Spiritual care is a component of the holistic approach to care and treatment. Also, health care providers face many challenges when it comes to spiritual care. To address these challenges, the implementation process must be identified and possible outcomes examined. This study aimed to investigate the process of providing spiritual care to Muslim cancer patients. This descriptive qualitative-exploratory research was conducted in 2020, in which 27 participants were selected through purposive sampling and had semi-structured interviews. The data analysis revealed two themes and five sub-themes including the process of spiritual care (identifying spiritual needs, analyzing situations to meet spiritual needs, expanding spiritual care and spiritual promotion) and the outcome of spiritual care (spiritual promotion and some erosion of faith and spiritual belief ). In this study, the received topics have been related to spiritual care which can help improve patient care. The findings of this study can shed light on the process and outcome of spiritual care for health care providers, and can be utilized in the design of a spiritual care program for these patients.
Spirituality is an essential source of care for a cancer patient (
Examining the causes and factors, clinical manifestations, patient history, and factors influencing pre-planning treatment and care is essential to providing physical care to the patient. In the same vein, spiritual care providers must explore the patient’s spiritual needs to plan for spiritual care and design a care plan for each patient accordingly (
For years, spiritual care by health care providers was a practice of religious traditions The first problem was that in order for spirituality to enter care and treatment, a comprehensive concept had to be explained (
To provide spiritual care, it is necessary to systematically specify the process (
This descriptive qualitative-exploratory study was conducted between July and November in 2020. This design may be particularly valuable to interpret the events and the participants’ comments and viewpoints (
The research setting was the medical cancer wards of four educational and non-educational medical centers and clinics in Isfahan, Iran. Isfahan has a reputation as a conservative, religious city, comprised of 99% Shia Muslims with the remaining one percent being Armenian, Jewish, and Zoroastrian religious minorities.
The sampling was performed with maximum diversity. There were two groups of participants in this study. The first group consisted of Muslim patients, at least 20 years old, with a type of advanced cancer in the end-of-life phase, who was referred to the hospital for treatment and wanted to participate in the study. The second group was comprised of health service providers who were willing to participate in the study. The provider’s span a range of roles, including nurses, oncologists, psychologists, and spiritual counselors with at least three years of experience working with cancer patients.
Participants were asked to sign written informed consent forms before entering this study. Semi-structured interviews were conducted with 27 participants, and one participant was interviewed twice. Each interview lasted between 40 and 60 minutes and all conversations were recorded. Before the interview, the definition of spirituality and the researcher’s conceptualization of this concept was explained to the participants to harmonize the researcher and participants’ perceptions. Then, the interview with the patient began with the main explanation and question: “Please talk about non-physical problems and the needs and expectations you have when you are hospitalized.” Interviews with health care providers began with the key question: “Please talk
Qualitative analysis of data was performed based on Granheim and Landman method where the data is categorized (
For member checking, a patient, a nurse, and a spiritual counselor reviewed the results of the analysis and confirmed the researchers’ interpretations. Regarding peer checking, the results of the analysis were reviewed by five external researchers. To achieve data rigor and trustworthiness, participants were selected from different ages, educational levels, and types of collaboration. To evaluate the transferability of the data, the results of the analysis were reviewed by three nurses and a psychologist who did not participate in the study but had similar experience to the participants. An external audit was performed by a person skilled in analyzing qualitative data.
The study population consisted of 17 health care providers and 10 patients. The mean duration of work experience of health care providers was (15 ± 2) years and the religion of all of them was Islam.
The Demographic Characteristics of the Participants
Married | Age range | Gender | Education Level | Number | Participants | |||
---|---|---|---|---|---|---|---|---|
Male | Female | Bachelor | Graduate | No academic education | ||||
80% | 23–68 | 50% | 50% | 48% | 21% | 31% | 10 | Patient |
100% | 25–58 | 57% | 43% | 74% | 26% | 0% | 17 | Health Team |
The themes, sub themes, and categories.
Themes | Sub themes | Categories |
---|---|---|
1. The process of satisfying the spiritual needs of the patient | 1–1 Identifying spiritual needs | Assessment of spiritual needs Investigating the patient’s attitude and behavior towards the disease Investigating the patient’s spiritual problems |
1–2 Situation analysis to meet spiritual needs | Analysis of community culture Evaluating patient’s self-care performance Investigating the underlying factors in meeting spiritual needs Investigating barriers to providing and receiving spiritual care |
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1–3 Expanding spiritual care | Providing basic strategies for spiritual care Developing a structure for providing spiritual care Providing spiritual care content |
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2. Outcome of spiritual care | 2–1 Spiritual promotion | Increasing resistance power Mood lift Creatinga sense of satisfaction Compatibility with the current situation Lowering expectations Reducing mental illness |
2–2 Some erosion of faith and spiritual beliefs” | Emotional turmoil Occurrence of internal conflicts |
A total of ten interviews were conducted with the participants of the first group, and 18 interviews were performed with members of the healthcare team. Five sub-themes including identification of spiritual needs, situation analysis to meet spiritual needs, expansion of spiritual care, spiritual promotion, and spiritual distress were extracted from 910 codes and were assigned into two themes of the process of spiritual care and the outcome of spiritual care.
Identifying spiritual needs, situation analysis to meet spiritual needs, and expanding spiritual care should be carried out step by step. Findings of this category showed that meeting spiritual needs requires cooperation between professional health care providers and receiving specialized training in this field. According to health care providers, identifying spiritual needs leads to accurate and effective planning for providing spiritual care. For this purpose, it is necessary to examine the patient’s spiritual needs, attitude, and behavior towards the disease and the patient’s spiritual problems [Sub themes 1–1]. One spiritual counselor shared the following:
The leukemia patient decided to separate two years ago after a fight with his wife. He had severe nosebleeds and was diagnosed with cancer a few days later. He felt that it had caused the disease, and no matter how much painkillers they took, the pain did not go away. We followed up and talked to his wife. We said that he might not be here for another month or two. Come and tell me I forgave and what happened, the patient’s methadone dose dropped drastically and he said, I was fine at all. “Although he died two months later, he regained his composure, and as soon as the cause of his pain was discovered and the cause resolved, it was a spiritual work.
Examining and analyzing the existing conditions by recognizing and exploiting facilitating factors, awareness of negative interfering factors, and proper planning to eliminate those factors can be effective in meeting the spiritual needs of patients. These factors can be the culture of the community, the practice of patient self-care, effective factors in meeting spiritual needs, and barriers to providing and receiving spiritual care [Sub themes 1–2]. One oncologist shared the following:
Usually in Iranian patients, it is not the culture to open up spiritual issues. Aside from the issue of medicine and treatment, neither physicians nor patients and families were accustomed to side discussions. It is the expertise and maturity and comprehensiveness of the physician and nurse that can give the patient the belief that the problem is not ineffective on physical symptoms.
The findings showed that despite the many obstacles, the provision of spiritual care can be facilitated by examining the above. Because cancer patients need frequent hospitalizations, it is necessary to take a closer look at their issues and problems to implement a series of operational strategies to establish, structure, and provide spiritual care. There is nothing desirable [Sub themes 1–3]. An oncology nurse reported the following:
Patients expect us not to be indifferent in dealing with their spiritual issues, but we do not know to what extent we can encroach on the patient’s beliefs. Is this correct at all? Does it matter to us at all? If someone wants to do this, colleagues will criticize him. Managers believe that you must take care of the problem for which the patient has referred. Solve other problems elsewhere. “Our task is to determine how this care should be done and who is responsible.
The purpose of providing spiritual care is to reduce the spiritual problems of patients by meeting their spiritual needs. The provided spiritual care should be evaluated for each patient and based on the measures taken based on the specific spiritual needs of the patient and based on the expected outcomes. However, what became clear from the analysis of the content of the participants’ speeches is that the result of spiritual care can be positive, in the direction of the patient’s spiritual development, or in a negative way, and cause him mental illness. Findings of this category showed that the evaluation of spiritual care helps health care providers in purposeful and effective planning.
The experiences of the participants showed that effective spiritual care strengthen patients to resist the problems caused by the disease, enhance morals, create a sense of satisfaction, adapt to the current situation, achieve peace of mind, reduce expectations, and alleviate mental illness. [Sub themes 2–1]. A breast cancer patient reported the following:
I was a teacher and I live with the power of my mind. I emotionally separated myself from the problems of the disease. “I see cancer as part of strengthening myself, and this kind of thinking has made me able to endure and resist to be alive.
Importantly, providing spiritual care based on the personal beliefs of health care providers leads to internal conflicts in the patient. Such inconsistencies in the provision of spiritual care cause spiritual turmoil in the patient [Sub themes 2–2]. A psychologist reported the following:
… When a spiritual counselor visits a patient at their bed, he should not talk to the patient about death and the other world; this will make the patient disappointed. Sometimes we see that with these actions, the patient loses the same spirituality he had and becomes angry with God.
In this study, the process of providing spiritual care to Muslim cancer patients in Iran was explained. The results of this study revealed five sub-themes: identifying spiritual needs, analyzing the situation to meet spiritual needs, expanding spiritual care, spiritual promotion, and spiritual illness, along with the two themes of the process of providing spiritual needs and the outcome of spiritual care.
In the category of the process of satisfying the spiritual needs of the patient, identifying the spiritual needs of patients was introduced as the first step of planning spiritual care. It is also necessary to investigate the patient’s attitudes and reactions to the disease for her spiritual problems to become clear. Although health care providers should not inquire into the patient’s beliefs, finding evidence of the patient’s spiritual problems leads physicians and nurses to discover their spiritual needs (
Situational analysis is also essential to meet spiritual needs. It is necessary to carefully assess the specific conditions of each patient, including age, gender, religion, the culture of the community, self-care ability, the underlying factors in providing spiritual care, and the barriers to providing and receiving it. The study by Gullate and colleagues showed that religion, spirituality, and belief in the fate of cancer played a role in delaying the search for treatment, and that this delay was related to personal characteristics such as education and marital status (
To expand spiritual care, items were identified as basic and structural strategies as well as the content of spiritual care. The basic strategies were measures to lay the groundwork for providing spiritual care to cancer patients. The results of this study showed that health care providers were not familiar with the importance of spiritual care and how to provide it, and only considered dealing with the patient’s physical affairs as one of their duties. This indicates the need to change the attitude of the health team. The gap of a structured spiritual care based on referring patients for specialized planning to meet their spiritual needs was also evident. Recognizing this gap, Irajpour and colleagues designed a program of palliative care interdisciplinary training and identified the various dimensions of the educational needs of health care providers. The results of this study were a guide for preparing the health team to provide optimal care in the form of inter-professional teams (
In the present study, it was found that spiritual promotion by strengthening the morale and resilience of patients is effective in creating a sense of life satisfaction and adaptation to the current situation. Patients’ spiritual enhancement can reduce their expectations of those around them and health care providers and bring them more peace of mind by overcoming stress. The results of Sankhe and colleagues’ work showed that eliciting patients’ opinions and participating in spiritual activities as a supportive factor can reduce patients’ stress, anxiety, and depression by creating hope, strength, and meaning in life (
In contrast, some erosion of faith and spiritual beliefs was identified as an unpleasant outcome of spiritual care. The results showed that staying between doubt and certainty poses obstacles to achieving the expected results. Also, it imposes new spiritual problems on the patient. This situation leads to internal conflicts and emotional turmoil. Asadi‐Lari concludes from a systematic study that although there is a deep belief in spirituality in Islamic societies, a well-codified spiritual care plan has not yet been developed for the care of these patients, and many of the health team behaviors are influenced by their attitudes toward outcomes. It is necessary to provide training for health care providers on how to provide spiritual care to patients so that they can meet their spiritual needs and reduce their level of dissatisfaction (
The findings of this study showed that for spiritual care of cancer patients, it is necessary to design a systematic program based on the care delivery process. After the implementation of a spiritual care plan, it should be evaluated, and based on the obtained results, a decision should be made on how to continue spiritual care. Achieving this goal requires paying attention to training and education for spiritual providers, spiritual counselors, doctors, nursing staff, and psychologists.
This study was conducted with a sample of cancer patients in the city of Isfahan in Iran. Isfahan has a reputation for a strongly religious population. Such believers sometimes interpret spirituality in the form of religion, which can affect the results of this study. Thus, the reported results may not fully reflect the process and outcome of spiritual care in all societies with other cultures.
Consent to participate: The informed consent form was completed by the participants.
Ethical Approval ID: No. IR.IAU.NAJAFABAD.REC.1398.049.
Conflicts of interest: The authors have no conflicts of interest to disclose.