Introduction
Spirituality is an essential source of care for a cancer patient (Merath et al., 2020). The diagnosis of cancer and its invasive treatments in many cases deprive patients of the ability to enjoy life and expose them to spiritual distress (Fischbeck et al., 2013). For these patients, there are several challenges related to the reason of suffering from an incurable disease and the meaning and purpose of life and death, which sometimes exposes them with severe spiritual conflicts (Zumstein-Shaha, Ferrell, & Economou, 2020). These patients see the suffering and pain as a test of God and consider illness as a chance to find meaning and purpose in life (Edwards, Pang, Shiu, & Chan, 2010). Following the suffering of the disease, patients tend to evaluate the turning points of their lives and constantly ask themselves “Is there a God? Will God help me? Does life have meaning or purpose? Will my illness hurt? Am I dying? Is there a trustworthy person to help me in these daunting moments?” (Cobb, Puchalski, & Rumbold, 2012). These questions are examples of spirituality which refers to a human’s relationship with itself, God, people, and nature. Spiritual care is answering these questions to help patients come to terms with their problems and adapt to their current situation (Taylor, Lillis, & Lynn, 2015). Accordingly, it is necessary to determine spiritual needs of these patients and plan to provide spiritual care (Moghimian & Irajpour, 2019).
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 (Surbone & Baider, 2010). When patients’ spiritual needs are not recognized, the patient may face the challenge of life dissatisfaction at the end of life (Pearce, Coan, Herndon, Koenig, & Abernethy, 2012). Cancer patients fear that they will be judged or denied if they express their spiritual challenges. Consequently, the spiritual needs of these patients may not be surface at all the stages of the disease (Clayton & Scherr, 2021). They expect the health team, especially nurses, to provide a source of spiritual support to help them cope with the illness. Studies have shown that the patient does not seek spiritual guidance from the doctor and nurse, but expects to have a good relationship with them so that the patient can talk about one’s fears and ambiguities (Best, Butow, & Olver, 2014).
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 (Canda, Furman, & Canda, 2019) so that although the health team did not specialize in spiritual and religious issues, they could address the spiritual problems and needs of terminally ill patients such as cancer patients. (Ross et al., 2016). Today, the concept of spirituality includes the meaning, purpose, and connection of one with their own humanity, with a superior force, with those in the community, and with the surrounding nature (Lazenby, 2018). Spiritual care is recognized as a legal aspect of the work of health care providers but the question remains as to the manner of practice of the care (Zollfrank et al., 2015). The results of several studies show that despite the benefits of spiritual care for cancer patients, unfortunately, the process of meeting the spiritual needs of these patients in health care systems is unclear, and physicians and nurses often provide spiritual care according to traditions and beliefs (Chandramohan & Bhagwan, 2015; Rabitti et al., 2020).
To provide spiritual care, it is necessary to systematically specify the process (Paal, Helo, & Frick, 2015) of providing spiritual care. The question of how to collect spiritual information from the patient is also important, so that the health team can provide a complete picture of his spiritual condition in assessing the patient’s overall health (Balboni et al., 2017). The components of this process should be clear in the form of an inter-professional collaboration for health care providers (Puchalski et al., 2019). The proposed spiritual care program should also be evaluated to determine the degree of success in achieving the goals and the health team can consciously improve their care (Snowden & Telfer, 2017). Numerous assessment tools are available to identify potential spiritual needs in patients as a guide for health teamwork (Timmins & Caldeira, 2017). These tools prevent religious bias and focus on broader concepts of spirituality, namely the meaning and purpose of life, the sources of power and hope, and the relationship with the self, God, others, and nature (Austin, Macdonald, & MacLeod, 2018). Importantly, doctors and nurses need training to meet the spiritual needs of patients (Vincensi, 2019). Explaining such concepts to the patients requires the cooperation of spiritual counselors and psychologists to cover all aspects of the patient’s mental problems. Accordingly, the present study inquired into the process of providing spiritual care to Muslim cancer patients with a sample in Iran.
Methods
Research Design
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 (Burns & Grove, 2010).
Research Setting
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.
Participants and Interview
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 about your experiences with the spiritual care you provide to chronic patients and what should be considered in the care and treatment of these patients.” In all the interviews, subsequent questions were asked progressively based on the participants answers.
Data Analysis
Qualitative analysis of data was performed based on Granheim and Landman method where the data is categorized (Graneheim & Lundman, 2004). After each interview, the first researcher [MM] transcribed it. Both researchers [AI and MM] then read the summaries separately and categorized the themes. The results of the researchers’ analysis were compared and summarized for the differences and similarities to emerge. No new data were obtained after 28 interviews with 27 participants. To ensure data saturation, two additional interviews [with one patient and one nurse] were performed but no new data were obtained.
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.
Results
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. Table 1 presents the demographic characteristics of the participants.
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 |
|
| 1–2 Situation analysis to meet spiritual needs |
|
|
| 1–3 Expanding spiritual care |
|
|
| 2. Outcome of spiritual care | 2–1 Spiritual promotion |
|
| 2–2 Some erosion of faith and spiritual beliefs” |
|
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.
Theme 1: The Process of Meeting Spiritual needs
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.
Themes 2: Outcome of Spiritual Care
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.
Discussion
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 (Graneheim & Lundman, 2004).
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 (Gullatte, Brawley, Kinney, Powe, & Mooney, 2010).
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 (Irajpour, Alavi, & Izadikhah, 2015).
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 (Sankhe, Dalal, Save, & Sarve, 2017). Strengthening psychological characteristics such as optimism and self-confidence along with other spiritual considerations are associated with life satisfaction and quality of life of patients (Kamitsis & Francis, 2013).
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 (Asadi-Lari, Gousheh, Majd, & Latifi, 2008).
Conclusion
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.
Limitations
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.
Notes
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.
References
Asadi, L. M., Gousheh, G. S., Majd, Z., & Latifi, N. (2008). Spiritual care at the end of life in the Islamic context, a systematic review. International Journal of Cancer Managment, 1(2),63–67.
Austin, P., Macdonald, J., & MacLeod, R. (2018). Measuring spirituality and religiosity in clinical settings: A scoping review of available instruments. Religions, 9(3), 70.
Balboni, T. A., Fitchett, G., Handzo, G. F., Johnson, K. S., Koenig, H. G., Pargament, K. I., & Steinhauser, K. E. (2017). State of the science of spirituality and palliative care research part II: Screening, assessment, and interventions. Journal of pain and symptom management, 54(3), 441–453.
Best, M., Butow, P., & Olver, I. (2014). Spiritual support of cancer patients and the role of the doctor. Supportive Care in Cancer, 22(5), 1333–1339.
Burns, N., & Grove, S. K. (2010). Understanding nursing research-eBook: Building an evidence-based practice: Elsevier Health Sciences.
Canda, E. R., Furman, L. D., & Canda, H.-J. (2019). Spiritual diversity in social work practice: The heart of helping: Oxford University Press, USA.
Chandramohan, S., & Bhagwan, R. (2015). Spirituality and spiritual care in in the context of nursing education in South Africa. Curationis, 38(1), 1–15.
Clayton, M. F., & Scherr, C. L. (2021). Nursing and Health Communication: A Research Alliance to Improve Patient Outcomes. Nursing Communication, 1(1), 10.
Cobb, M., Puchalski, C., & Rumbold, B. (2012). Oxford textbook of spirituality in healthcare: OUP Oxford.
Edwards, A., Pang, N., Shiu, V., & Chan, C. (2010). The understanding of spirituality and the potential role of spiritual care in end-of-life and palliative care: a meta-study of qualitative research. Palliative Medicine, 24(8), 753–770.
Fischbeck, S., Maier, B.-O., Reinholz, U., Nehring, C., Schwab, R., Beutel, M. E., & Weber, M. (2013). Assessing somatic, psychosocial, and spiritual distress of patients with advanced cancer: development of the Advanced Cancer Patients’ Distress Scale. American Journal of Hospice and Palliative Medicine®, 30(4), 339–346.
Graneheim, U. H., & Lundman, B. (2004). Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse education today, 24(2), 105–112.
Gullatte, M. M., Brawley, O., Kinney, A., Powe, B., & Mooney, K. (2010). Religiosity, spirituality, and cancer fatalism beliefs on delay in breast cancer diagnosis in African American women. Journal of religion and health, 49(1), 62–72.
Irajpour, A., Alavi, M., & Izadikhah, A. (2015). Situation analysis and designing an interprofessional curriculum for palliative care of the cancer patients. Iranian Journal of Medical Education, 14(12),1040–1050.
Kamitsis, I., & Francis, A. J. (2013). Spirituality mediates the relationship between engagement with nature and psychological wellbeing. Journal of environmental psychology, 36, 136–143.
Lazenby, M. (2018, August). Understanding and addressing the religious and spiritual needs of advanced cancer patients. In Seminars in oncology nursing (Vol. 34, No. 3, pp. 274–283). WB Saunders
Memaryan, N., Ghaempanah, Z., Aghababaei, N., & Koenig, H. G. (2020). Integration of spiritual care in hospital care system in Iran. Journal of religion and health, 59(1), 82–95.
Merath, K., Kelly, E. P., Hyer, J. M., Mehta, R., Agne, J. L., Deans, K., & Pawlik, T. M. (2020). Patient perceptions about the role of religion and spirituality during cancer care. Journal of religion and health, 59(4), 1933–1945.
Moghimian, M., & Irajpour, A. (2019). The requirements of hospital-based spiritual care for cancer patients. Supportive Care in Cancer, 27(7), 2643–2648.
Paal, P., Helo, Y., & Frick, E. (2015). Spiritual care training provided to healthcare professionals: a systematic review. Journal of Pastoral Care & Counseling, 69(1), 19–30.
Pearce, M. J., Coan, A. D., Herndon, J. E., Koenig, H. G., & Abernethy, A. P. (2012). Unmet spiritual care needs impact emotional and spiritual well-being in advanced cancer patients. Supportive Care in Cancer, 20(10), 2269–2276.
Puchalski, C. M., Sbrana, A., Ferrell, B., Jafari, N., King, S., Balboni, T., & Balducci, L. (2019). Interprofessional spiritual care in oncology: a literature review. ESMO open, 4(1), e000465.
Rabitti, E., Cavuto, S., Iani, L., Ottonelli, S., De Vincenzo, F., & Costantini, M. (2020). The assessment of spiritual well-being in cancer patients with advanced disease: which are its meaningful dimensions? BMC palliative care, 19(1), 1–8.
Ross, L., Giske, T., Van Leeuwen, R., Baldacchino, D., McSherry, W., Narayanasamy, A., & Schep-Akkerman, A. (2016). Factors contributing to student nurses’/midwives’ perceived competency in spiritual care. Nurse education today, 36, 445–451.
Sankhe, A., Dalal, K., Save, D., & Sarve, P. (2017). Evaluation of the effect of Spiritual care on patients with generalized anxiety and depression: a randomized controlled study. Psychology, health & medicine, 22(10), 1186–1191.
Snowden, A., & Telfer, I. (2017). Patient reported outcome measure of spiritual care as delivered by chaplains. Journal of Health Care Chaplaincy, 23(4), 131–155.
Surbone, A., & Baider, L. (2010). The spiritual dimension of cancer care. Critical reviews in oncology/hematology, 73(3), 228–235.
Taylor, C. R., Lillis, C., & Lynn, P. B. (2015). Skill Checklists for Fundamentals of Nursing: The Art and Science of Person-centered Nursing Care: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Timmins, F., & Caldeira, S. (2017). Assessing the spiritual needs of patients. Nursing Standard, 31(29), 47.
Vincensi, B. B. (2019). Interconnections: spirituality, spiritual care, and patient-centered care. Asia-Pacific journal of oncology nursing, 6(2), 104.
Zollfrank, A. A., Trevino, K. M., Cadge, W., Balboni, M. J., Thiel, M. M., Fitchett, G., & Balboni, T. A. (2015). Teaching health care providers to provide spiritual care: a pilot study. Journal of palliative medicine, 18(5), 408–414.
Zumstein-Shaha, M., Ferrell, B., & Economou, D. (2020). Nurses’ response to spiritual needs of cancer patients. European Journal of Oncology Nursing, 48, 101792.
