Background
The Dictionary of Public Health offers the following definition of health“a structural, functional and emotional state that is compatible with effective life as an individual and as a member of family and community groups” [1]. One integral part of the well-being of all people is spirituality. The term ‘spirituality’ derives from the root ‘spirit’ and corresponds to the Latin spiritus, which means being alive or life is supreme [2]. Specifically, spirituality can be defined as “a way of life, informed by the moral norms of one or more religious traditions, through which the person relates to other persons, the universe, and the transcendent in ways that promote human fulfillment (of self and others) and universal harmony” [3]. Giske et al. define spirituality as “The dynamic dimension of human life that relates to the way persons (individuals and communities) experience, express and/or seek meaning, purpose and transcendence and the way they connect to the moment, to self, to others, to nature, to the significant and/or the sacred” [4].
Spiritual care begins with the encouragement of human contact in a compassionate relationship and develops in whatever direction need requires [5]. As an integral part of holistic care, spiritual care should be taken more seriously by nurses and nursing students in their relationships with patients [6]; however, spiritual care is often neglected in practice [7]. Yet the literature reports that spiritual care is effective in reducing pain, stress, and depression in patients [8, 9] and increases the quality of care and patient satisfaction [10, 11]. Therefore, increasingly more attention has been paid to the spiritual care competency (SCC) of nursing interns. SCC refers to the ability of nurses to assess and implement measures to meet the spiritual needs of patients in cooperation with a multidisciplinary healthcare team [12]. The current general standards for nurses’ SCC include intrapersonal spirituality, interpersonal spirituality, spiritual care assessment and planning, and spiritual care intervention and evaluation. Spiritual care education is a pivotal factor in improving nursing students’ ability to recognize and respond to people’s spiritual needs and in increasing their open-mindedness towards diverse religious and cultural perspectives [13]. However, the inclusion of spiritual care education in nursing curricula has been overlooked [14]. Understanding nursing students’ perspectives and how their spiritual development is shaped is crucial for informing nursing spiritual care education and cultivating qualified nurses with strong spiritual care skills and professional competence.
Anzeige
Previous studies have shown that factors influencing students’ competence include clinical experience [15], positive attitudes [16], prior spiritual care education and liking the nursing profession [17], willingness to provide spiritual care [18], and experience of personal life events (both positive and negative) [19]. Research on the SCC of nurses in foreign countries is relatively mature. National guidelines and nursing care regulations emphasize the importance of competent spiritual care, but evidence for best practices in building spiritual care competency among pre-licensure and licensed nurses is sparse [20, 21]. Therefore, in 2019, the members of our research team sinicized the Spiritual Care Competence Scale (SCCS), a scale that has good reliability and validity, for research among nurses in China [22].
Spiritual health is a state that transcends individual limitations. It requires individuals to constantly analyze themselves, clarify the meaning of life, shape good values, and form the ability to harmoniously connect with others, society, and nature [23]. Research has indicated that spiritual health serves as a coping mechanism to enhance individual mental health, facilitate emotional regulation, and promote inner comfort and peace [24]. Nurses with elevated levels of spiritual health are more inclined to comprehend and empathize with the perspectives, emotions, and behaviors of patients from a spiritual care standpoint, fostering more harmonious patient relationships [25]. High levels of spiritual health are essential for delivering high-quality spiritual care. Nurses must possess faith in order to provide both psychological and spiritual care to patients, while also being able to recognize the barriers and challenges involved in providing spiritual care and maintaining sufficient levels of spiritual health to deliver high-quality service [26].
Nurses in the United States [27], Turkey [28], Taiwan (China) [29], and other regions have been found to have a moderate level of SCC. Nursing education should cultivate the SCC of nursing students during their studies, preparing them for their future job responsibilities. However, limited research has focused on the SCC and spiritual health of student nurses, as well as the potential relationships between these factors. Therefore, this study investigates the current state of SCC and spiritual health among nursing interns in China, examining the relationship between them. The findings will assist nursing managers and educators in developing appropriate intervention strategies.
Methods
Study design and participants
This cross-sectional study recruited 361 nursing interns from three general hospitals in Henan province, China, from February to April 2024. The sample size was determined using data from the literature, considering a 5% level of signifcance and an 80% power of study. The sample size can be determined using the following formula: n=(Z2α/2α2) /d2. Where Zα/2 = is the standard normal variate, at 5% type 1 error, it is 1.96, d = absolute error or precision. So, n = (1.96)∧2*15∧2/22=346. According to the formula above, 346 is the total sample size needed for the investigation. Our sample is statistically signifcant because its size of 361 was greater than the minimum of 346. Therefore, we are confdent that our fndings will be reliable and robust. The inclusion criteria were: (1) nursing students with a college or bachelor’s degree; (2) at least six months of internship experience; and (3) voluntary participation in the study. The exclusion criteria were: (1) termination of internship for any reason; (2) withdrawal from the study.
Anzeige
Data collection
After obtaining consent from the hospital administrators, one or two investigators were assigned per hospital and used social communication programs (e.g., WeChat) to inform participants about the purpose of the study, survey duration (10–20 min), and inclusion and exclusion criteria. These details were also included in the questionnaire instructions. After obtaining participant consent, all electronic questionnaires were collected using the professional platform ‘SO JUMP’.
Measurements
The self-rating online questionnaire included sections on sociodemographic characteristics, the SCCS [30], and the Spiritual Health Scale-Short Form [22]. Participants’ sociodemographic data included sex, age, education, night shift work, only child status, homestyle, origin of student, exercise habits, religion, future engagement in nursing care, scholastic attainment, sharing feelings behavior, and willingness to share feelings. Nursing interns’ SCC was measured using the SCCS, which was developed by van Leeuwen et al. (2009) and translated by Hu et al. [22]. The SCCS consists of 27 items distributed over three metrics: assessment, implementation, specialization, and quality improvement of spiritual care (12 items); individual and group support (9 items); and spiritual attitude and communication with patients (6 items). This instrument is scored on a 5-point Likert scale, with a total score for SCCS ranging from 27 to 135. A higher score indicates higher SCC. Scores of 27–56 were classified as the mild-level group, 57–105 as the moderate-level group, and 106–135 as the high-level group. In this study, Cronbach’s alpha for the SCCS ranged from 0.956 to 0.987.
The Nurses’ Spiritual Health Scale (NSHS) was developed by scholars in Taiwan (China) [30] in 2013, using nursing students as the sample group. In this study, the nursing interns used The Nurses’ Spiritual Health Scale Short Form. The questionnaire consists of 24 items distributed over five metrics: connection to others (4 items), meaning derived from living (6 items), transcendence (6 items), religious attachment (4 items), and self-understanding (4 items). This instrument was scored on a 5-point Likert scale, with a total score ranging from 24 to 120. In this study, Cronbach’s alpha for the questionnaire ranged from 0.917 to 0.967.
Ethical considerations
This study received approval from the Ethics Committee of Guangzhou Medical University(L202306002).All participants were provided with comprehensive information regarding the study objectives and purposes before inclusion. Subsequently, participants were requested to independently and anonymously complete the online questionnaires.
Data analyses
All analyses were performed using IBM SPSS 25.0 (IBM Corp., Armonk, NY, USA).
Normal distributions for nursing interns’ SCC and spiritual health were examined using quantile-quantile plotting. Descriptive analysis was conducted for all data, including percentages, means, and standard deviations. The t-test and analysis of variance (ANOVA) were used to compare demographic differences in nursing interns’ SCC. Pearson correlation analysis was employed to examine the relationship between nursing interns’ SCC and their spiritual health. Multiple stepwise linear regression analysis was used to identify factors influencing nursing interns’ SCC.
Results
Demographics
At the time of this study, most participants were women (86.1%), and over half (76.5%) intended to engage in nursing care in the future. Among the participants, 85.6% held an associate degree, and 50.7% worked four to nine night shifts per month. Additionally, 89.2% came from complete families, 9.4% were only children, and 76.5% were from the countryside. More than half of the participants (57.6%) had good grades, and 46.3% had good exercise habits. Most participants (95.8% and 96.7%) exhibited behaviors and willingness to share feelings. The t-test and ANOVA revealed significant differences in nursing interns’ SCC concerning night shift work, department exercise habits, scholastic attainment, sharing feelings willingness, and future engagement in nursing care (P < 0.05) (Table 1).
Table 1
Comparison of spiritual care competency among nursing interns with different socio-demographic characteristics (N = 361)(P < 0.05)
Socio-demographic characteristics | N (%) | Spiritual care competency M (SD) | t/F | P |
|---|---|---|---|---|
Sex | ||||
Male | 50(13.9) | 111 ± 22.52 | 1.417 | 0.157 |
Female | 311(86.1) | 106.63 ± 19.85 | ||
Education background | ||||
Associate degree | 309(85.6) | 107.26 ± 19.19 | 0.002 | 0.963 |
Bachelor degree | 52(14.4) | 107.12 ± 25.99 | ||
Night shift/M | ||||
0–4 | 135(37.4) | 110.66 ± 19.24 | 3.137 | 0.045 |
5–9 | 183(50.7) | 105.33 ± 20.76 | ||
≥10 | 43(11.9) | 104.60 ± 20.25 | ||
Only child | ||||
Yes | 34(9.4) | 106.76 ± 20.12 | -0.142 | 0.887 |
No | 327(90.6) | 107.28 ± 20.3 | ||
Homestyle | ||||
Complete family | 322(89.2) | 107.84 ± 20.48 | 1.699 | 0.167 |
Single-parent family | 26(7.2) | 105.38 ± 19.5 | ||
Reconstituted family | 9(2.5) | 93.11 ± 13.15 | ||
Separated families | 4(1.1) | 102.75 ± 7.27 | ||
Origin of student | ||||
City | 67(18.6) | 106.15 ± 23.63 | 0.173 | 0.842 |
Country | 276(76.5) | 107.49 ± 19.6 | ||
Urban-rural continuum | 16(4.4) | 105.5 ± 17.28 | ||
Exercise habit | ||||
Yes | 167(46.3) | 111 ± 19.88 | 3.320 | 0.001 |
No | 194(53.7) | 103.99 ± 20.08 | ||
Religion | ||||
Yes | 11(3) | 111.18 ± 12.16 | 0.103 | 0.513 |
No | 350(97) | 107.11 ± 20.46 | ||
Engaged in nursing care in the future | ||||
Yes | 276(76.5) | 109.36 ± 19.47 | 11.158 | 0.000 |
Unsure | 82(22.7) | 101.55 ± 20.00 | ||
No | 3(0.8) | 67.33 ± 35.22 | ||
Scholastic attainment | ||||
Excellent | 120(33.2) | 113.02 ± 22.89 | 7.651 | 0.001 |
Good | 208(57.6) | 104.17 ± 17.98 | ||
Qualified | 33(9.2) | 105.52 ± 19.73 | ||
Sharing feelings behavior | ||||
Yes | 346(95.8) | 107.37 ± 20.21 | 0.592 | 0.554 |
No | 15(4.2) | 104.2 ± 21.93 | ||
Sharing feelings will | ||||
Yes | 349(96.7) | 107.66 ± 19.87 | 2.182 | 0.030 |
No | 12(3.3) | 94.75 ± 27.80 |
Anzeige
Spiritual care competency
Quantile-quantile plotting showed that the data for SCC and spiritual health were approximately normally distributed. Therefore, means and standard deviations were used to describe the states of these two variables. The total mean SCC score among nursing interns was 107.24 ± 21.67. The mean scores for the components of assessment, implementation, specialization, and quality improvement of spiritual care; individual and group support; and spiritual attitude and communication with patients were 47.75 ± 9.27 (out of 60), 34.65 ± 7.72 (out of 45) and 24.84 ± 4.68(out of 30), respectively. These scores indicated that nursing interns had a medium-high level of SCC (Table 2).
Table 2
Descriptive analyses of spiritual care competency and spiritual health (N = 361) (P < 0.05)
Variables | Min. | Max. | Dimension M | Item M | SD |
|---|---|---|---|---|---|
Spiritual care competency | |||||
Assessment, implementation, specialization and quality improvement of spiritual care | 12.00 | 60.00 | 47.75 | 3.98 | 9.27 |
Individual and group support | 9.00 | 45.00 | 34.65 | 3.85 | 7.72 |
The spiritual attitude and communication of patients | 6.00 | 30.00 | 24.84 | 4.14 | 4.68 |
Total score | 27.00 | 135.00 | 107.24 | 11.97 | 21.67 |
Spiritual health | |||||
Connection to others | 4.00 | 20.00 | 17.70 | 4.43 | 3.39 |
Meaning derived from living | 6.00 | 30.00 | 26.41 | 4.40 | 4.63 |
Transcendence | 6.00 | 30.00 | 25.98 | 4.33 | 4.83 |
Religious attachment | 4.00 | 20.00 | 8.09 | 2.02 | 4.71 |
Self-understanding | 4.00 | 20.00 | 17.19 | 4.30 | 3.31 |
Total score | 24.00 | 120.00 | 95.37 | 19.48 | 20.87 |
Spiritual health
The total mean score of nursing interns’ spiritual health was 95.37 ± 20.87 out of a possible 120. The mean scores for the components were as follows: connection to others (17.7 ± 3.39 out of 20), meaning derived from living (26.41 ± 4.63 out of 30), transcendence (25.98 ± 4.83 out of 30), religious attachment (8.09 ± 4.71 out of 20), and self-understanding (17.19 ± 3.31 out of 20), indicating that nursing interns experienced medium levels of spiritual health (Table 2).
Relationship between SCC and spiritual health
The total mean score for SCC and its three dimensions was significantly positively correlated with the total score for spiritual health and its four dimensions (P < 0.01). Most correlation values ranged from 0.3 to 0.5, indicating a moderate correlation between SCC and spiritual health (Table 3).
Anzeige
Table 3
Correlation analyses (R values) between spiritual care competency and spiritual health (N = 361) (P < 0.05)
Assessment, implementation, specialization and quality improvement of spiritual care | Individual and group support | The spiritual attitude and communication of patients | Total score for spiritual care competency | |
|---|---|---|---|---|
Connection to others | 0.365** | 0.243** | 0.310** | 0.331** |
Meaning derived from living | 0.544** | 0.418** | 0.495** | 0.522** |
Transcendence | 0.548** | 0.420** | 0.486** | 0.523** |
Religious attachment | 0.077 | 0.150** | 0.031 | 0.1 |
Self-understanding | 0.525** | 0.434** | 0.504** | 0.522** |
spiritual health | 0.563** | 0.459** | 0.497** | 0.547** |
Factors associated with SCC
SCC scores among nursing interns were taken as the dependent variable, and the six statistically significant variables (night shift per month, exercise habits, future engagement in nursing care, scholastic attainment, willingness to share feelings, and five dimensions of spiritual health) identified in univariate and correlation analysis were taken as independent variables. Multiple stepwise linear regression analysis showed that night shifts per month, transcendence, religious attachment, and self-understanding were the main predictors of nursing interns’ SCC, explaining 32.1% of the total variation (Table 4).
Table 4
The multiple stepwise linear regression analysis of spiritual care competency of nursing interns (N = 361) (P < 0.05)
Variables | B | SE | Beta | t | P |
|---|---|---|---|---|---|
Night shift/M | -0.112 | 0.050 | -0.098 | -2.233 | 0.026 |
Spiritual health | 0.653 | 0.053 | 0.547 | 12.393 | 0.000 |
Discussion
This study aimed to investigate the current state of nursing interns’ spiritual care competency (SCC) and its relationship with their spiritual health.
Anzeige
Spiritual care competency
The mean SCC scores of nursing interns in this study were consistent with the findings in Turkey [31], but significantly higher than those in the five Middle Eastern countries [32]. Although nursing students’ self-evaluation scores for spiritual care competency are at a medium-high level, there is considerable room for improvement, especially in the areas of personal and group support, spiritual attitude, and communication with patients. In this study, the average scores for the components of assessment, implementation, specialization, and quality improvement of spiritual care were the highest, while the scores for spiritual attitude and communication with patients were the lowest. This suggests that while nursing interns can identify patients’ spiritual needs and have a partial understanding of spiritual care, significant gaps remain in their training. The field of educational research on spiritual care in China is still in its nascent stage, and nursing students currently lack access to professional courses focused on spirituality. This leads to a lack of theoretical knowledge and practical challenges. Therefore, it becomes imperative for educators and nursing management to find ways to enhance the level of spiritual care competence among nursing students.
Factors influencing nurses’ SCC
In this study, it was observed that a significant proportion of nursing interns experience a high frequency of night shifts, with implications for their well-being and performance. Long-term repeated night shifts disrupt regular work and rest patterns, often leading to psychological stress and physical and mental fatigue [33]. These factors ultimately affect the SCC (specific competency or outcome being discussed) of nursing interns. To address this, it is recommended that nursing managers implement a flexible scheduling system tailored to the rotation status and individual capabilities of nursing students. Such an approach would enable a more balanced distribution of night shifts, reducing the overall workload and alleviating psychological pressure on interns. This adjustment could contribute to improved well-being and performance among nursing interns, fostering a more supportive and sustainable work environment.
The findings also highlight considerable room for improvement in the spiritual care competency (SCC) and spiritual health level of Chinese nursing interns, with a positive correlation identified between the two. Spiritual care teaching enhances understanding of spirituality’s complexity and increases confidence in engaging with spiritual care. Personal beliefs and values play a key role in perceived SCC. However, integrating spiritual care content into an already loaded undergraduate nursing curriculum remains challenging, particularly in creating opportunities for students to practice this abstract skill [34]. Many participants expressed limited knowledge of spiritual care, with a significant portion stating that the concept was not adequately addressed in their nursing curriculum or that they were unsure how to approach patients’ spiritual needs [17, 31] This lack of training may explain the participants’ limited competence in spiritual caregiving, a finding consistent with other studies in the literature [18, 19, 35].
To address these gaps, it is essential to inform and train nursing students about spiritual care. When students are equipped to recognize and address spiritual care needs, the quality of nursing care can be significantly improved. As suggested by Cruz et al. [36], providing spiritual care training to nursing students can effectively enhance their spiritual caregiving abilities. This study further supports the importance of improving spiritual education and training, as nursing interns’ spiritual health was found to be positively correlated with their SCC. Therefore, nursing managers and educators should prioritize spiritual care practice and strengthen interventions to improve nursing interns’ spiritual health. This approach will enhance SCC, enabling nursing interns to better meet patients’ spiritual needs and provide optimized care.
Spiritual health
The spiritual health of the study participants reflected a moderate level, with meaningful insights derived from their practical experiences. Nursing students demonstrated a strong sense of meaning derived from living, which was the highest-scoring dimension. This suggests that their clinical and practical experiences contributed significantly to their understanding of life’s purpose. Conversely, the dimension of religious attachment received the lowest score, likely due to the fact that only a small proportion (3%) of the nursing students identified as having religious beliefs. As a result, most participants had limited exposure to or understanding of religious activities and beliefs, which may explain the lower scores in this dimension. These findings align with previous literature [37], highlighting the importance of addressing spiritual health in nursing education, particularly in areas where students may have less exposure or familiarity, such as religious attachment. This underscores the need for a more holistic approach to spiritual care training, ensuring that nursing students are equipped to address diverse spiritual needs in their practice.
Effects of nursing interns’ spiritual health on SCC
In our study, nursing interns’ spiritual care competency (SCC) was found to be positively correlated with their spiritual health, highlighting the importance of spiritual well-being as a predictor of SCC. Nursing interns with higher spiritual care competence often exhibit strong communication skills and foster harmonious relationships with patients. They are more likely to empathize with and understand patients’ perspectives, emotions, and behaviors through the lens of spiritual care, a process that can subtly enhance their own spiritual health. As Wang et al. have emphasized, nurses’ spiritual health serves as the foundation of clinical nursing services and plays a critical role in shaping nursing practice [38]. Nurses with higher levels of spiritual health are better equipped to deliver high-quality spiritual care [25]. Recognizing this, organizations such as the American Nursing Association and the International Nurses Association have integrated spiritual health into their practice guidelines and norms to evaluate spiritual care competence [39].
Additionally, nursing interns with a high level of spiritual health are better equipped to recognize their limitations and the significance of spiritual care in clinical practice. These individuals demonstrate strong listening and empathetic skills, actively fostering harmonious relationships with patients. They are adept at utilizing available resources to address patients’ spiritual perceptions, emotions, and life circumstances. Through systematic and scientific training, they strive to enhance the efficiency and standardization of spiritual care, ultimately achieving genuine spiritual health and self-harmony. This process not only improves their personal well-being but also fundamentally strengthens their capacity to provide effective spiritual care.
As highlighted by Yi-Chiang’s research [40], nurses’ perspectives on spirituality and their own spiritual health play a crucial role in shaping their ability to understand and address patients’ spiritual needs. Not all nursing interns are inherently prepared to deliver spiritual care; their competence in this area is closely tied to their level of spiritual health. A key component of spiritual health, as measured by the SHS-short form, is “meaning derived from living,” which reflects how nurses find and express purpose in their lives. This dimension underscores the importance of fostering a sense of meaning and fulfillment in nursing students, as it directly influences their ability to provide compassionate and effective spiritual care to patients. By prioritizing the development of spiritual health in nursing education, we can better prepare interns to meet the holistic needs of their patients.
Nursing is fundamentally a profession centered on helping others [40]. Through the process of providing spiritual care to patients, nurses can enhance their own sense of life values and meaning, often experiencing a profound sense of fulfillment and reward in their work [41]. By addressing the spiritual distress of patients, particularly those facing life-threatening conditions, nurses not only support their patients but also cultivate their own spiritual well-being and find deeper meaning in their lives.
Strengths and limitations
The strengths of our research lie in the following factors. First, this study explored the relationship between SCC and spiritual health, a topic that is rarely reported. Second, our research team used the SCCS in this study, which has been shown to have good reliability and validity and has been widely applied by scholars worldwide. Third, this study aims to provide a theoretical foundation for future research on the spiritual care abilities of nursing students, thereby facilitating the optimization and reform of spiritual education courses for nursing educators in our country.
However, several limitations should be considered. First, we adopted a self-report questionnaire, which may introduce response bias; participants’ responses might not accurately reflect the actual situation. Second, the sample size was not sufficiently large. Third, the survey could not track changes in nursing interns’ SCC over time. Future longitudinal studies with larger samples and path analysis are needed to increase the practicality of spiritual care research and provide a basis for formulating spiritual care education and intervention for nursing students.
Conclusions
This study suggests that there is considerable room for improvement in the spiritual care competency and spiritual health of Chinese nursing interns and that there is a positive correlation between the two. Spiritual health and the number of night shifts per month were the main predictors of SCC among nursing interns. This study demonstrated the correlation between nursing interns’ spiritual health and SCC, providing new insights for nursing managers and educators to formulate intervention measures to improve nursing interns’ SCC. In the future, to promote nursing students’ awareness of spiritual care and cultivate their ability to engage in it, we must focus on two main aspects: first, spiritual care should gain more attention in nursing education, addressing the spiritual perspectives of students; second, spirituality and spiritual care should be integrated into nursing curricula to develop nursing students’ competence and improve their attitude toward spiritual care in clinical practice.
Implications for nursing managers and educators
We evaluated the SCC among nursing interns and explored the relationship between spiritual health and SCC. The results of this study suggest that further improvement of the SCC of nursing interns in China remains necessary. To achieve this, the following strategies are recommended: First, introducing spiritual theoretical knowledge to pre-nursing students early in their education. Clinical practice should be integrated to allow students to have close contact with patients, fostering empathy and enhancing their spiritual cognition. Second, utilizing the internship stage of nursing students to provide training in spiritual care skills. As nursing students have more contact with patients during this period, it is an optimal time to train them in practical spiritual care skills. Third, encouraging students to pay attention to the spiritual needs of patients by using case reports. This approach enables students to apply the theories and skills they have learned in real-world scenarios. Fourth, given the relationship between the spiritual health of nursing students and their spiritual care ability, it is essential to focus on their spiritual health from an early stage. This can be done by creating a supportive cultural atmosphere within the school and hospital that promotes the spiritual well-being of nursing students, especially intern nursing students, and cultivates their common capabilities and empathy. Moreover, helping nursing students form healthy values and affirm the meaning of life by fostering healthy relationships with others, the universe, beliefs, and nature can be achieved through a supportive educational and clinical environment.
Acknowledgements
We gratefully thank all participants, who voluntarily participated in the survey.
Declarations
Ethics approval and consent to participate
Informed consent was obtained from all participants (the consent obtained was written). This study received approval from the Ethics Committee of Guangzhou Medical University(L202306002), and the methods of the current research were carried out in accordance with the relevant guidelines and regulations involving human participants of the above institutional review board.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
