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Explaining the perception of spiritual care from the perspective of health personnel: A qualitative study

BACKGROUND: Spiritual care is one of the important and essential aspects of healthcare. The impact of spirituality on healing, health‐related states, and the ability to cope and adapt to the disease is undeniable. Thus, this study is aimed to explain the perception of the spiritual care of patients by health‐care providers. MATERIALS AND METHODS: The present study was performed with a qualitative approach using content analysis by the conventional method in hospitals of Qom University of Medical Sciences. The data were collected through in‐depth semi‐structured interviews with 11 participants through a purposeful sampling method and analyzed simultaneously. The consistency of the data was confirmed by the participants. RESULTS: Data analysis provided four main categories as follows: “Observing the patient’s rights” with subcategories of respect, right to choose, preserving the patient’s privacy, proper communication with the patient, “professionalism” with subcategories of responsibility, acceptance of mistakes, development of technical skills and knowledge, “supportive behaviors” with subcategories of paying attention to emotional and psychological needs and “Strengthening the patient’s religious dimension” with subcategories of honoring religious beliefs and providing healthcare along with trust in God. CONCLUSIONS: According to the study findings, spiritual care from the perspective of health‐care providers was explained as attention to emotional and psychological needs, reverence for patients’ religious beliefs, respect for human dignity, and sense of responsibility.


Introduction
S pirituality is one of the most important aspects of human existence. Spirituality consists of a set of values, attitudes, hope, belonging, and attachment that links the individual to his/her self, family, community, nature, and the higher being and connects him/her to health, well-being, and improvement (recovery). Spirituality gives meaning to life and helps with one's challenges, especially during illness and crisis. [1,2] Special attention is paid to the role of spirituality nowadays in promoting the patient's health so that meeting the spiritual needs of patients and their families, is considered as an essential element of clinical care. Spiritual care involves a set of activities that support the individuals, including worshiping and praying with the patient, talking to the patient about God, clarifying the patient's relationship with God, the use of religious texts, the referral of the patient to religious authorities, communication skills, counseling, emotional and spiritual support of the patient, encouraging the patient to express emotions, active listening and encouraging the patient to think positively, availability, empathetic relationship with the individual, and respecting the client. [3][4][5] Spiritual care is also considered as one of the holistic care areas of nursing, [6] characterized with seven features, including healing presence, the therapeutic use of self, visual sense, spiritual perspective exploration, patient-orientation, meaning-orientation, therapeutic interventions, and creating a spiritually nurturing environment. [7] This definition highlights the importance of providing spiritual care by nurses as those in close contact with the patient as well as the therapeutic interventions provided in this regard. [8] In addition, the impact of the spiritual and religious role of physicians in treating patients and also in the formation of the relationships between physician and patient seems to be undeniable. [9] Therefore, providing spiritual care to the patients and their families can bring alleviate and comfort physical pains, provide mental relaxation, reduce depression, decrease anxiety, increase the recovery rate, increase hope, lead to communication between the patient and service providers, and create purpose and meaning in life. [10] However, the domain of spiritual care seems to be a domain that is often overlooked, and many patients demanding such care do not receive spiritual care, or it is delegated to a religious leader in some countries. [5,10] On the other hand, research has shown that the lack of education and ambiguity of service providers in the area of spiritual care, lack of time, inappropriate communication with the patient, and the notion that spirituality is a private matter are among the reasons for ignoring spiritual care in clinical settings. [11,12] Furthermore, providing spiritual care is influenced by the nurses' understanding of spirituality and spiritual care, their cultural background, and religious beliefs. [13] Few studies have been done regarding the explanation of spiritual care in Iran despite the focus of attention on the issue of spirituality in the field of healthcare, and especially spiritual care in recent years, which is one of the mandatory duties of service providers and despite the cultural, religious, and social context in our country. Moreover, according to the research, there is a passion among health care providers for addressing the patients' spiritual needs; however, there is also ambiguity in understanding the concept of spiritual care and the duties of health-care providers in this regard are unclear. Since on the one hand, the experiences of health-care providers can play an important and valuable role in explaining spiritual care, and on the other hand, the views and experiences of health-care providers in the field of spiritual care in Iran have been studied limitedly, thus, as the first step, we studied the perception the care providers of spiritual care. Therefore, the purpose of this study was to explain the perception of the spiritual care of patients by the health-care providers.

Materials and Methods
The present qualitative study was conducted with the approval of the Ethics Committee of Qom University of Medical Sciences No: IR. MUQ. REC.1396.63.

Recruitment
The present study was conducted with a qualitative approach using the content analysis method in 2018-2019. Content analysis is a valid research method for data analysis. [14] Content analysis is an appropriate approach to get valid results from contextual data aimed at building knowledge and new insights and providing facts and practical guides for performance. The qualitative content analysis can also be seen as a research method for the subjective-content interpretation of textual data through systematic classification processes, coding, making themes, and designing known models. [15]

Data collection
The research environment included the hospitals of Qom University of Medical Sciences. The study population consisted of health-care providers (two physicians, six nurses, and three midwives). Using purposeful sampling method, 11 participants were selected from people with rich subject experience who showed a willingness to participate in the study. Other inclusion criteria for participants (service providers) were formal or contractual employment status, having at least 5 years of experience in different areas and sections of different health centers in Qom province, and having at least a bachelor's degree. The sampling was continued until data and categories saturation. Given the principle of maximum diversity in sampling, the care providers participating in the study had differences in age, gender, work experience, and workplace.
After obtaining informed written consent and agreement from the participants and providing them with a brief description of the study, an in-depth interview was done with the samples individually. In-depth, face-to-face, and semi-structured individual interviews and field notes were used to collect the data. In general, each interview took between 30 and 60 min. Each of the interviews was begun with the following question: "What does spiritual care mean to you?" "How do you describe spirituality care?" and "What do you experience of spiritualty care?
Further exploratory questions were raised according to the participants' answers. Exploration questions like "May you explain more about this?" and "Did you mean this by was that?" were also used. The subsequent interviews' questions were also set based on the extracted categories.

Data analysis
The data obtained from the participants were analyzed simultaneously with the qualitative method of conventional content analysis. The researcher listened to the interviews several times immediately after recording each interview session. After finding a general view of them, the whole interview was written word for word. The transcribed text was then inserted into MaxQDA 10 software product is supported and distributed by VERBI Software. Berlin, Germany, and the coding process was performed. Hence, the transcribed text was read line by line; important sentences and phrases were identified and underlined, and their essence was named (coding). Then, similar codes were merged and categorized. The categories were named based on the idea they included. The categories extracted from the interviews were compared together, and in the case of similarity, they were placed together and the main categories emerged. The spiritual care was explained from the perspective of health-care providers with the help of the extracted categories.
The criteria presented by Guba and Lincoln, namely, acceptability, reliability, transitivity, and authenticity, were considered and used to achieve the accuracy and validity of the study. [16] To this end, with the emphasis on choosing the right platform, information resources, and qualified participants, close, accurate, long-term, repeated and continuous participation and interaction, engaging the participants, adopting a team approach by using the collective feedback of the research team, referring back to the participants as well as benefiting the confirmatory views of experts outside the study but aware of the various aspects of the studied phenomenon, we attempted to verify the validity and accuracy of the study findings. The researcher's ethical principles used in the study were as follows: Making necessary coordination with the authorities of hospitals of Qom University of Medical Sciences, explaining the aims and methods used in the research for the participants, obtaining informed written consent from the participants in the research, confidentiality of all material, explaining the purpose of using audio recordings, recalling the voluntary participation in the research, the possibility of leaving the study at any stage, and observing principles of trusteeship in quotations and the copyrights.

Results
In this section, the results of the data analysis process from 11 interview sessions with the participants were presented. The participants included 6 nurses, 2 physicians, and 3 midwives. The age of participants ranged from 27 to 50 years. Five of the participants were male and 6 were female. The interviews were coded and then, with merging a lot of common items, four main categories were eventually extracted in this article to explain the perception of spiritual care of patients by the health personnel as follows: "Observing the patient's rights," "professionalism," "supportive behaviors," and "strengthening the patient's religious dimension [ Table 1].

Observing the patient's rights
The patient's rights include duties such as observing legitimate and reasonable physical, mental, spiritual, and social needs within the therapeutic standards, laws, and regulations that the health-care providers are responsible for them concerning the patients. [17] The participants identified the observance of the patient's rights as one of the most important components of spiritual care delivery. They also reported that factors such as respect, the right to choose, preserving the privacy of the patient, the disclosure of information to the patient and their companions, and proper communication with the patients and their relatives are effective in stabilizing spiritual care, which were presented in the following along with quotes from the participants.

Respect
One of the signs of observing the patients' rights is respecting them. In respecting the patient, some things like humane behavior and talking to the patients and their relatives, not blaming the patient, standing in respect for the patient, respecting the patient regardless of religion and socioeconomic status, introducing oneself, and avoidance of humiliation were discussed. In this context, a participant said: "Spiritual doctors and nurses speak respectfully to the patient, listen to the patient and let him/her ask his/her questions; even if the patient does something wrong, they won't be angry and treat the patient as a human with a loving attitude such as one of their family members."

Right to choose
Another important aspect of "observing the patient's rights" is the right to choose. The participants believed that spiritual care is based on receiving sufficient and comprehensive information, coupled with the patient's free and informed choice and decision making that after providing the patient with information gives him/ her enough and necessary time to make decisions and choices. One participant said: Preserving the patient's privacy The health-care providers considered privacy as one of the most important and fundamental rights of a human being. Preserving the privacy of their patients dignifies them and establishes mutual trust. Observing patients' privacy is one of the spiritual care aspects. One of the nurses said in this regard:

Proper communication with the patient
One of the subcategories in understanding spiritual care from the perspective of health care providers is "proper communication with the patients and their companions." The ability to communicate is an essential human skill. The purpose of communication is to exchange information, build common understanding, trust, and reach common decision-making. For health-care providers, basic skills such as interpersonal skills like greeting, listening actively, showing interest, giving information and training the patients and their companions are highly important. Establishing proper communication with the patient and companion was one of the issues that health-care providers emphasized since it is very important in the spiritual care process. In this regard, one participant said: "I think spiritual care should be accompanied with warm and intimate relationship and physical touch (shaking hands) with the patient and the examination and visit should begin with greetings. The measures made must be well explained to the patient and his/her companion. We need to understand the patient's stress and listen well to the questions of the patient and his/her companion and answer them."

Professionalism
Professionalism is one of the main categories of explaining the perception of spiritual care from the perspective of health care providers, which subcategories include the sense of responsibility, acceptance of mistakes, technical skills development, and knowledge development.

Responsibility
A sense of responsibility for the patient means performing assigned tasks and responding to the patient's needs. The participants defined spiritual care for the patient involving being careful and accurate in doing tasks, paying attention, and showing sensitivity to cases of negligence and shirking, and considering the best interests of the patient. A participant said: "If the colleagues want to provide spiritual care, they should get a complete history of the patient and make time for their patient. They should not put off the patient. They should not ignore the patient's words and comments. They should not prescribe the drug without careful examination of the patient."

Acceptance of mistakes
Acceptance of mistakes is one of the "professionalism" subcategories. A participant said: "Some of the colleagues are not flexible about their mistakes; in providing spiritual care, if the colleagues make a mistake, they must admit that mistake to correct the mistake in the group and try to compensate for it."

Development of technical skills and knowledge
One of the aspects of professionalism in any field involves professional knowledge and skills. The participants believed that colleagues must develop their technical knowledge and skills to provide spiritual care. One participant said in this regard: "For providing spiritual care, we need to develop our professional information and skills and attend retraining categories; we have to go to congresses and conferences related to our work and try to read more new articles and new references to keep up to date with the latest scientific information and advancements in the world and to run them for our patients."

Supportive behaviors
Supportive behaviors refer to any behaviors that facilitate the provision of appropriate care. One area of supportive behaviors is related to care providers. Supportive behaviors include subcategories of attention to emotional and psychological needs.

Paying attention to emotional and psychological needs
Emotional and psychological needs are the most important needs of human life. One of the most serious needs in human communication is the provision of emotional and psychological needs. These include loving, expressing, and showing expressing emotions and feelings, feeling secure physically, mentally, emotionally, socially and economically, empathy, attention, and hope. The participants believed that the patient needs affection, love, and attention of the service providers to achieve a sense of security and to know that he/she has not been neglected. Financial security is also very important for patients, and they have to be assured of their medical expenses while staying in the hospital since financial worries cause anxiety in patients. In addition, patients need empathy for their griefs and sorrows and expect empathy from the care providers. Furthermore, creating a lively and joyful environment in the ward and the patient's hospital room, providing a private room, if needed, and paying attention to the comfort of the ward during patient admission have been known essential as well. One participant said: "Spiritual care is, in my opinion, paying attention to the physical space of the ward and the room that the patient has been hospitalized within; for example, placing a beautiful painting on the wall or well-groomed and clean curtains.

It involves paying attention to the patients' wishes, being available and feeling empathetic with them so that they think they are in a safe environment and others care about them and want to meet their needs. If a woman is hospitalized and has a child at home, we should understand her anxiety and make it possible for her to see her child as far as possible."
In this regard, another participant said: "Hospital costs are an important concern for patients, and we, as service providers, have to be aware of this issue and try to explain to them the legal ways and the use of insurance and reduce the patients' anxiety in this regard as much as possible. We should also let our patients express their feelings and help them to cope with these harsh conditions and use promising and soothing words, and ask the patients to have good thoughts about their illness and hope for healing and recovery. All service providers should strengthen the sense of security in their patients by giving hope to the patients about resolving the existing problems and the occurrence of pleasant events in the future and good faith in God."

Strengthening the patient's religious dimension
Strengthening thepatient's religious dimension was one of the concepts of spiritual care from the perspective of service providers. The best way to restore hope in the patient is to strengthen the religious sense, trust in God, and believe in the truth that God is the true healer and healing is in His hand. This category includes subcategories of honoring religious beliefs and providing healthcare along with trust in God. According to the participants' viewpoints, spiritual care includes orienting the patient beliefs, helping the patient to do his/her religious practices, encouraging the patient to do religious activities, remembrance of God in the provision of healthcare, and talking about the possibility of recovery following miracles and trust in God.

Honoring religious beliefs
Religious beliefs become more important at the time of illness than at any other time in one's life and help the patient to accept the disease. Therefore, it is an essential and necessary matter to maintain religious principles and create the necessary facilities to perform religious activities and to meet the religious needs of patients when they are hospitalized and are not capable of doing their most vital actions alone. Worship, prayer, vow, repentance, and almsgiving, saying prayers, and reading the Qur'an can increase one's tolerance and resistance to the disease and its resulting problems. The health-care providers considered helping to perform religious rituals and referring the patients to religious authorities as components of spiritual care. One participant said: "There must be places for worship and prayer and necessary religious books in the wards so that the patients can be in touch with God when they are sick, and we must also help our patients to perform their religious activities; for example, we should remind the time of Azan (call to prayer)." In this regard, another participant said:

"Some patients like to talk about their relationship with God or want us to pray and read the Koran with them."
Another participant said: "Some of our puerperas women believe in attaching a written prayer to their feet to have a more comfortable delivery that we also respect their beliefs." A participant acknowledged that some relatives of dying patients would like their patients' beds facing the Qiblah, which is not possible for us in the ICU." In addition, one participant said: "Sometimes, for the relief and comfort of patients, especially for cancer patients, we seek help from religious authorities, which reduces the anxiety and stress of the patients and their relatives. It will also increase trust in God."

Providing healthcare along with trust in God
The religious beliefs of health care personnel are certainly effective in the treatment process. Trust in and hope in the Almighty, the true healer, is not only effective in the therapeutic activities of healthcare providers but also in the morale and acceptance of the treatment of patients and in accelerating their healing. The sense of belonging in life to a lofty source and having hope in God's help and assistance in the case of problematic conditions such as illness are among the resources that the religious people can benefit from them for their recovery and improvement. In this context, one participant said: "When I go at the patients' bedside to insert the Angiocatheter (peripheral venous catheter, because I know Muslims believe that anything that starts with the name of God so the God will help us with it, then, I do this in the name of God and the patient becomes calmer and feels less pain." Another participant said: "When I go to visit a patient, along with the necessary recommendations to the patient, I remind him/her to pay attention to the healing and original healer, God, and I encourage him/her to trust and resort in God, which makes the patient more hopeful."

Discussion
The results of the present study achieved four main categories in explaining the perception of spiritual care from the perspective of health care providers. From the participants' perspective, observance of the patient's rights was one of the pillars of spiritual care. Respect for patients' rights in the area of health services is an important factor in improving and regulating the relationship between providers and recipients of the service, and naturally, it is highly important in health system management.
From the viewpoint of health care personnel, a commitment to preserving and respecting humans' dignity, especially in conditions of sickness, preserving the patients' privacy and proper communication with the patients and their companions were of particular importance in spiritual care. From the Islamic point of view, providing spiritual care based on religious teachings will lead to the optimal function of physiological systems through the autonomic nervous system by generating positive emotions. If a person is ill, we can help him/her heal in this way, and if he/she is healthy, it will help improve his/her health. Rasouli and Salmani also emphasized the need for nurses to be familiar with the principles of communicating to provide spiritual care. In fact, nurses should be familiar with how to start and end communication to establish spiritual care and learn about empathic communication, religious and cultural sensitivity, and how to interact with the patient and the patient's family, and establish a trust-based relationship, accompanied with respect and sensitivity to the patients' beliefs, and ultimately provide holistic care. [18] In their study, Penman et al. mentioned religious and communicative domains as areas, in which, nurses can help the patient with spiritual care. Rahnama et al. also cited communication and functional domains as the activities of nurses while providing spiritual care. [19] Kaddourah et al. also showed in their study that nurses consider spiritual care as affection, respect, preserving the patient's privacy, understanding the concerns, and cordiality during the patient therapeutic care. [5] Rahnama et al. also referred to spiritual care as a two-way relationship with preserving the patient's dignity and respect. [19] Professionalism was another major category of explaining the perception of spiritual care from the perspective of health care providers. Based on the study results, the spiritual care for healthcare providers included a sense of responsibility, acceptance of mistakes, and the development of technical skills and knowledge. Heidari et al. believed that the set of necessary skills for spiritual care and counseling for nurses include communication, supportive, knowledge, and attitudinal skills to do spiritual care and referral to the professionals. [20] Puchalski et al., conducted a study entitled "Spirituality and Health: Expanding the Field." Its results indicated that six areas of competence include health-care systems, knowledge, patient care, humanitarian presence, personal and professional development, and communications, [21] which are consistent with the results of this study in the area of developing technical and knowledge skills. In their study, Tirgari et al. considered spiritual care as a simple concept involving mutual communication, giving information, trust, dignity, respect, and in total, the professionalism of nurses. [22] Rahnama et al. also acknowledged in their qualitative research that nurses' competencies in the areas of self-awareness, communication, skills, trust, and respect for patients' beliefs and feelings are essential for the provision of spiritual care. [19] Supportive behaviors were one of the areas of spiritual care from the perspective of the participants of this study, which include love, expressing and showing emotions, security, empathy, attention, and hope. Rahnama et al. showed in their study that from the viewpoint of cancer patients, the mood characteristics (good-morality, compassion, kindness, and good-manner) of a nurse represent spiritual care. Rahnama et al. also mentioned the sympathy with patients and empathy with them as religious and spiritual interventions to provide spiritual care. Taylor also named in his study kindness, respect, and trustworthiness as a nursing approach to patients' spiritual needs. [19] A study by Zamanzadeh et al. showed that, from the perspective of patients, spiritual care can be provided in the context of an effective relationship; a relationship in which nurses can transfer happiness, passion, affection, sense of trust, and empathy in communicating with the patient and act as the source of energy, hope, and strength. [23] Dell states that spiritual care requires the use of a patient-centered approach, which needs simple interventions such as making time for the patient, paying attention, and listening to him. [24] Hanson also considers the creation of peace and hope in patients to be a part of spiritual care. [19] Strengthening the patient's religious dimension was one of the concepts of spiritual care from the perspective of service providers. According to their point of view, spiritual care includes directing the patient's beliefs, helping the patient in doing religious practices, encouraging the patient to do religious activities, remembering God in providing healthcare, talking about the possibility of recovery following miracles and trust in God. For Indonesian Muslim nurses, spiritual care includes attention, spending time with the patient, support, respect for religious and cultural beliefs, preserving the patient's privacy, kindness, happiness, finding meaning and purpose in illness, facilitating prayer, helping to say prayers five times per day, reading or listening to the Holy Quran, and the remembrance of God. [13] Abu-Ras and Laird believe that in Islam, every Muslim performs his or her religious duties under the condition of illness and sees the disease as a test or an opportunity for purification and forgiveness of his/her sins, and in fact, the disease is atonement for sins. Therefore, for nurses who care for Muslim patients, the meaning of illness and suffering is of particular importance in assisting with religious duties such as saying the prayers and reading the Qur'an. [25] In their study, Iranmanesh et al. also reported that spiritual care interventions include giving information to the patients and assisting them in the worship of patients during hospitalization. [26] A study by Lionis describes that spiritual care includes interventions such as taking into account the patient's spiritual beliefs and cultural beliefs, communication with the patient, being with the patient through caring, supporting, empathy, providing facilities for attending religious ceremonies, improving the sense of well-being, and referral to the clergy. [27] Zamanzadeh et al. also showed that patients saw spiritual care as nurses' praying for their healing, patience in caring, and respecting religious and cultural beliefs. [23] It was found in the study of Rahnama et al. that nurses provide help to the patient to perform worship by providing the necessary facilities for performing prayer and purification; they even encourage the patients to perform religious activities. Nurses also help to comfort the patient by relying on God while providing care and help the patient gain hope by expressing words about the possibility of recovery following miracle and trusting in God. Rahnama et al. write about this, religious interventions to provide spiritual care may include providing religious support in keeping with the religious practice and encouraging the patients to do religious activities. Ardbridge defines attention to religious aspect distinct from spiritual care and writes religious care means helping individuals to maintain their religious beliefs and worship activities and spiritual care assists individuals maintain their personal relationships and connection with the superior power (God or whatever one believes in) and identify the meaning and purpose in life. [19] This study was performed on Iranian Muslim health care providers, which is its limitation. Therefore, its results cannot be generalized to doctors and nurses in other countries and religions.
Our study limitation was the lack of interviews with religious minorities.
The innovation of the present study was the diversity of participants from all treatment groups and different wards of the hospital.

Conclusions
In general, spiritual care from the perspective of health care providers was explained as paying attention to emotional and psychological needs, honoring the patients' religious beliefs, respect for human dignity, and professionalism. Hence, the provision of spiritual care depends on the presence of compassionate health-care providers, who understand the patients and treat them with respect, and also establish a human relationship with others, are responsible and are somehow committed to professional ethics, which involves specific tasks such as loving, expressing and showing positive emotions, creating a sense of physical, mental, emotional, social, and economic security, empathy, attention, hope, helping the patient doing religious practices, encouraging the patient to do religious activities, remembering God in providing health care, and talking about the possibility of recovery following miracles and trusting in God. Meanwhile, they provide a convenient place for patients' worshiping and referring them to religious authorities if needed.