The Effect of Spiritual Intelligence Training on Job Stress, Self-Efficacy and Spiritual Intelligence of Midwives Working in Hospitals

Introduction

Midwifery is a profession that is predominantly designated for women due to religious and cultural convictions, encompassing significant physical and psychological demands (1). Nonetheless, women have a vital role to play in matters concerning their families, and the psychological stress they encounter in their professional lives not only endangers their physical and mental well-being but also result in individual, familial, and societal disturbances (2). Work-related stress, as defined by WHO in 2016, is the result of individuals facing work demands and pressures that do not align with their knowledge and abilities, thereby challenging their coping abilities (3). Within the realm of stress, job stress emerges as a distinct type. It encompasses the unfavorable physical and psychological responses that individuals encounter when the demands of their occupation fail to align with their capabilities, resources, or personal needs (4).

According to the World Health Organization, over 50% of employees in industrialized countries complain of work-related stress (5). Knezevic et al. (2011) conducted a study on the work-related stress experienced by midwives working in Greek hospitals. Inadequate staff, unforeseen events, insufficient income, night shifts, and childbirth were all highlighted by 30% of these individuals as the sources of their stress. Additionally, a significant percentage of midwives (43.3%) have highlighted inadequate work organization and their interactions with superiors (supervisors and department managers) as significant stress-inducing factors (6). The study conducted by Hasheminejad et al. (2013) revealed that midwives had an average job stress score of 77.6% (1). Compared to other health professions, midwives working in Swiss maternity hospitals experienced higher levels of work-related stress and a stronger intention to seek alternative employment opportunities (7).

Self-efficacy is a crucial concept that influences an individual's performance in demanding circumstances. It pertains to the extent to which individuals believe in their ability to achieve success and their level of motivation. It influences individuals' thoughts, feelings, and performance and is considered a regulatory factor and performance predictor in difficult situations (8). It was noted by Bandura that self-efficacy is the way in which individuals view their own capabilities and self-assurance when performing tasks in a specific situation (9). The clinical performance self-efficacy of midwives was measured to be 91.9% in study conducted by Rezaei et al. (2016) (10).

Individuals with low self-efficacy have negative thoughts about their abilities, and they tend to avoid situations that exceed their perceived capabilities (11). Therefore, these individuals may avoid situations where they believe the current state is unsolvable, leading to stress, depression, and narrow-mindedness in problem-solving (12). Insufficient self-confidence may result in heightened increased work-family conflicts. Various solutions have been proposed to reduce job stress, including social and managerial support, coping skills training, and the use of experienced counselors to ensure the mental health of staffs (14). In recent times, much attention has been given to identifying the sources of stress and the methods individuals use to cope with it. It has been evidenced that employing effective coping styles plays a pivotal role in mitigating stress levels (15).  In the study conducted by Bloom (2017), relaxation exercises were employed during employees' leisure time as a means of alleviating stress (16). By fostering a sense of happiness, motivation, capability, resilience, and embracing the belief in a higher power or "God," individuals were able to effectively modify their attitudes, leading to a reduction in stress levels (17). Makki (2006) also emphasizes the importance of shifting the perspective of nurses on stress and stressors as a tactic for stress management (18). Utilizing the evidence-based teaching method in a study led to a significant improvement in the self-efficacy of nursing students, particularly within the intervention group where self-efficacy scores were notably higher (19). Furthermore, the cognitive-behavioral method of teaching happiness has been employed to enhance self-efficacy beliefs (20). In recent decades, psychologists and mental health experts have shown a growing interest in the concept of spiritual intelligence, which has been developed and emphasized within the realm of religion and spirituality (21). The World Health Organization classifies humans as biological, psychological, social, and spiritual beings, with spirituality being recognized as an essential component. Spiritual intelligence encompasses a range of abilities, capacities, and spiritual resources that, when employed in everyday life, can enhance an individual's adaptability (22). The ruler contemplates the four fundamental aspects of spiritual intelligence, which include: a) critical existential thinking, b) personal meaning production, c) transcendental awareness, and d) conscious state expansion (23). As per McSherry et al. (2002), spiritual intelligence is viewed as the fundamental core of an individual's beliefs, determining the trajectory of their life (24). Individuals possessing high spiritual intelligence demonstrate enhanced flexibility, self-awareness, and a heightened ability to confront obstacles and challenges (25).  In research conducted by Barouj Kiyakala et al. (2021), it was revealed that the package of training programs for spiritual intelligence has proven to be successful in enhancing productivity and promoting organizational commitment (26).

Also, in a study conducted by Iqbal et al. (2022), it was found that spiritual intelligence had a significant impact on the resilience of the nurses. Furthermore, another research study indicated that the joint presence of spiritual intelligence and resilience was a significant factor in predicting the level of self-efficacy among nurses (27). The implementation of spirituality has been identified as a potent resource in assisting individuals to effectively cope and adjust in the face of obstacles. By embracing spiritual values, employees can not only improve their work-life quality but also play a pivotal role in enhancing the overall performance of the organization (28). Current research has shown a clear correlation between spiritual intelligence, job-related stress, and mental health (29). Nevertheless, there is a lack of knowledge regarding the specific influence of spiritual intelligence on midwives' stress levels and self-efficacy. Midwifery is a stressful job and it is necessary to prevent the mental and behavioral effects of stress(7). Also, since the management role is crucial in improving the mental health of midwives, and also based on the researcher’s review, the identified studies were descriptive-analytical or correlational in nature, this study conducted to investigate the effect of spiritual intelligence training for midwives on job stress and self-efficacy.

Materials and Methods

A quasi-experimental study was conducted with a pretest-posttest design and a control group to examine the impact of spiritual intelligence enhancement on job stress and self-efficacy of midwives. The study was conducted on 60 employed midwives in the maternity, postpartum, and women and infant wards of three governmental hospitals in Ahvaz, Iran, from Feb. to Oct. 2020. The inclusion criteria include: 1) having a minimum midwifery associate education; 2) having working experience of at least six months and three months at the current workplace; 3) not having a history of taking drugs or being hospitalized due to mental illness; 4) not having major stress (seriousness of oneself, spouse, or children; death of a close relative; immigration; an accident; severe family disputes); and 5) failure to participate in the spiritual intelligence and stress management workshop. And the exclusion criteria included: 1) unwillingness to continue the plan; 2) absence from more than one training session.

The sample volume was measured according to Cochran's formula at a confidence level of 95% as follows: n=δ^2*z^2 1-α/2 /D^2; n = sample size; δ^2 = community variance based on past studies (32), which is equal to 0.78. Z^2 1-α/2 = confidence level for two-domain hypotheses, which is equal to 1.96 at the 95% level. D^2 = acceptable error which is equal to 0.05. n=0.78*1.96 /.025 ≅ 60.

To initiate the study, a call for participation in the spiritual intelligence training program was announced in three hospitals, and 80 midwives voluntarily enrolled in the study and assessed for eligibility. Of these, 15 midwives did not meet the inclusion criteria and 5 declined to participate; ultimately, 60 midwives were allocated to the intervention and control groups, with 30 participants in each group. All participants in both groups proceeded with the study (Figure 1).

For prevention of contamination, by a simple random method (odd number as the interventions, and even number as control) one hospital was selected for the control group and two other hospitals were selected for the intervention group. Also, the three hospitals were situated at a distance from each other, preventing any interaction among participants.  However, in each hospital, participants were purposively selected based on the inclusion and exclusion criteria. Blinding of the researcher and participants was not feasible in this study. Nonetheless, the individual responsible for distributing and collecting the questionnaires, as well as the statistical analyst, remained unaware of the allocation to the intervention and control groups. The spiritual intelligence training program (Table 1) was conducted in groups of 4 to 8 midwives, considering their work shifts every week for 8 weeks at Imam Khomeini and Amiralmomenin hospitals in Ahvaz. Following the intervention, midwives in the experimental group were directed to maintain their practice of training exercises, such as anger management, relaxation methods, self-awareness enhancement, and seeking significance in their professional and personal lives. These activities were distributed through CDs and were to be upheld for a period of 4 weeks. The control group did not receive any training. The training was provided by the first researcher, who was a M.Sc. midwifery student. She participated in a 3-day spiritual intelligence workshop and received a valid certificate. It should be noted that the second author, who was a psychologist and was a project consultant, had full supervision over the implementation of the training sessions.

The research instruments used in this study included demographic questionnaire, the Ross and Altmaier Job Stress Scale (25),  the Sherer General Self-Efficacy Scale (30) and the King's Spiritual Intelligence Scale (23), A demographic questionnaire was completed before intervention, and the job stress, general self-efficacy and spiritual intelligence scales were administered and collected before intervention, immediately after the intervention, and once more after a period of four weeks following intervention in both groups.

The demographic questionnaire consisted of data including age, workplace, educational attainment, marital status (single, married), number of children, professional background, type of employment (official, contractual, temporary, other), and job status (permanent, rotating). The Ross and Altmaier job stress scale consisted of 28 items and employs a 4-point Likert scale ranging from 1 to 4 (26). Scores below 28 suggested minimal stress, while scores between 23 and 40 signified mild stress. Moderate stress fell within the range of 80 to 86, whereas severe stress was indicated by scores between 84 and 112.  The validity of the questionnaire was confirmed through content validity by Shahraki et al. in 2010. The reliability was assessed using the test-retest method, and the Pearson correlation test demonstrated a reliability coefficient of 86 % (31).

The Sherer General Self-Efficacy Scale (GSES) was developed by Sherer and colleagues in 1982 (30). It is a 5-point scale with a score range of 17 to 85. Higher scores (closer to 85) indicate higher self-efficacy. Sherer reported the reliability of the scale as 0.76 using Cronbach's alpha. The validity of the scale was obtained through construct validity. The validity and reliability of the Persian version of the Sherer questionnaire have been confirmed in Iran by Asgharanjad et al. (2006) (Cronbach's α = 0.83) (32).

The King's Spiritual Intelligence Scale consists of 24 items and was designed and developed by King in 2008 (24). It has four subscales: critical existential thinking, personal meaning production, transcendental awareness, and conscious state expansion. The total score for spiritual intelligence ranges from 0 to 28, with higher scores indicating a higher level. King's research reported a reliability of 0.97 for the scale, using the alpha coefficient. The validity of the scale was assessed by comparing it with other valid questionnaires, including the Transpersonal Self-Interpretation Scale, the Mystical Experience Scale, and the Inner and Outer Religiosity Scale, with correlation coefficients of 0.67, 0.63, and 0.78, respectively. The validity and reliability of the Persian version of the King questionnaire have been confirmed in Iran (Cronbach's α = 0.87) (33).

Statistical analysis was conducted utilizing SPSS 25 software. An independent t-test was used to assess between-group differences, and a paired t-test was applied to examine within-group changes. Also, repeated measures tests were employed to compare continuous data within the groups. The significance level set at 0.05.

Results

The data presented in Table 2 indicates that there were no statistically significant differences observed among the participating midwives in terms of age (p = 0.306), work experience (p = 0.739), marital status (p = 0.184), education (p = 0.140), shift work (p = 0.456), employment type (p = 0.378), and workplace (p = 0.869) between the intervention and control groups (Table 2).

According to the table 3 indicates that there was no substantial distinction in the mean job stress variable between the intervention group (5.84 ± 4.12) and the control group (5.79 ± 10.96) before the training. However, immediately after the training, there was a significant difference in the mean job stress variable between the intervention group (3.65 ± 6.7) and the control group (8.76 ± 4.31) (P < 0.001), with a reduction in mean stress in the intervention group. Additionally, one month after the training, there was a significant difference in the mean job stress variable between the intervention group (5.5 ± 8.66) and the control group (6.4 ± 9.74) (P < 0.001), with a reduction in mean stress in the intervention group. The repeated measures test showed a significant reduction in job stress in the intervention group (Table 3).

Moreover, table 4 shows the mean self-efficacy score in the intervention group increased from 3.50 ± 3.30 before the training to 5.56 ± 2.49 immediately after the training and to 5.95 ± 2.59 one month after the training (P < 0.001). The distinction in the control group was not substantial; however, the intervention group exhibited a significant improvement in self-efficacy as indicated by the repeated measures test (Table 4).

Also, in the table 5, the results demonstrated that there was no notable disparity in the average spiritual intelligence variable and its components between the intervention group (3.56 ± 2.63) and the control group (3.57 ± 6.1) prior to the training (P˃0.05).

Upon completion of the training, a significant distinction in the mean spiritual intelligence variable emerged between the intervention group (5.5 ± 3.70) and the control group (6.8 ±

8.56) (P < 0.001), with the intervention group displaying a higher mean spiritual intelligence.  Furthermore, a month following the training, a notable difference in the average spiritual intelligence factor was observed between the intervention group (6.4 ± 2.79) and the control group (2.6 ± 9.49) (P < 0.001), indicating a higher average spiritual intelligence within the intervention group. The repeated measures test showed a significant increase in spiritual intelligence scores and its components in the intervention group (Table 5).

Discussion

This study sought to investigate the influence of spiritual intelligence training on the job stress and self-efficacy of midwives. The findings of study indicated that spiritual intelligence training had a notable impact on reducing job stress and enhancing self-efficacy and spiritual intelligence among midwives. These competencies play an important role in improving communication skills in midwifery practice.  In this study, factors influencing the job stress, self-efficacy and spiritual intelligence such

as marital status, education level, work shifts, employment type, and workplace were considered potential confounding variables and were homogenized between the groups prior to the intervention.

In the present study, spiritual intelligence training led to reduced job stress among midwives.

Zolfaghary et al. (2023) conducted a study on 143 midwives in Babol city, with the aim of exploring whether spiritual intelligence could be beneficial for midwives in coping with stress associated with their profession. The findings indicated that individuals with elevated levels of spiritual intelligence experienced reduced stress levels, thereby aiding midwives in effectively coping with work-related difficulties (34). Furthermore, the study conducted by Ghaleei et

1. (2016) revealed that highlighting spiritual intelligence and its components within the hospital, coupled with establishing a psychologically healthy atmosphere, led to a decrease in job stress among nurses (35). These findings are consistent with the results of the present study that spiritual intelligence training was associated with a reduction in workplace stress. Also, in both immediately and one month following the training to enhance spiritual intelligence, the elements of existential critical thinking, personal meaning generation, awareness, and mindfulness advancement exhibited a noteworthy impact in alleviating stress.

Moreover, the components of emotional intelligence—namely self-awareness, self-regulation, self-motivation, empathy, and social skills—play a significant role in influencing job-related stress. Accordingly, it is essential for professional authorities to implement educational interventions and design empowerment programs aimed at strengthening these competencies. Individuals with higher levels of emotional intelligence demonstrate greater resilience in the face of challenges and difficulties. Moreover, they tend to exhibit stronger leadership and guidance abilities and show a greater inclination toward participation in group and collaborative activities (36).

Furthermore, training in spiritual intelligence led to an improvement in midwives’ self-efficacy by 5.9 points. Specifically, improvements were noted in initiation, self-efficacy tendency, effortful perseverance, and obstacle resistance among the intervention group compared to the control group. In a study conducted by Rezaee  et al. (2016), 59.5% of the midwives working in maternity wards and healthcare centers in Mashhad, exhibited high clinical performance self-efficacy (10). Furthermore, Biranvand et al. (2020), investigated spiritual intelligence and its relationship with nurses' self-efficacy. The study revealed a significant and moderate correlation between spiritual intelligence scores and nurses' self-efficacy, highlighting a positive association. Furthermore, the results indicated that nurses with higher spiritual intelligence demonstrated greater levels of self-efficacy (37). These findings are consistent with the results of the present study that training spiritual intelligence enhanced the midwife’s self-efficacy. This relationship can be explained by considering spiritual intelligence as the highest level of an individual’s existential intelligence, which fosters the development of a new and positive perspective toward oneself, others, and the surrounding world. Given that self-efficacy refers to an individual’s belief in their abilities and skills, it may be argued that a higher level of spiritual intelligence, through the positive self-perception it cultivates, enables individuals to effectively utilize their skills and competencies during task performance (38).

It is essential for midwives to have a sufficient level of self-efficacy, in addition to their knowledge and skills, in order to effectively provide health services. The presence of self-efficacy and work engagement can significantly enhance the performance of midwives in recognizing neonatal emergencies (39).

The strength of this study is that it is the first experimental study focusing on how spiritual intelligence training impacts the job stress, self-efficacy and spiritual intelligence of midwives in Iran who work in maternity, post-partum, gynecological, and neonatal departments in hospitals. However, there were some limitations, one of which is the inability to evaluate and control other forms of intelligence, such as general intelligence and emotional intelligence. These intelligences can have an effect on the level of spiritual intelligence, but they were not taken into consideration in this study. Mental and psychological characteristics, cultural contexts, and the interest and motivation of the participants have a different effect on education, which was out of the researcher's control. 

Conclusion

The research revealed that training spiritual intelligence can decrease job stress among midwives and improve their self-efficacy and spiritual intelligence. Hospital supervisors and authorities need to conduct psychological and educational workshops to aid midwives in improving their capabilities and dealing with stress in a productive manner. It is imperative for midwifery authorities to gain familiarity with job stress, self-efficacy and spiritual intelligence concepts. By implementing positive alterations in the working environment, they can effectively mitigate stress and enhance the self-efficacy and spiritual intelligence of midwives.  It is hoped that this study will lead to improved maternal and neonatal care services.

It is recommended that midwifery authorities promote the development of spiritual intelligence in midwives and create a supportive work environment with adequate resources, support, and recognition to improve job satisfaction and retention.

Declarations

Acknowledgements

This article is based on the Master thesis of the first author (SY) and research project coded U-97117, which was approved by the Research Council of Jundishapur University of Medical Sciences, Ahvaz, Iran.  We would like to express our gratitude and appreciation to the research deputy of the university and all the midwife colleagues who supported us in this research.

Conflicts of interest

The authors declared no conflicts of interest.

Ethical approval

This research was conducted with observing confidentiality and obtaining verbal and written permission from participants. Additionally, the first researcher assured participants that their information would remain confidential and that they could withdraw from the study at any time.

Code of Ethics

The ethics committee of Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran has approved this research with the code (IR.AJUMS.REC.1397.417).

Use of Artificial Intelligence (AI)

The authors acknowledge the use of artificial intelligence tools, including GPT-5 (Open AI) and Cloud AI Services, to assist with language editing.

Funding

This study funded by the Research Vice Chancellor of Ahvaz Jundishapur University of Medical Sciences (Code of U-97117).

Authors’ contribution

SY participated in data collection and data analysis. ShKh assisted with supervision of educational sessions. SML assisted with data analysis, and ZA participated in data interpretation and also supervision of the study. All authors have read and approved the manuscript.