The effects of nurse-led spiritual care on psychological well-being in the healthcare services of patients with cardiovascular diseases in Iran: a systematic review

Abstract

Background

Cardiovascular disease (CVD) significantly impacts patients’ lives, affecting not only their physical health but also their spiritual well-being. While holistic care acknowledges the importance of addressing spiritual needs, the integration of nurse-led spiritual care within CVD management remains understudied.

Objectives

This systematic review aimed to evaluate the effectiveness of spiritual and psychological interventions in enhancing quality of life and reducing anxiety among CVD patients.

Methods

Following the PRISMA guidelines, we conducted a comprehensive search across multiple databases (PubMed, Scopus, EMBASE, CINAHL, Cochrane Library, SID, Magiran, and Web of Science) for relevant articles published in English and Persian between 2013 and 2023. The risk of bias in included experimental and quasi-experimental studies was assessed using ROB 2 and ROBINS-I scales.

Results

The initial search yielded 1416 articles. After applying inclusion and exclusion criteria, along with qualitative evaluation, 15 studies with a total of 1035 participants were selected for review. These studies explored the impact of spiritual interventions (e.g., healthy heart model, emotion-oriented approach, communication with a higher power, acceptance, and relationship improvement) on anxiety, stress, life expectancy, depression, blood parameters, spiritual experiences, pain, and negative emotions in CVD patients. All reviewed studies reported positive outcomes with spiritual interventions, demonstrating their effectiveness in reducing anxiety, depression, pain, stress, and negative emotions, while also improving quality of life and possibly life expectancy.

Conclusion

Integrating spiritual care into routine care for CVD patients presents a promising approach to improve their overall well-being. This review highlights the effectiveness of spiritual interventions in reducing various negative emotions and enhancing quality of life.

Trial registration

PROSPERO (CRD42023448687).

Introduction

Epidemiological changes over time have increased the importance of chronic diseases. Today, non-communicable and chronic illnesses are recognized as a leading health challenge in both developed and developing nations [1]. Cardiovascular diseases (CVDs) are particularly widespread, claiming the lives of 17.7 million people annually, constituting one-third of all global deaths. This burden is significantly heavier in Iran, with some studies reporting it to be closer to 50% [2]. Furthermore, the prevalence of heart disease continues to rise, solidifying its position as the number one cause of disability worldwide [3].

Heart disease presents a multitude of challenges for patients, significantly impacting their physical and mental well-being. Beyond the immediate concerns of managing symptoms and preventing complications, patients often grapple with anxiety, depression, and fear of mortality [4]. These emotional burdens can be further compounded by a sense of loss of control and altered self-image, as the limitations imposed by the disease can drastically impact their lifestyle and activities [5]. Moreover, a diagnosis of heart disease can raise profound existential questions, leading to spiritual distress – a struggle to find meaning and purpose in the face of illness [6]. This spiritual distress can manifest in various ways, such as questioning the fairness of their situation, feeling disconnected from their faith or higher power, or struggling to reconcile their values with the limitations of their illness. Studies have shown that addressing these spiritual concerns can significantly improve a patient’s overall well-being and quality of life [7].

While spiritual health refers to an individual’s sense of purpose, connection, and meaning in life, spiritual care is a distinct concept that focuses on addressing these spiritual needs within a healthcare setting. This care can be provided by chaplains or religious leaders, but nurses are increasingly recognized as having a crucial role to play. Studies have shown that nurse-led spiritual care interventions can have a significant positive impact on cardiovascular patients [4]. It was highlighted the importance of nurses initiating conversations about spiritual concerns with heart failure patients, leading to improved patient well-being and reduced healthcare utilization. These findings suggest that nurse-led spiritual care has the potential to be a valuable tool for improving the holistic well-being of patients with CVDs [8].

Living with CVDs can be a significant challenge, often leading to anxiety, depression, and feelings of sadness and loss. These chronic conditions impact all aspects of a patient’s life over time. Failure to adapt effectively to these new limitations can exacerbate existing problems, such as increasing the prevalence of mental health disorders and hindering daily activities [9]. Therefore, patients with CVD diseases should adapt appropriately to their new conditions. Studies have shown that CVD patients face numerous obstacles in adjusting to their condition [10]. For instance, poor medication adherence can significantly hinder the recovery process [11]. The disease itself can be a source of stress, leading to physical changes and limitations in activities, further contributing to psychosocial adjustment difficulties [12]. Also, chronic diseases such as CVDs affect a person's identity in psychological, social, emotional, relationships, and self-satisfaction dimensions and disrupt adaptation [13].

Spiritual health is a crucial dimension of overall well-being, focusing on the interconnectedness of inner strengths. It encompasses a sense of stability, peace, physical well-being, and harmony, often accompanied by a connection to a higher power [14]. This concept has two key aspects: vertical and horizontal. The vertical dimension emphasizes a healthy relationship with a higher power (religious aspect), while the horizontal dimension focuses on finding meaning and purpose in life (existential health) [15]. Spiritual well-being goes beyond simply feeling good. It represents the dynamic process of cultivating a harmonious connection with oneself, others, nature, and a higher power, ultimately leading to a deeper understanding of life’s purpose [16]. Research suggests that other aspects of health are dependent on spiritual well-being. Disruption in spiritual health can lead to mental disorders, depression, problems with the meaning of life, and low quality of life [17].

Current cardiac rehabilitation guidelines prioritize preventative measures [18]. However, achieving optimal physical health through rehabilitation hinges on a patient’s psychological well-being [19]. Therefore, effectively managing CVD risk factors and modifying patients’ lifestyles are crucial, as this empowers them to take a more active role in their self-care [20]. Recent studies have explored various treatment and intervention approaches to help chronic disease patients adapt to their conditions, with psychological interventions playing a prominent role. These interventions go beyond simply reducing CVD risk factors; they aim to improve patients' psychological outcomes through a range of techniques. Examples include relaxation and stress management, treatment for mood disorders, and enhancing disease adaptation and coping skills [21]. The nursing profession recognizes patients as multifaceted beings with spiritual, social, biological, and psychological dimensions. The comprehensive care model emphasizes the importance of nurses considering the spiritual aspects of patient care to provide holistic support [15]. Supportive interventions, such as spiritual interventions, can significantly improve the overall health of CVD patients. In palliative care, for instance, spiritual interventions are a cornerstone of a holistic approach that views patients as whole beings [22]. Fostering a spiritual connection can provide reassurance to patients and their families, reminding them of a powerful source of support. In such cases, faith can serve as a wellspring of hope for the future [23].

Spiritual well-being and spirituality can affect psychosocial adaptation to illness, especially in chronic patients. Patients with CVDs may experience different physical and psychological symptoms compared to other patients; Therefore, it is necessary to study the psychosocial adaptation to the disease in these patients and the related factors [24].

Previous research has explored the significant connection between spirituality and positive health outcomes in patients with CVD. For instance, researchers investigating spirituality and heart failure patients found a link between strong spiritual beliefs and improved quality of life, as well as reduced levels of depression [16]. Similarly, another study focusing on coronary heart disease patients highlighted the various spiritual dimensions that can be impacted by the illness, including a sense of purpose, meaning-making, and connection to a higher power [25]. In addition, it is claimed that spirituality is in direct association with religious beliefs, while it seems that spirituality is behind the religiosity as the current systematic review is focused on it.

Although a growing body of research explores the positive impact of spiritual care on CVD patients, a comprehensive review specifically examining nurse-led spiritual care interventions in this population is lacking, especially in Iranian context that spirituality is emphasized.

Overall, while prior reviews have established the relationship between spirituality and cardiovascular health, a crucial gap exists in our understanding of how healthcare systems are currently integrating spiritual care into their services for this specific patient population. Additionally, in recent years, several interventional studies have been conducted on the effectiveness of psychological and spiritual interventions on the improvement of symptoms and other components related to CVD patients in Iran. Since there has been no systematic review of this category of interventions, the present systematic review study was conducted with the aim of gathering and integrating spiritual and psychological interventions in CVD patients to raise awareness about the effects, challenges, and solutions of these interventions.

Methods

This systematic review was conducted and reported following the PRISMA guidelines for reporting systematic studies [18]. The study protocol was registered in PROSPERO (Registry of International Prospective Systematic Reviews) with ID: CRD42023448687. At first, according to MESH keywords, PubMed, Scopus, EMBASE, CINAHL, Cochrane Library, SID, Magiran, and Web of Science databases were searched from 2013 to 2022, and then articles in English and Farsi were extracted. For this purpose, “OR/AND operators were used. To complete the article retrieval process, similar review articles were searched and reviewed in the Cochrane Library database. An unsystematic search of the Google Scholar database was conducted to find other gray sources.

The search strategy was as follows:

(((((((((((((Spiritual care[Title/Abstract]) OR (Spiritual Healing[Title/Abstract])) OR (Exorcism[Title/Abstract])) OR (Spiritual Intervention [Title/Abstract])) (Faith Healing[Title/Abstract])) OR (Prayer Healing[Title/Abstract])) OR (Spirituality[Title/Abstract])) AND (Cardiovascular Disease[Title/Abstract])) OR (Cardiac Event[Title/Abstract])) OR (Adverse Cardiac Event[Title/Abstract])) OR (Major Adverse Cardiac Events[Title/Abstract])) AND (clinical trial[Title/Abstract])) OR (randomized controlled trial[Title/Abstract])) OR (controlled clinical trial[Title/Abstract]).

In this study, the title and abstract of all searched articles were reviewed separately by two authors in terms of compliance with the inclusion criteria. In case of disagreement, regarding the exclusion or consideration of an article, the final decision was based on the full text of that article. In case of disagreement, the comments of another expert in the field of systematic reviews was considered to resolve any conflict. On the other hand, the articles were screened in three independent stages and finally, 13 studies were included in the systematic review. Figure 1 shows the process of selecting articles for this study.

Fig. 1.

PRISMA Flowchart of selected studies

Screening and selection steps

• Identification: The first step involves identifying potentially relevant records through database searching and other sources. In the figure, database searching yields 1416 records, and other sources identify 81 records.

• Data Duplication: After identification, duplicate records are removed. The figure shows that 167 duplicates are removed, leaving 1330 records for screening.

• Screening: The remaining records are screened based on pre-defined inclusion and exclusion criteria. This step involves reviewing titles and abstracts to assess whether the studies meet the eligibility criteria for the review. In the figure, 1195 records are excluded due to a lack of relevance, leaving 135 records for full-text assessment.

• Full-text Assessment: The full text of the remaining records is retrieved and assessed in detail to determine if they meet all the inclusion criteria for the review. In the figure, 23 records are excluded because the population of interest is not studied, 43 records are excluded because the outcome of interest is not studied, 52 records are excluded because the intervention of interest is not studied, leaving 15 records to be included in the final synthesis.

• Final Synthesis: The studies that meet all the inclusion criteria are included in the final qualitative or quantitative synthesis of the research evidence. In the figure, 15 studies are included in the final synthesis.

The selection criteria of articles for systematic review based on PICOS items included type of study (S), population (P), used intervention (I), comparison group (C), outcome (O).

Type of study

In this study, experimental and semi-experimental studies were considered.

Population

Primary studies were considered whose samples had at least one type of CVD and had not received any specific psycho-spiritual treatment in the past few months. CVD include coronary artery disease, angina pectoris, heart attack, heart failure, cardiac arrhythmia, valvular heart disease, hereditary heart disease, and congenital heart disease or defect. Patients and clients over 18 years old were considered.

Intervention group

Studies were included in this systematic review that had at least one intervention group in the form of spiritual care or a combination of psycho-spiritual interventions.

Comparison group

To compare the effectiveness of spiritual and psychological treatments, the non-intervention groups included CVD patients under routine ward treatment or conventional drug therapy or other interventions.

Outcome

Improving the quality of life score and improving the anxiety score of CVD patients were defined as the primary outcomes. On the other hand, reducing pain, improving sleep, increasing self-efficacy in self-care, improving other psychological symptoms such as stress and depression, and other outcomes reported by the participants were considered secondary outcomes.

Exclusion criteria

Observational studies, reviews, case reports, and studies on participants under 18 or with recent psycho-spiritual treatment. Interventions not related to spiritual or psycho-spiritual approaches and studies without a comparison group were also excluded. Finally, studies without data on pre-defined outcomes or with unreliable outcome measures were omitted. In addition, studies published in languages other than Persian or English were not considered.

Qualitative assessment of studies

The risk of bias of randomized clinical trial type studies was done using RoB 2: A revised Cochrane risk-of-bias tool for randomized trials. In RoB 2, five domains of randomization, implementation of the intervention, missing data, measurement of outcomes, and reporting of findings are assessed [18]. Non-randomized experimental studies with the ROBINS-I instrument were examined in terms of bias in seven areas: selection of participants, planning to perform interventions, how to correctly perform interventions, examining the effect of missing data in the research, how to measure the determined outcomes and the possibility of bias in Announcing the results [19]. The categories of risk of bias in the instruments were as follows:

• Low: The bias is not large enough to affect the validity of the results.

• Moderate: The bias is such that the validity of the results may be doubted.

• High: A significant bias that results in inaccuracy is certain.

The result of Qualitative appraisal of studies is depicted in Table 1.

Table 1.

Overview of Included studies

No	Author (Year)	Setting	Sample size	Type of cardiac disease	Intervention type (Type of study)	Number of sessions	Content of session	Questionnaire (When used)	Results
1	Movahedi et al. (2021) [26]	Hospital	74	Heart failure	Spiritual care (Non-randomized clinical trial)	Two virtual training sessions (1.5 h each) and follow-up for a month three times a week for 1 h in each session via WhatsApp	- Cultivating inner peace - Building connections: forgiveness, charity, fostering positive relationships - Connecting with nature - Playing Mozart’s symphony - Prayer therapy	- Questionnaire of the quality of life of Iranian heart failure patients Dunning’s religiosity questionnaire (before the intervention and one month after the intervention)	- Increasing the overall quality of life score in heart failure patients (P < 0.01)
2	Babamohamadi et al. (2020) [27]	Hospital	92	Myocardial infarction	Spiritual care (Non-randomized clinical trial)	three days in a row (17:00 to 20:00) and an extension for 1 month after discharge at home	- Healthy Heart Model interventions: fostering spiritual connections with God, self, others, and nature	- Palutzian and Ellison spiritual well-being scale (before the intervention and one month after the intervention)	- Increasing the quality of life score in patients with myocardial infarction (P < 0.05)
3	Mohammadi et al. (2020) [28]	medical education Center	61	Positive psychological care	Positive psychological care (Randomized Controlled Trial)	Eight weeks of weekly 2-h sessions	- Workshop focused on positive thinking strategies, coping exercises for challenges, and building social skills	-	- Decrease of C-reactive protein with high sensitivity (p = 0.002) and fibrinogen (p = 0.016) and increase of irisin (p = 0.027) in the intervention group
4	Fasihizadeh and Nasiriani (2020) [29]	Hospital	80	Heart surgery patients	Spiritual care (Randomized Controlled Trial)	-	- Emotional support: active listening and verbal communication -Religious practice facilitation: providing facilities and equipment for prayer, prayer materials, and assistance with religious rituals	-Visual scale of pain and anxiety (before, immediately after and 10 min after removing the chest tube)	-Reducing anxiety and pain after chest tube removal
5	Baba mohammadi et al. (2019) [30]	Hospital	92	Acute myocardial infarction	Spiritual care (Non-randomized clinical trial)	3 days in a row (17:00 to 20:00)	- Healthy Heart Model Interventions: promoting spiritual well-being through connections with: • God (higher power) • Self • Others • Nature and environment	World Health Organization quality of life questionnaire (before the intervention and one month after the intervention)	- Increasing the quality of life of patients with myocardial infarction (p < 0.05) - Improving the mental health of patients in the intervention group (p < 0.001)
6	Azimian et al. (2019) [31]	Hospital	100	Ischemic heart disease, stable angina, heart failure and cardiac arrhythmia	Spiritual care (Randomized Controlled Trial)	3 days in a row (from 17:00 to 21:00)	Spiritual care program: Provides emotional support (active listening, communication) and facilitates religious practices by offering: -Worship facilities and equipment (prayer mats, tents for females) -Religious materials (prayer books, Quran recordings) - Assistance with rituals (ablution, prayer)	Templar’s 15-item death anxiety scale (first day and third day)	-Non-significant reduction of death anxiety in the intervention group (P = 0.898)
7	Heidari et al. (2019) [32]	Hospital	48	Coronary Artery Disease	Psycho-spiritual treatment based on emotion and acceptance and commitment (Quasi-experimental)	Eight sessions for each intervention group	- Boosting positive emotions: Forgiveness training, self-compassion techniques, and their impact on performance - Managing negative emotions: Recognizing the harms of delayed forgiveness, practicing mindfulness exercises, and identifying core values to overcome life challenges - Goal setting: Helping participants define and commit to personal goals -Values clarification: Identifying and recording personal values for ongoing reference	- Boss and Perry hostility and anger scale - Type D personality scale	- Reduction of negative emotions in both groups (p < 0.01) - More significant results in the emotion-oriented therapy group compared to the acceptance and commitment-based therapy group
8	Salimi et al. (2017) [33]	Hospital	111	Coronary Artery Disease	Spiritual care (Randomized Controlled Trial)	3 sessions of 1.5 h (one session per week)	psycho-spiritual concepts from Richards & Bergin’s framework focused on Islamic perspectives based on: - Trust - Patience -Thankfulness & Gratitude	Miller’s life expectancy questionnaire (before and after the intervention)	- Significant increase in life expectancy in coronary artery patients (p < 0.001)
9	Soltani et al. (2017) [34]	Hospital	70	Patients undergoing coronary bypass surgery	Spiritual care (Randomized Controlled Trial)	3 days	-Supportive Presence: Active listening and communication - Religious Ritual Support: facilities and assistance for prayers, ablutions, etc. (tailored to specific denominations)	Magill Pain Questionnaire	-Significant reduction of patients’ pain in the intervention group (P ≤ 0.0001)
10	Nikrahan et al. (2016) [35]	Outpatient medical centers	55	Cardiovascular patients	Positive psycho-spiritual care (Randomized Controlled Trial)	6 sessions (once a week for 90 min)	-Gratitude & Apology: Cultivate thankfulness and practice sincere apologies -Joy & Resilience: Plan enjoyable activities and develop coping mechanisms for negative thoughts -Kindness & Connection: Practice kindness in five ways and strengthen social bonds through eye contact and acceptance - Positive Focus: Reduce worry by recognizing its futility and impermanence - Social Support: Increase participation in social activities and value close relationships	-Oxford happiness questionnaire -Life satisfaction scale - Client’s hope scale -Client’s hope scale -Beck depression questionnaire	- Improvement in scores of depression (p = 0.049), hope (p = 0.017), and happiness (p ≤ 0.001) in the intervention group after the implementation of psycho-spiritual interventions
11	Tajbakhsh et al. (2016) [36]	Hospital	68	Patients after coronary bypass	Spiritual-religious care (Quasi-experimental)	5 sessions (twice a week for 45 to 60 min)	-Discussion on Islamic rituals (prayer, Quran recitation) and their psychological benefits. Explores religious figures and stories -Interventions: Supportive listening, fostering hope, positive reinforcement, encouraging religious practices (Prayer, Quran)	Depression, Anxiety, Stress Questionnaire (21 DASS) (first and fifth session)	-Significant reduction of patients’ stress in the intervention group (p = 0.000)
12	Cajanding et al. (2016) [37]	Hospital	100	Heart failure	Spiritual-based cognitive-behavioral therapy (Randomized Controlled Trial)	12 weeks	- Cognitive behavioral therapy combined with spiritual coping strategies	The Minnesota Living with Heart Failure, The Rosenberg Self-Esteem Scale, The Cardiac Depression Scale	- Significant improvement in quality of life (p = 0.82), self-esteem (p = 0.50), and mood scores (p = 0.92) in the intervention group
13	Asadi et al. (2014) [38]	Hospital	60	Coronary artery transplant candidate patients	Spiritual care based on the healthy heart model (Non-randomized clinical trial))	All days of hospitalization (8:00 a.m. to 2:00 p.m.)	-Chosing interventions based on a "Healthy Heart" model booklet focusing on four spiritual relationships: -God (worship, Quran) - Self (reflection, mindfulness) Others (kindness, connection) -Nature (appreciation, care)	Beck’s anxiety questionnaire (at admission, before operation and before discharge)	-Significant reduction in patients’ anxiety level (p < 0.001)
14	Momeni Ghale- Ghasemi et al. (2013) [39]	Hospital	64	Ischemic heart	Spiritual care (Randomized Controlled Trial)	3 days in a row (from 17:00 to 21:00)	-Support & Presence: Active listening and communication -Religious Practices: Provides facilities and assistance for personalized religious rituals	Spielberger Anxiety Questionnaire (first and third day)	-Significant reduction of anxiety in the intervention group (P = 0.030)
15	Saeedi, Taheri (2013) [40]	Hospital	60	Coronary Artery Disease	Spiritual care based on the healthy heart model (Randomized Controlled Trial)	All admission days from 9 am to 12 noon	-Relationship with God: The model suggests facilitating religious practices like prayer, Quran recitation, and charity -Relationship with oneself: self-reflection through meditation, journaling, and avoiding negative thoughts -Relationship with others: The importance of acts like giving, spending time with family, and maintaining positive interactions -Relationship with nature: connecting with nature through walks, appreciating greenery, and caring for the environment	Questionnaire of daily spiritual experiences (admission time and two months later)	- Higher total score of spiritual experiences (p < 0.001)

Extracting the data

Two authors were responsible for data extraction. The data extracted from the selected articles included the first author/year of publication, sampling location, sample size, type of heart disease, type of intervention, content of the intervention, name of the outcome measurement tool, and findings.

Reviewers meticulously examined included studies for missing outcome data (both continuous and categorical). This involved checking for unreported means, standard deviations, or other key information needed for analysis. In other words, complete case analysis was conducted.

Results

In this systematic review, 15 interventional studies with a sample size of 1191 people were examined. The average age of the participants was 62.7 ± 6.8. 9 studies of the type of randomized clinical trial and 8 studies of the quasi-experimental type. Table 3 provides details of the included studies (Table 1).

Table 3.

Evaluation of the risk of bias in selected studies of the type of randomized clinical trials

The first group: spiritual interventions

In this group, 11 articles included components such as quality of life [18–21], anxiety [22–24, 41], life expectancy [33], pain [42], stress [26], and spiritual experiences [27] were investigated.

Second group: psycho-spiritual interventions

The articles in this category investigated factors such as the number of changes in blood components [18], reduction of negative emotions [19]and depression, meaning in life [20], hope, and happiness [20, 21] in CVD patients. Thus, in total, 7 studies reported outcomes related to secondary outcomes of psychological and religious care practices.

All included studies such as Healthy Heart Care Package [22], Connecting with Self and Others [23], Quadruple Spiritual Relationships [22], Listening to the Bible and Interpreting it, and Listening to the Hymn of Nature (Rain, Water, Animals) [24], practicing the 5 principles of kindness [21], therapy based on acceptance and commitment and encouraging apology and self-expression [19], cognitive behavioral therapy with spiritual focus [41], psycho-spiritual training to maintain diet and increase bonding With the holy source [20], the presence of a religious person [33] indicated a positive and meaningful effect of psychological and spiritual care in different ways. However, only one study showed that anxiety was not significantly reduced after a spiritual intervention [42].

Across all the studies reviewed, interventions that addressed both psychological and spiritual well-being consistently yielded positive and impactful results for patients. This was evident regardless of the specific approach, whether it involved studying religious texts, practicing acts of kindness, or engaging in spiritually-oriented therapy. Patients reported improvements in various aspects of their overall well-being. It’s important to acknowledge, however, that one study did not observe a statistically significant decrease in anxiety following a spiritual intervention.

The classification of the content of sessions

The interventions can be broadly categorized into spiritual care programs, psycho-spiritual programs based on Islamic principles, and interventions based on the Healthy Heart Model (Table 1):

• - Spiritual care programs: These programs provide emotional support through active listening and communication. They also facilitate religious practices by offering worship facilities and equipment, religious materials, and assistance with rituals.

• - Psycho-spiritual programs: These programs focused on cultivating inner peace, building positive relationships, and connecting with nature. They also emphasized the importance of forgiveness, gratitude, and self-compassion. Techniques like mindfulness exercises and goal setting are used to help participants manage challenges and achieve personal goals.

• - Interventions based on the Healthy Heart Model: This model emphasizes fostering spiritual connections with God, self, others, and nature. Interventions based on this model include workshops focused on positive thinking, coping mechanisms, and social skills development. It also promotes religious practices and gratitude cultivation.

The results of risk of bias assessment in selected primary studies can be seen in Tables 2 and 3. Overall, only one study had a high risk of bias. In other selected studies, a low or unclear risk of bias was reported.

Table 2.

Evaluation of the risk of bias in selected studies of the type of non-randomized clinical trials

Discussion

This study aimed to investigate the role of spiritual care in healthcare services for CVD patients. The majority of findings suggest that both spiritual and psychological interventions are equally effective in alleviating the physical and psychological symptoms of CVD patients.

This study demonstrated a significant increase in both psychological limitations and quality of life scores. Interestingly, these findings align with research conducted in the United States, where spiritual interventions were shown to improve overall quality of life in CVD patients [43]. Similarly, an Iranian study reported positive outcomes, indicating that spiritual interventions can be effective in enhancing quality of life for elderly patients with acute coronary syndrome [44]. Furthermore, the healthy heart theory suggests that spiritual interventions can improve quality of life in myocardial infarction patients [20]. However, it’s important to acknowledge conflicting findings. A US-based study reported that spiritual interventions did not significantly impact quality of life or reduce hospital readmissions among CVD patients [45]. This discrepancy might be attributed to the foundation of Iranian spiritual studies on Islamic teachings. Additionally, ethnic, cultural, and religious variations exist across different countries.

This study found that the spiritual care program did not significantly improve death anxiety in CVD patients. However, this result appears to contradict other research. A 2016 study indicated that spiritual-religious care significantly reduced anxiety in patients undergoing coronary artery bypass surgery [36]. Similarly, another study demonstrated that nursing interventions focused on spiritual care can lead to positive outcomes, specifically reducing death anxiety in patients [46]. The lack of effectiveness observed in this study might be attributed to a limitation in nurses’ spiritual care training. Research suggests that insufficient in-service and academic training related to spiritual care can hinder its effectiveness [47].

Several studies in this review demonstrated the effectiveness of both spiritual and psycho-spiritual interventions in alleviating depressive symptoms among CVD patients. In this regard, a study on the effect of the sound of the Holy Quran on the anxiety and depression of hemodialysis patients showed that in this way, the anxiety and depression of the patients can be reduced [48]. Acceptance and commitment therapy (ACT) with a spiritual focus and psycho-spiritual training aimed at fostering hope and connection with a higher power were examples of interventions linked to reduced [49]. These findings suggest that incorporating spiritual and psycho-spiritual interventions into patient care could offer a valuable tool for managing depression alongside traditional pharmacological and psychological treatments [50]. Future research should explore the underlying mechanisms by which these interventions exert their antidepressant effects.

While this study suggests positive effects of spiritual interventions, it’s important to acknowledge conflicting findings. One study reported no significant improvement in anxiety and depression scores in CVD patients following spiritual interventions [43]. Similarly, another study found no benefit for behavioral-cognitive or religious-spiritual interventions in reducing depression and anxiety symptoms among women with breast cancer [51]. These discrepancies may be attributed to significant cultural and demographic variations across study populations.

This study also highlights the effectiveness of emotion-focused therapies ACT in improving the well-being of CVD patients. Supporting this finding, an Iranian study demonstrated that ACT can enhance resilience scores in coronary artery disease patients after intervention [32]. Additional research suggests that ACT can be effective in managing negative emotions and potentially even improving life expectancy in individuals with non-clinical depression [52]. The core principle behind the success of these interventions lies in accepting negative thoughts without judgment and shifting focus away from them. ACT employs six key processes: acceptance, defusion from thoughts, connection with the present moment, identifying core values, and taking committed action based on those values [53]. Furthermore, ACT fosters awareness and adaptation to challenging thoughts, ultimately leading to more efficient cognitive processing [54]. Effectively managing psychological risk factors post-intervention is crucial for CVD patients’ treatment adherence. Negative emotions and psychological burdens can significantly hinder a patient’s ability to follow treatment protocols [55].

One study included in this systematic review explored the potential link between blood factors and psychological interventions. Interestingly, the research found that positive psychotherapy can lead to reduced inflammation levels in coronary artery disease patients [56]. Similarly, another meta-analysis study proved that positive psychotherapy was effective in reducing reactive protein in chronic patients [57]. Another positive psychotherapy-type study was conducted to investigate reactive protein, interleukin 6 and interleukin 1 on 55 adults suffering from one type of CVDs. After the intervention, a significant decrease in reactive protein and an increase in interleukin 6 and interleukin 1 were observed [35].

The findings of other studies have shown that spiritual interventions can be effective even in reducing the level of anxiety in caregivers and families of people with heart failure [21]. In this regard, 36-week spiritual interventions over the phone reduced stress, anxiety, and depression and improved the quality of life of caregivers with dementia [58].

This study also revealed an interesting contrast. While death anxiety in CVD patients didn’t significantly decrease after the spiritual care program, their overall clinical condition improved. This finding seems to contradict existing evidence suggesting that death anxiety lessens as spiritual health scores increase [59]. In contrast, another study involving multiple sclerosis patients showed a significant reduction in death anxiety following a spiritual care intervention [60]. Furthermore, research on patients with chronic kidney failure undergoing hemodialysis suggests that spiritual care programs can also significantly decrease death anxiety in this population.

Limitations

Several limitations are worth noting. Firstly, the heterogeneity of the data precluded the possibility of conducting a meta-analysis. Secondly, limiting the search to English and Farsi languages potentially excluded relevant studies. Thirdly, some studies may have been conducted without fully considering prior research, potentially leading to redundancy. This highlights the need for more targeted research efforts moving forward.

Despite these limitations, the findings of this review suggest the potential benefits of novel spiritual and psychological methods in improving both physical and psychological symptoms in CVD patients. Future research should explore this promising avenue further.

Conclusion

A review of experimental and semi-experimental studies showed that most of the spiritual and psychological methods were effective in improving the symptoms of CVD patients. In general, the current research confirmed the positive effects of spiritual and psychological care in patients with CVD diseases from various aspects such as reducing pain and anxiety, increasing life expectancy, improving quality of life, reducing stress, etc. Therefore, the use of such interventions is suggested as a holistic care approach to improving the symptoms and quality of life of CVD patients. The findings suggest that incorporating psychological and spiritual interventions into CVD patient care can significantly improve their well-being. These interventions offer a diverse range of approaches to address patients’ holistic needs, potentially leading to improved overall health outcomes and quality of life. For practical application, spiritual care interventions should be tailored to individual needs and preferences. Understanding a patient’s religious background, cultural beliefs, and personal values can inform the most appropriate approach. Additionally, spiritual care interventions should be integrated seamlessly into existing treatment plans. Collaboration between healthcare providers and spiritual care specialists can ensure a holistic approach to patient care. On the other hand, it is suggested that by conducting interventional studies at the community level with a wider and more detailed sample size, its use as an alternative or auxiliary method in the nursing care of patients should be considered and investigated.

Authors’ contributions

Fatemeh Moghaddam-Tabrizi  as the corresponding author contributed to the conception and design of this study, conducted the whole study process and participated in the writing of this manuscript. Mahmonir Haghighi  Contributed to designing the study and critically reviewed the manuscript.  Shirin Nazarzadeh Performed data collection and data analysis led the drafting of this manuscript.  Rasool gharaaghaji Conducted statistical analysis and participated in a revision of this manuscript. All the authors reviewed and confirmed the final version of the manuscript.

Funding

This study has no funding support.

Availability of data and materials

Data is provided within the manuscript or supplementary information files.

Declarations

Ethics approval and consent to participate

This study is approved under the ethical approval code of IR.SBMU.PHARMACY.REC.1401.279 from Research Ethics Committees of School of Pharmacy and Nursing & Midwifery belonging to Shahid Beheshti University of Medical Sciences.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.