient's family.Due to the Covid-19 pandemic, religious leaders did not visit the patient.Based on the results of the analysis of the knowledge variable on the behavior variable, the value was not significantly different and the results of the relationship test between the variable self-efficacy and the behavior variable showed a significant relationship.This can occur because knowledge determines someone to do something or show behavior, but before the behavior is formed, it can shape the nurse's behavior in providing spiritual care for patients.Other research explains that nurses with the knowledge of spiritual care can provide effective spiritual care, which can increase nurses' selfefficacy to form good behavior in providing spiritual care to patients (Burns et al., 2017;Frouzandeh et al., 2015).
Social cognitive theory supports this because behavior can be formed starting from the cognitivemotivational process and experiences to make a behavior (Bandura, 1997).This is supported by the knowledge and good self-efficacy needed by nurses to fulfill spiritual care needs.When conducting spiritual care nursing interventions, the support of good knowledge that can be obtained not only from education but at work, where there is a desire to learn to solve problems when dealing with child patients with different conditions; this can help form a high self-efficacy that is needed by nurses and can have a positive impact on their psychological condition (Harrad et al., 2019).Nurse behavior is an activity performed that can be on a basis directly and observed to show care to patients within certain constraintslimits (Alligood & Tomey, 2010).Behavior-based on care theory means nurses have an important role in providing nursing care to patients.A cure is a patient receiving nursing care from nurses, and bio-psychosocial-spiritual, spiritual and core aspects are the essence of nursing care.That is, the essence of the patient itself is receiving nursing care (Gonzalo, 2021).The study by Leeuwen and Schep-Akkerman (2015) explains good behavior is formed from nurses' perceptions of spiritual care and spiritual care competence as well as experience in increasing nurses' behavior in gifting spiritual care to children.Research supported by data at the time of the research mentions spiritual care relates to patient beliefs by providing patients with opportunities to pray together.

Conclusions
There is no significant relationship between knowledge and nurse behavior in providing spiritual care for school age children.Self-efficacy and spiritual care training are significantly related to nurses' behavior in providing spiritual care in the pediatric nursing room.Future research with the hope of parental involvement can assess the behavior of nurses providing spiritual care in the pediatric nursing room.

Table 3 .
Description of knowledge, self-efficacy, and characteristic of nurses with nurses behavior of respondents (n = 102)

Table 2 .
Description of knowledge, self-efficacy, and behavior of respondent (n 102)