Explaining the Nurses’ Spiritual Needs in the Oncology Department: A Qualitative Study

Abstract

Background:

It seems that improving the spiritual dimension of cancer patients can play an effective role in their mental and emotional peace. Meanwhile, oncology ward nurses are one of the most important healthcare providers that can help improve patients’ relationship with God due to their more interaction and communication with patients. For this reason, this study aimed at explaining nurses’ spiritual needs in an oncology ward.

Materials and Methods:

This study was conducted based on the qualitative content analysis method. The participants included 11 nurses from the oncology ward of Seyed Al Shahada Hospital in Isfahan from 2021 to 2022. A semi-structured interview was administered to determine nurses’ spiritual needs.

Results:

Analysis of 11 interviews conducted with nurses revealed a total of four main codes, 13 sub-codes, and four sub-sub-codes. According to nurses’ point of view, their spiritual needs can be classified into four dimensions as follows: communication with God, communication with oneself (intrapersonal communication), communication with others (interpersonal communication), and communication with environment. Administered interviews revealed the role of communication with God with six sub-codes as nurses’ most important point of attention.

Conclusions:

According to nurses’ point of view, nurses’ spiritual needs were divided into the dimensions of communication with God, communication with oneself, communication with others, and communication with environment. Therefore, it is necessary to simultaneously pay attention to oncology nurses’ personal and social aspects to increase their spirituality.

Introduction

Cancer is one of the growing diseases[1] that changes the normal life process of patients and creates a feeling of fear of death and anxiety in them.[2] Those who are close to death suffer from spiritual grief to find meaning and purpose in life.[3] Therefore, paying attention to these patients’ spiritual distress and spiritual resources related to their quality of life can play a crucial role throughout their cancer experience.[4,5] Considering that nurses, as compared to other healthcare providers, spend more time with patients, they play a very important role in helping patients find meaning and purpose in life, improve health status, and resolve crises of illness, hospitalization, and death of loved ones.[5] It seems that nurses knowledgeable about spirituality provide better spiritual care. Spiritual nurses bring their knowledge and experiences of spirituality to the care center and respond to a portion of patients’ spiritual needs.[6]

Some researchers believe that spirituality in nurses is one of their most important value and belief systems and can have a great impact on their attitude and performance in caring for patients and their professional commitment. Studies have shown that nurses with higher spirituality take care of their patients with more love and affection and pay more attention to their spiritual care.[7] In fact, it can be stated that nurses’ spirituality can play an imperative role in their attention to spiritual aspects of care such that nurses’ spirituality increases self-awareness, communication, and building trust with patients to provide spiritual care.[8] A study in three European countries showed that nurses who have more spiritual needs rarely provide spiritual care to patients.[9] In addition, studies in Iran have also evaluated nurses’ spiritual needs in different wards of hospitals. They have shown that strengthening the relationship with God and trusting in Him and asking for healing from God through their mediation is one of nurses’ spiritual needs. However, it is worth mentioning that the main purpose of these studies was to point out the importance of teaching spiritual care to patients in different age-groups[10,11]

Although nurses believe that spiritual care is a central part of nursing care, they rarely pay attention to their patients’ spiritual needs.[12] This issue can be due to time limitation, high workload, lack of private space for nurse and patient, nurses’ non-understanding of help in the spiritual dimension, nurses’ inexperience, difference in their religion and beliefs, and non-explanation of nurses’ needs. In this regard, despite the importance reported about nurses’ spiritual needs and spirituality, few studies have paid attention to explaining nurses’ spiritual needs, especially in an oncology ward. Nurses should be able to identify and respond to their patients’ spiritual needs during their interactions with patients. These needs and the way they are responded to vary according to the perception of patients and the nurses, which is affected by individual, cultural, and social differences.[13] Perhaps the individual characteristics of nurses (including physical, mental, and psychological characteristics), social outlook, spiritual evaluation and the importance of its role in patients’ mental health, and the prevailing spirituality in a country can have an effect on medical staff’s spiritual needs.[11,14] However, regular research studies addressing spirituality in the field of health have been performed mainly in Western countries, so the information is limited regarding specific religious and cultural contexts.[15] In fact, religion has been proposed as a way to answer basic questions about life and death in spiritual care models,[13] which may have a special position in patients’ spiritual adaptation in the Islamic culture of Iran.

Therefore, discovering nurses’ real perceptions and experiences that are directly related to cancer patients can be a more accurate and valid measure to determine nurses’ spiritual care in the real world. This understanding and discovery of experiences can be obtained in qualitative studies, in which individuals’ actual events, opinions, and experiences can be addressed in various areas.[16] Hence, this study was conducted with a qualitative approach to identifying nurses’ spiritual needs in the oncology ward of Seyed Al Shahada Hospital in Isfahan, Iran.

Materials and Methods

This study was qualitative and based on a qualitative content analysis method with a descriptive and exploratory approach. Sampling was conducted from March 2021 to February 2022. The participants in this study were selected from among nurses working in the oncology ward of Seyed Al Shahada Hospital in Isfahan. Sampling was continued using purpose-based method until saturation of data was achieved. The inclusion criterion was employment in the oncology ward with at least 2 years of working experience and willingness to cooperate in the study.

A semi-structured interview was used to collect information. To organize and integrate the information, an interview guide prepared by Galletta was used.[16,17,18] Then, a final guide was prepared and compiled by conducting three pilot interviews.[17,18] During the interview, the interviewer tried to help the researcher to focus on important and specific information by asking clear and exploratory questions and clarifying ambiguous points. In addition, it was attempted to provide an opportunity for participants to fully describe their feelings and beliefs without any biased comments on their statements. To meet the mentioned goal, the researcher started the interview with an open-ended question such as “What gives you peace and meaning?” As the interview progressed, the focus on specific issues increased and the researcher followed the interview in a semi-structured manner through probing questions. Examples of probing questions comprised the following ones: “What worries you?” “What is the source of your worry?” “What do you think a nurse needs psychologically and spiritually in their professional life?” “Do patients require spiritual matters?” “Have you ever talked to your patients about their spiritual needs?” and “If possible, express your experiences in conversation with patients in order to reassure them.” Moreover, the researcher used field and reminder notes. Field notes included descriptions of conditions and some informal interviews. To avoid any possible problems during interview recording, the interviewer used two audio recorders. The interview continued until theoretical saturation was reached. Thus, 11 interviews were conducted with an average time of about 35 minutes in this study. In all stages of the study, the researcher tried to avoid any orientation and prejudice about the phenomenon under study. Interviews in the hospital were preferably conducted in a physicians’ room or in places where participants could feel more relaxed. At the same time as interviews were conducted, transcription of the content was performed in a word file format, and important points of each interview were noted down to improve the quality of future interviews.

Moreover, to classify qualitative data and achieve a suitable level of abstraction, data analysis was performed using the conventional method of qualitative content analysis. In this analysis, raw data were classified into categories based on researchers’ precise interpretation and inference. This process is conducted using the logic of induction, which is extracted by careful investigation of the researcher and constant comparison of data, categories, and themes. Then, these concepts were coded, summarized, and classified, and themes were extracted. In detail, primary codes were obtained using open coding. Internal codes were used to name and choose titles. Internal codes were expressions or concepts expressed by interviewees. In the next step, core codes were obtained. In other words, sub-codes were obtained through making association between internal codes. Finally, selective coding was used to obtain main codes. In this way, participants’ perspectives were considered in a more comprehensive way by taking advantage of all interviews. All decisions taken in this process were clearly recorded so that readers could easily understand the progress of the study.

In this research, the research validity and the reliability of the data were determined using four procedures including credibility, transferability, dependability, and confirmability. To get credible data (Internal validity), observation, interview, and documentation were used. After transcribing interview data, the researcher also reduced and wrote it on paper, and got confirmation from informants individually. To comply with transferability (External validity) of data, the researcher had tried to report the research in a clear and understandable way. The researcher wrote it in a detailed, clear, systematic, and believable format. All information, the way of collecting data, and the manner of presenting data were explained clearly so that the study can be transferred to different settings or contexts by other researchers. Dependability (Reliability) of qualitative data is concerned with consistency of research results when observing the same point twice. To get a good quality of measurement, the research data were also checked by one university lecturer as an interrater. The result showed that both researcher and interrater had the same contemplation on research data. Confirmability of research refers to the objectivity of the research. This has similarity with dependability so that they can be done together in the process of research. Accordingly, the researcher used interrater to measure both dependability and conformability of the study.[19]

Ethical considerations

This study was approved by the Research Ethics Committee of Isfahan University of Medical Sciences (approval code: IR.MUI.MED.REC.1400.046). Ethical considerations including confidentiality of participants’ information, obtaining informed consent from participants, explanation of research goals, voluntary participation in the research, permission to leave the study at any time, and trust in using texts were taken into account.

Results

This research reported the results of 11 interviews. Eight and three of interviewees (nurses) were female and male, respectively. Four, five, and two nurses had a master’s, bachelor’s, and postgraduate degree in nursing, respectively. The work experience of these nurses varied from 2 to 23 years. Moreover, their mean age was between 40 and 45 years. According to Table 1, four main codes, 13 sub-codes, and four sub-sub-codes were obtained from interviews.

Table 1.

Main and sub-categorizations extracted from qualitative data from needs analyses of nurses in an oncology ward

Main code	Sub-code	Sub-sub-code
Communication with God	The need for strengthening inner-spiritual drives
	The need for spiritual gratitude
	The need for spiritual relaxation and stress relief
	The need for trusting in God
	The need for resolving spiritual conflicts
	The need for sharing spiritual experiences
Communication with oneself (intrapersonal communication)	The need for self-esteem
The need for patience and tolerance
	The need for self-care
	The need for not accusing oneself
Communication with others (interpersonal communication)	Communication with family	The need for improving negative relationships with family
		The need for an optimistic view of the future of their family
	Communication with the patient	The need for controlling anger and discomfort in dealing with patients
		The need for increasing hope
Communication with environment	The need for dominance of a positive atmosphere in the ward and removal of feelings of emptiness in life

Communication with God

Communication with God means those factors that, according to nurses, can be felt as a need to communicate with God. This main code had six sub-codes including the need for strengthening inner-spiritual drives, the need for spiritual gratitude, the need for spiritual relaxation and stress relief, the need to trust in God, the need to resolve spiritual conflicts, and the need to share spiritual experiences.

The need for strengthening inner-spiritual drives

In the sub-code of the need to strengthen inner-spiritual drives, according to nurses, despite the fact that providing services to these patients is difficult, only inner-spiritual drives and motivations can be effective in improving nurses’ services to patients as much as possible. For example, one interviewee expressed that: “When I help patients and when I see the joy in their faces, I have a good and sacred feeling inside” (Interview 5/female).

The need for spiritual gratitude

According to nurses’ point of view, believing in God supervision over their services to patients can be the greatest gratitude for them. Therefore, the need for spiritual gratitude can be one of their most important needs. For instance, one interviewee stated that: “I feel God is watching me; I receive 100% good energy to continue working” (Interview 4/male).

The need for spiritual relaxation and stress relief

According to nurses’ perspective, considering their stressful work conditions, having a spiritual relaxation such as patients’ praying for them and spiritual support can reduce their stress and give them relaxation. In this respect, one interviewee mentioned that: “The spiritual view gives me relaxation in doing my work in the hospital and it is a kind of brake for cases when I want to be ungrateful” (Interview 1/female).

The need for trusting in God

Regarding the coexistence and interaction with cancer patients, as nurses accentuated worry about the future and fear of the occurrence of this disease for them, which can be overcome only by trusting in God. Some interviewees have stated that: “Due to my relationship with a cancer patient, I am constantly worried that I might get this disease, so I always try to trust in God” (Interview 7/female).

The need for resolving spiritual conflicts

Considering types of cancer patients in different ages, ethnic groups, and socioeconomic levels, one of the concerns is the occurrence of spiritual conflicts expressed in some questions such as why should this patient suffer from this disease? Why at this age? And many unanswered questions. Therefore, nurses feel the need for resolving these spiritual conflicts. In an interviewee’s words: “Sometimes I wonder why God gives so much misery to a person? I think it is not fair at all” (Interview 10/female).

The need for sharing spiritual experiences

According to the nurses’ vantage point, each nurse might have experienced different spiritual events based on their religious beliefs and length of their work experience. Therefore, according to them, sharing these experiences is another sub-category in the communication with God dimension. In one interviewee’s terms: “I personally have experiences about spiritual care, but these are very few and personal. Therefore, I really need to be trained in this respect and use experiences of my colleagues” (Interview 5/female).

Communication with oneself (intrapersonal communication)

The communication with oneself relates to increasing nurses’ patience and tolerance, having self-importance along with paying full attention to the patient, and being less engaged with patients’ issues. In fact, they seek to compensate for the void of their forgetfulness. This main code had four sub-codes as follows: the need for self-esteem, the need for patience and tolerance, the need for self-care, and the need for not accusing oneself.

The need for self-esteem

Nurses believed that, as compared to other medical staff, they are overlooked and their work value is not noticed by patients and their companion. Therefore, they have a feeling of weakness and inferiority and consider dealing with this feeling as one of their main needs in relation to themselves. One of the interviewees expressed that: “In some cases, I am not noticed by patients. For example, there have been many times when I was calling the physician and the patient’s companion said that you did not do anything, you were speaking on the phone!” (Interview 3/male).

The need for patience and tolerance

Due to stressful working conditions, many nurses have admitted that they have lost their tolerance when faced with some patient’s difficulties and problems and felt the need for resilience training in these conditions. For example, in this regard, one interviewee said that: “Nursing these patients requires a lot of patience. If we are not patient, we may get into trouble with them over minor matters. If you don’t tolerate and communicate well with them, you will have a very hard time” (Interview 11/female).

The need for self-care

In this sub-code, nurses’ lack of self-care due to their engagement with patients’ problems and their inability to fully assist them have been considered. For example, according to the nurses’ standpoint, the only thing that was not important for them was themselves and they only thought about their patients. In this respect, one interviewee stated that: “Our work is so hard that during these few years of serving patients, the only thing that was not important for me was myself” (Interview 11/female).

The need for not accusing oneself

Nurses believed that due to some patients’ difficult conditions and their death, many times they felt guilty for not being able to do more for those patients, and in various ways, they consider themselves delinquent in patients’ death or their failure to recover. For instance, one of the interviewees stated that: “Nightmares, sometimes I see that I am questioned, I fear God so much in these matters. For example, I wonder whether I paid attention to patients’ rights in the hospital” (Interview 10/female).

Communication with others (interpersonal communication)

Communication with others means those factors that, according to nurses, can be felt as a need in communicating with patients’ or nurses’ family. These communications were divided into four sub-codes consisting of the need for improving the negative relationship with the family, the need for having an optimistic view of the future of the family, the need for controlling anger and discomfort in dealing with the patient, and the need for increasing hope.

Communication with family

The need for improving negative relationships with nurses’ family

Nurses expressed that their stressful work conditions have made their relationship with their families weak, and they have a lot of family tensions. Therefore, they felt this void and it seems that there is a need for fixing this problem. For example, an interviewee stated that: “I constantly have problems at home. We are under a lot of mental pressure, and arguments arise at home due to an insignificant matter and I get upset” (Interview 5/female).

The need for an optimistic view of the future of nurses’ family

Nurses believe that they are constantly afraid of their family’s future due to experiencing unfortunate events in their hospital. It seems that they need to reduce this stress and develop an optimistic view toward the future of their family. In this regard, an interviewee noted that: “I am more worried about my family and my mother. For example, I find any small incident such as coughing or lethargy of my family members worrying. I keep thinking that they might have got some diseases, I always consider the future dark” (Interview 10/female).

Communication with patients

Nurses highlighted that this sub-code refers to their point of view regarding factors affecting their relationship with patients. These factors have created gaps and problems, and there is a requirement to solve these matters. The following two sub-codes are discussed in this respect.

The need for controlling anger and discomfort in dealing with patients

Many nurses have suffered from extreme fatigue due to difficult work conditions, and this fatigue has caused them to be unable to control their anger. In one of the interviewees’ words: “In such a difficult working condition, several issues make me angry, so that I can’t control myself” (Interview 3/male).

The need for increasing hope

According to critical conditions of cancer patients, the possibility of death in this ward is more likely, and it is necessary for nurses to have a higher patience in this ward and be able to increase their life expectancy while dealing with these patients. One of the interviewees highlighted that: “Communicating with a dying patient affects me a lot. There were times when I was next to the patient’s bed and cried. Maybe if I had a better mood, I could have given the patient hope and encouragement until the last moments” (Interview 10/female).

Communication with environment

Communication with environment includes those factors that can be effective in creating positive atmosphere in hospitals and removing feelings of emptiness and meaninglessness of life. Therefore, this main code has been addressed under the sub-code the need for dominance of a positive atmosphere in wards and removal of the feelings of emptiness in life.

The need for dominance of a positive atmosphere and removal of the feelings of emptiness in life

As pointed out by nurses, the positive and negative atmosphere of environment has been very significant and, in many cases, has been associated with a feeling of emptiness and meaninglessness of life for nurses. For example, some interviewees stated that: “It used to be significant for me that how long I will live, but now I don’t care” (Interview 11/female).

Discussion

This study outlined nurses’ spiritual needs in an oncology ward. In communication with God dimension, nurses need a lot of spiritual support so that they can improve their spiritual skills by sharing their experiences and use those of their colleagues and achieve a spiritual relaxation to avoid tension and stress.

In this regard, Zamanzadeh et al.[11] also identified strengthening relationships with God and trusting in Him as the supreme power and resorting to Imams and seeking healing from God through their mediation as nurses’ spiritual needs. In addition, according to the results of the Amoah study, three main axes of strengthening faith, creating hope, and cultivating love and affection in nurses have been listed as their basic spiritual needs. These axes increased nurses’ spirituality and improved their professional qualification to provide spiritual care for their patients.[20]

Furthermore, oncology nurses in intrapersonal communication dimension were the need for self-esteem, patience and tolerance, self-care, and not accusing themselves. In fact, nurses need to reduce feelings of guilt induced by patient death and increase their patience to improve their intrapersonal communication. In fact, it is necessary to pay special attention to increasing nurses’ self-esteem in this ward due to the existence of mental tensions.

The results of previous studies have also indicated that improving nurses’ spiritual needs can cause job satisfaction, satisfaction, happiness, well-being, patients’ satisfaction with nursing care, improved self-esteem, increased social abilities, and oncology nurses’ augmented life satisfaction and positive mood. Moreover, nurses’ confrontation with patients’ spiritual needs was facilitated.[8,21,22,23]

In addition, due to the pressure and difficulty of work in such wards, nurses may have problems in interpersonal communication dimension, especially with their family and patients that are two groups closely related to nurses. For example, they get annoyed with their family members very soon due to their decreased patience and tolerance, or they may not have a positive view of the future of their family due to observing unfortunate conditions. They may not have enough motivation to create and increase patients’ life expectancy due to terrible conditions of some patients. Therefore, from nurses’ perspective, there are needs related to their family and patients to improve the negative relationship with their family, develop a positive view toward the future, control anger and discomfort in dealing with patients, and increase hope in patients and their companion.

According to previous reports, it can be claimed that manifestations of spiritual care in nurses (especially Iranian nurses) comprise having empathy and hope, facilitating worship and communication with God, maintaining inner solitude with oneself, respecting fellow humans, and listening and paying attention.[13,24,25] In fact, tendency toward spirituality in nursing profession is related to optimal care in interaction with patients, constructive cooperation with colleagues, avoiding negative behaviors, and tending to constructive behaviors.[8]

Finally, the last dimension to explain nurses’ need in the oncology ward was related to the environment. Actually, nurses’ view of hospital or oncology ward environment can be negative or positive. Patients of these wards are more in need of God and are interceding due to considering themselves closer to death; consequently, this state can cause a positive and spiritual atmosphere in their hospital. In contrast, some other nurses have considered that patients’ death and difficult conditions create a negative atmosphere in their hospital. Therefore, in this interview, it seems that creating a positive and hopeful atmosphere that eliminates feelings of emptiness and meaninglessness of life can be considered a basic need.

In this regard, many previous studies have also stated that it is possible to provide adequate spiritual care in a good and facilitative care environment.[9,26,27,28,29,30,31] In such a situation, nurses can support their patients by understanding their spiritual experiences, set conditions for spiritual practices, and respect their spiritual beliefs.[26] The results of previous studies indicated that neglecting nurses’ spiritual needs causes a sense of loss of meaning in life,[27] confusion,[28] tension,[29] stress, anxiety, and anger,[30] and fatigue[31] in their life and can weaken their communication with their environment.

It is worth mentioning that cultural and religious differences in Muslim and Western countries can play a role in observed differences in the codes obtained from nurses’ spiritual needs as spirituality in Islam is based on Allah’s words in the Holy Quran. Moreover, Muslims consider worship and lifestyle according to Allah’s instructions presented in the Holy Quran as the spiritual resource for developing their spiritual life.[14] Considering Islam the dominant religion in Iran, religious beliefs can play a special role in confronting stressful events so that nurses’ higher spiritual needs (especially in the oncology ward) may not only help nurses in providing spiritual care to patients but also may provide higher physical, social, mental, and health status as well as a higher quality of life.

It is necessary to mention that oncology departments, as one of the most stressful hospital wards and in need of a spiritual dimension, are of special importance. In addition, in this study, we were able to identify and code nurses’ spiritual needs in this ward comprehensively and through interviews administered with these nurses. So far, few studies have addressed the spiritual needs of nurses in oncology wards. Therefore, these cases can be considered the strong points of this study. Considering that demographic characteristics of nurses (including age, gender, work experience, education level, and different religious beliefs) were not controlled in explaining their needs, it is not possible to judge whether demographic characteristics affect their spiritual needs or not. Therefore, this can be another weak point of this study. So, it is suggested to carry out further studies to evaluate spiritual needs of nurses taking care of cancer patients by paying due attention to their demographic characteristics. Furthermore, although this study aimed at performing in-depth interviews to provide a more extensive and inclusive framework of aspects, it is still possible that some aspects of nurses’ spiritual needs have been overlooked. Besides, although the focus of this study was not on comparing the possible effect of different departments on nurses’ perspective, it will be more illuminative to perform studies addressing various departments in hospitals.

Conclusion

According to nurses’ point of view, their spiritual needs comprised the dimensions of communication with God, communication with oneself, communication with others, and communication with environment. From nurses’ perspective, the first dimension, that is, communication with God, had six sub-codes including the need for strengthening inner-spiritual drives, the need for spiritual gratitude, the need for spiritual relaxation and stress relief, the need to trust in God, the need to resolve spiritual conflicts, and the need to share spiritual experiences. The second dimension, that is, communication with oneself, included four sub-codes: the need for self-esteem, the need for patience and tolerance, the need for self-care, and the need for not accusing oneself. The third dimension, that is, communication with others, consisted of four sub-codes: the need for improving the negative relationship with the family, the need for having an optimistic view of the future of the family, the need for controlling anger and discomfort in dealing with the patient, and the need for increasing hope. The final dimension, that is, communication with environment, was addressed under the sub-code the need for dominance of a positive atmosphere in wards and removal of the feelings of emptiness in life. The obtained findings can shed more light on nurses’ way to more successfully identify and respond to their own and their patients’ spiritual needs during their interactions with patients.

Financial support and sponsorship

Isfahan University of Medical Sciences

Conflicts of interest

Nothing to declare.