Training well-rounded healthcare professionals through developing religious/spiritual competencies: a grounded theory study in Iran

Abstract

Background

Given the growing role of humanistic components in medicine and the significance of religion/ spirituality in healthcare, medical practitioners must acquire religious/ spiritual competencies. This study aimed to develop and present a paradigmatic model for fostering religious/spiritual competencies within Iran’s medical education system.

Method

The study was conducted in 2022 at Qom University of Medical Sciences, Iran. Using a qualitative grounded-theory approach, we conducted semi-structured interviews with 18 medical education experts (each with ≥ 5 years of experience). Data analysis included open, axial, and selective coding that were performed through constant comparisons to identify main themes and represent their interrelationships as a model.

Findings

Integrity -the coherent integration of religious and spiritual values into clinical practice and decision-making- emerged as the main theme or core category of the study, around which other categories were formed and organized to form a paradigmatic model: Motives: Islamic spirituality, Persian medicine tradition, global experiences, and future trends; Strategies: paradigm shift, collaboration, integration, and interdisciplinary approach; Intervening Conditions: conceptual differences and dynamic environment; and finally the Consequences: transcendence, patient-centeredness, and accountability. This was considered in a multilayer context.

Conclusion

The proposed model provides a roadmap for integrating religious/spiritual training into medical education, highlights key enablers and barriers, and suggests that targeted interventions can enhance practitioners' integrity. Limitations include the study's focus on Iranian institutions; future research should validate the model across diverse cultural and healthcare settings.

Background

Providing optimal healthcare requires considering both physical and non-physical aspects of human beings. In recent decades, healthcare has gradually shifted from a purely biomedical model towards a holistic and more humanistic approach that considers physical, psychological, social, and spiritual aspects inseparable [1]. Within this framework, spirituality and religion are increasingly recognized as associated with mental health, overall well-being, and quality of life [2, 3], thus highlighting the importance of integrating these considerations into healthcare. Due to the increasing attention to the religious and spiritual (R/S) issues in healthcare, these concerns are no longer restricted to groups such as the elderly, end-stage patients, and those in critical situations [4, 5] but are gaining widespread interest among other patients and clients as well. In this way, R/S considerations are widely recognized as the needs and demands of patients for which the healthcare-providing individuals and organizations should be prepared [6].

To address these needs effectively, healthcare professionals require a set of R/S competencies: that is, integrated knowledge, skills, attitudes, and motivations enabling them to recognize, assess, and respond to patients’ spiritual concerns [7]. Such competencies foster humanistic care through honesty, empathy, compassion, altruism, and respect for diverse beliefs [8]. To achieve effective performance of the graduates according to their expected roles [9], competency-based medical education should explicitly articulate these competencies in curricula and facilitate the graduates'getting equipped for holistic practice [10].

Although several frameworks for R/S competence have been proposed for psychology, counseling, and social work -ranging from Whitley’s cultural sensitivity model (2012) [11] to Vieten et al.’s psychologist-oriented competencies (2013) [12], Magaldi‐Dopman's multicultural competence for counseling trainees (2014) [13], Hodge’s tripartite spiritual domains (2014, 2017) [14, 15], and Oxhandler's recommendations (2018) [16]- these models are inherently shaped by their cultural and religious contexts. Given the culture-dependent nature of R/S competencies [17], it is essential to explore and develop a context-specific model for Iran, with regard to its rich religious heritage and unique sociocultural dynamics. The integration of R/S competencies into Iranian medical education has received growing attention in recent years and several studies have highlighted the need for incorporating R/S issues in medical education [18, 19]. Despite these efforts, there remains a lack of consensus on the components of R/S competencies and their prerequisites and outcomes in Iranian medical education.

This study aimed to present a model for developing R/S competencies in medical education in Iran. We employed a grounded-theory approach with the contribution of 18 experienced medical educators and utilized their experiences and perspectives to identify the components of R/S competencies in the Iranian context, ultimately proposing a paradigmatic model for their systematic integration. It is important to clarify that while there is a distinction between the terms “religion” and “spirituality”, we use them interchangeably in this study. Religion typically refers to specific faith-based beliefs and practices, whereas spirituality may encompass broader existential concerns, values, and sources of meaning that may or may not be tied to organized religion [20]. But, in the Iranian context, religion and spirituality are deeply intertwined with cultural identity and daily life and thus, the two terms overlap significantly.

Methods

Setting

This study was conducted in 2022 in Qom University of Medical Sciences, Iran. However the scope of the study expanded through Iran’s Universities of Medical Sciences and Health Services, where medical education is integrated with healthcare delivery. Although our primary focus was the seven-year general medicine program (admitted directly after high school), the findings are broadly applicable to other undergraduate and postgraduate health professions programs (e.g., dentistry, nursing, allied health, rehabilitation) particularly those including clinical training. While the national competency framework for general medicine specifies a broad range of clinical and professional skills, the religious, spiritual, and cultural dimensions remain under-emphasized.

Design

We adopted a qualitative grounded-theory design, following Corbin and Strauss’s 1998 approach [21]. The grounded theory approach is located within the interpretive paradigm in that data collection and analysis are based on the subjective reflection and interpretation of the meaning and experience of the participants. This enabled us to develop a context-sensitive model grounded in participants’ lived experiences.

Participants and sampling

Using purposive theoretical sampling, we recruited 18 experts with at least five years of experience in medical education, research, administration, or clinical practice. The participants were selected according to their relevant experiences accounting for their inclusion in the study. Authorship of books and articles in the fields of spirituality in healthcare, membership of the Spiritual Health Committee of the Iranian Academy of Medical Sciences, being well-known among colleagues and students as moral and spiritual role models, and pioneering in the field of addressing spiritual issues in medical education processes were among the inclusion criteria.

Sampling continued iteratively -guided by emerging concepts- until no new codes or themes appeared. Data saturation was reached after 15 interviews, with three additional interviews conducted to confirm saturation. To maximize diversity, participants varied by gender (13 men, 5 women), academic rank (professor to non-academic expert), disciplinary background (medicine, pharmacology, nursing, medical ethics, medical education, religious studies, future studies, history of medicine, epidemiology), and geographic affiliation (eight universities across Iran). Detailed participant characteristics are summarized in Table 1.

Table 1.

Participants’ characteristics

Characteristics		Number
Gender	Men	13
	Women	5
Academic status	Professor	4
	Associate professor	5
	Assistant professor	6
	Non-academic experts	3
Professional expertise	Medicine	6
	Pharmacology	3
	Nursing	1
	Medical ethics	1
	Medical Education	2
	Religious studies	2
	Future studies	1
	History of medicine	1
	Epidemiology	1
Affiliated Universities	Qom	6
	Tehran	3
	Mashhad	3
	Iran	2
	Shahid Beheshti	1
	Qazvin	1
	Tabriz	1
	Shiraz	1

Data collection

From April to September 2022, the corresponding author conducted in-person, semi-structured interviews lasting 40–90 min. Interviewees were invited via email or messaging apps with an invitation letter outlining study aims, and when requested, received the interview guide in advance (uploaded as Supplementary Document). The interview sessions were held with prior agreement and at a time and place of the interviewees'convenience. Interviews began with an open-ended question about participants’ experiences with R/S competencies and proceeded with probes tailored to each expert’s background. Interviews began with a general question: How would you define religious and spiritual competencies in medical professions? And went on with questions such as:

• What attributes or characteristics do you think it is needed for a medical practitioner to be considered as a religiously and spiritually competent professional?

• Could you provide some instances in which the religious and spiritual competencies prove to be helpful in healthcare especially, in doctor-patient relationships?

• What are the prerequisites for developing religious and spiritual competencies in medical education?

• What outcomes are expected from the development of religious and spiritual competencies in healthcare?

• What experiences do you have about religious and spiritual competencies as a student/educator/healthcare provider? …

The questions and structure of the interview sessions were not the same and were modified according to the expertise and experiences of any participant and the information needed in the process of data analysis and theory formation. To mitigate the effect of interviewer's biases on the interviewees, the interviewer tried to provide an atmosphere of trust and safety so that the interviewees could talk freely and share their ideas, feelings, and experiences honestly. He avoided leading language and self-disclosure. His prior familiarity with the participants added to this trust. Nevertheless, the deeply subjective nature of spirituality means participant interpretations may inevitably be co-shaped by the interviewer’s presence. All sessions were audio-recorded with consent. The interviews were transcribed verbatim within 24 h. The data collection accompanied by data analysis lasted for six months.

Data analysis

Data analysis proceeded concurrently with data collection. Transcripts were first read to make a general perception. The text was read once more, this time more exactly, and the meaning units were identified and a code was assigned to each, either in vivo (participants’ own words) or researcher-generated codes. Codes of any interview were used to guide the next interviews. Wherever needed, the interviewees'opinions were taken about the codes extracted from their interviews. Coding continued in a constant comparison process and led to the correction and refinement of codes. Codes were clustered in axial coding to form categories, which were then related in selective coding to build a paradigmatic model. Memo-writing and diagramming supported analytic rigor.

To clarify and enhance the transparency of the coding process, an example is provided in Table 2. We found different characteristics as the components of spiritual competencies. A set of competencies was termed as self-control that prevents one's committing a sin or a wrongdoing; the second category consisted of one's relationships with others to ascertain respect for others'rights and moral conduct, especially with patients. But, a third category emerged including such concepts as humility, sincerity, empathy, compassion, hopefulness, inner peace, resilience, meaningfulness, purposefulness, and conscience as attributes of religiously and spiritually competent medical practitioners. These characteristics are regarded as added value for their owners, giving them spiritual strength and charisma and enabling them not only in their actions but empowering them to affect others. These are not explicitly seen in behaviors, rather they have practical implications. We categorized them under the title of"spiritual capital". This category facilitates the former two categories that have an external appearance and provide a more coherent personality with a kind of intangible and informal power and wealth with less burnout better forgiveness, and an enjoyable workplace.

Table 2.

An example of a coding process

Trustworthiness

We applied Lincoln and Guba's criteria to ensure qualitative rigor: credibility was attained through prolonged engagement with data, iterative member checks, and peer debriefing that ensured accurate capture of participants’ perspectives. Peer debriefing was used randomly to seek feedback from a colleague experienced in qualitative study and the research subject; For dependability, we documented all research decisions, coding iterations, and analytic memos; To ensure confirmability, interpretations were grounded in raw data, with reflexive notes minimizing researcher bias; and finally, to transferability, thick description of context, participant demographics, and recruitment procedures were recorded that allows readers to assess applicability to similar settings. Additionally, Creswell’s recommendations for model validation (prolonged engagement, member checking, and peer review) were adhered to throughout the analytic process [22].

Results

Eighteen experts contributed to this study, including six medical doctors (a pulmonologist, an orthopedist, a psychiatrist, a legal medicine expert, and two experts in community medicine), three pharmacologists, two medical education experts, two religious studies experts, and one expert in each of medical ethics, future studies, and history of medicine, and finally an epidemiologist. The participants with expertise in religious studies, medical ethics, and future studies had an MD degree in general medicine, and those with medical education had a preliminary master's degree in nursing or midwifery. Moreover, Six participants had formal seminary training and most combined expertise in both medical sciences and humanities or religious studies.

The analysis of the 18 interviews was coded to preliminary codes that were refined and led to 110 concepts that entered the next phases of analysis. The concepts extracted from the interviews varied from the weaknesses of the existing model of medical education in Iran including reductionism in medical education, secular outlook, the dominance of biomedical approach, insufficient supporting mechanisms, unaligned criteria for faculty promotion, unquestioning use of Western sources, lack of academic freedom, imbalanced response to societal needs to outcomes of developed R/S competencies like restricted personal interests, open-mindedness to other thoughts and ideas, better relationship with patients, improved patient trust, reduced professional misconduct, cost-effective services, reduced unnecessary interventions, enhancement of holistic health, preventive self-care, and attention to the spiritual aspect of health. After conducting the three phases of open, axial, and selective coding in a grounded theory framework, we developed a theoretical model illustrated in Fig. 1.

Fig. 1.

The model of developing spiritual competencies in Iranian medical education

1. Core category: Integrity

   Integrity emerged as the hallmark of a spiritually competent healthcare provider, signifying the seamless integration of R/S attributes into professional identity. It comprises two interrelated subcomponents:

   1. Spiritual health literacy

      • R/S knowledge: Familiarity with the history, theories, and research linking religion/spirituality to health.
      • Holistic view: Recognizing patients as indivisible entities of body and soul.
      • Skills: Proficiency in communication, spiritual history-taking, needs assessment, and referral to spiritual care providers.
   2. Inner religiosity/spirituality

      • Self-control: Inner regulation driven by personal piety rather than external control.
      • Moral virtues: Consistent ethical behavior with patients, peers, etc. grounded in R/S values.
      • Spiritual capital: An internal reservoir of empathy, compassion, hopefulness, inner peace, resilience, meaningfulness, etc. derived from one’s relationship with the Divine.
2. Motives

   • Islamic tradition: The Qur’anic emphasis on the believer’s bond with God guides thought and action.
   • Persian medicine heritage: Classical scholars (e.g., Avicenna, Rhazes) wove spirituality into medical instruction, producing graduates more devout than entrants.
   • Global trends: A growing body of international scholarship and practice on spirituality in healthcare.
   • Future outlook: Anticipated shifts toward increasingly humanistic, spiritually informed healthcare systems.
3. Barriers

   • Conceptual differences: Lack of clear definitions and theoretical agreement that causes misunderstanding and resistance.
   • Dynamic socioeconomic context: External stressors—economic pressures, societal materialism—undermine professionals’ ability to maintain spiritual orientation in practice.
4. Strategies for implementation

   • Paradigm shift: Moving from a strictly biomedical to a holistic paradigm, counterbalancing textbook secularism with spiritual sensitivity.
   • Collaboration: Engaging faculty, administrators, humanities scholars, peers, and even families to create a spiritual learning milieu.
   • Integration: Leveraging the hidden curriculum, role-modeling by instructors, arts and media, and extracurricular activities, to infuse spirituality throughout training.
   • Interdisciplinary approach: Bridging gaps between medical experts and religious scholars to develop shared understanding and practical applications.
5. Consequences

   • Transcendence: Personal and communal growth toward connection with the Divine.
   • Patient-centeredness: Truly holistic, dignity-respecting care that supports patients’ spiritual as well as physical journeys.
   • Accountability: Enhanced social responsibility, ethical decision-making, and prioritization of patient welfare over self-interest.
6. Contextual layers

   1. Intra-institutional: The formal medical education system.
   2. Intra-professional: The healthcare delivery environment.
   3. Societal: National economic, political, and cultural conditions.
   4. Global: International trends and standards in healthcare and education.

The categories and the themes constituting them are described as follows. Verbatim quotes from the interviews are presented to illustrate the concepts and themes of the study.

Integrity

The term integrity has been adopted as the central category of the model and implies the quality of a well-rounded physician that integrates and unifies different aspects of R/S attributes in a whole that is not divisible or separable. Integrity is characterized by two components of spiritual health literacy and inner religiosity/spirituality. By spiritual health, we mean the worldview encompassing all non-physical aspects of human beings and their manifestations in one's relationships with self, others, the environment, and the divine power. Spiritual health literacy in turn is composed of R/S knowledge, holistic view, and spiritual skills. Inner spirituality is characterized by self-control, moral virtues, and spiritual capital.

Spiritual health literacy

R/S knowledge

Medical learners need to be informed about the main issues regarding the spiritual dimension of health and the interconnectedness between religion/spirituality and health including its history, concepts, theories, trends, and so on. The new findings of interdisciplinary studies have clarified and highlighted this relationship. The participants believed that the familiarity of the healthcare professionals with these issues helps draw their attention to spiritual health as a main dimension of holistic health and accordingly attempt to empower themselves in this regard.

Holistic view

The participants regarded as a pitfall the deficiency in the attitude of the healthcare providers to their profession and the lack of an accurate definition of health in its comprehensive sense. A nursing professor mentioned,"A human being is a whole. It cannot be divided into parts. So is his health. We cannot have a healthy human being when his soul is frail". The holistic view can integrate and unify different components to fulfill the ultimate goal of human health.

Spiritual skills

To provide healthcare with spiritual considerations, the professionals need to be equipped with some skills required. The most necessary skills are in the field of communication, but further skills including the ability to take a spiritual history, identify spiritual needs, and refer to expert spiritual care providers were mentioned by an expert of medical education.

Inner spirituality

Self-control

Self-control is an internal control system as opposed to external mechanisms of control and regulation. In this way, the actions and behaviors are guided by inner motives. Piety as a pillar of personal spirituality leads to self-control and decision-making according to one's value system. Another expert in medical education declared: that it is not the others'confirmation or encouragement that determines how a professional decides and acts. What is important is one's personality and personal characteristics and loyalty to their beliefs, principles, and values.

Moral values

Morality is a capability that helps one behave in the right manner. To be sustainable, morality should be based on values that are preferable to wishes and momentary pleasure. A professor of forensic medicine mentioned the failure of ethics to guide and direct the professionals and underscored morality. He said that morality is the demonstration of R/S values in one's personal and social life. Good behavior is the natural tendency of human beings, but it is directed by inner beliefs and values that make it meaningful and purposeful. Religion shows the right path to morality and is the source of genuine and permanent peace.

Spiritual capital

Spiritually competent professionals have the privilege of enjoying a spiritual capital that enriches them with such assets as hopefulness, meaning of life, internal peace, resilience, compassion, and sincerity. A pharmacologist believes that belief in God is a source of energy and an added capacity that enables its owners to act well in different contexts. An expert of medical ethics believed that being connected with God as the absolute infinity, enhances and develops the professionals and makes them more competent in their personal and professional lives.

Motives

The need to develop R/S competencies is not a spontaneous or accidental phenomenon. It is a natural consequence of a set of events in the past and present and even the future perspective. As practitioners in a society in which nearly all the population have religious orientation, ignoring the R/S aspects of health is the denial of a main part of humans and reducing them to mechanical beings. R/S considerations are rooted both in the Islamic instructions and the Persian medicine tradition, which has been practiced for several centuries. Moreover, the recent trends are embracing the humanistic approach to medicine and highlighting the role of spirituality and religion. Thus, the main points uttered by the interviewees and the concepts extracted by the researchers are summarized as follows:

Islamic spirituality

Islam along with all other monotheistic religions, has based its foundations on the the relationship between man and his Creator. A physician believed that such a relationship in case of its proper understanding and implementation, can direct and correct all human thoughts and behaviors by admitting God as the ultimate reality to be sought rather than one's wills and wishes. Such an attitude could be influential in nurturing spiritual characteristics among all believers including healthcare professionals in a religious context.

Persian medicine tradition

Participants mentioned the long and leading history of R/S issues in Iranian tradition. R/S issues are highlighted in the works of such outstanding scholars as Avicenna, Rhazes, etc. This has been a trend in other communities and civilizations too until the disruption occurred in the age of enlightenment and modernization. An expert in the field of history of medicine refers to the books of ancient Iranian scholars stating that they had interwoven spirituality into medicine so that students did not need to pass an extra course in spirituality. In this way, those exiting medical training were more religious than when they entered it. An internist doctor believed that now that spirituality is being addressed once more in medicine, our traditional assets could play a main role.

Global experiences

For decades, spirituality has been a subject matter in medical studies. An expert in the field of future studies mentioned that the number of papers being published in this field and the increasing attention to it reminds us of the necessity of being in line with this movement, otherwise, the health system of the country will miss the opportunity and the gap will be deepened.

Future trends

It seems that the healthcare system in the future will experience a more humanistic nature than its existing condition. Along with the rapid technological changes and achievements in the field of medicine, the healthcare environment and its integration and enrichment with other aspects of human needs will be an outstanding feature of future healthcare systems. Medical education could play a pioneering role in this regard to prepare future practitioners to act successfully.

Barriers

Despite the need for R/S competencies and efforts for its development, there are obstacles that hinder its pace and may counteract or weaken its effects.

Conceptual differences

R/S competencies seem ambiguous and controversial in definition, components, and implications. The participants believed that the concept should be clarified and disclosed to both actual and potential professionals. An expert in medical education believes that our students do not have a clear perception of how spirituality could influence the health of their patients. So it is not strange that they resist or at least do not show sensitivity to these issues. Healthcare professionals are increasingly showing interest in spiritual issues, but most of them do not know how to apply it in their work. In the words of an expert in religious studies, what they know about spirituality is mostly abstract ideas, while they need more applied knowledge.

Dynamic socioeconomic context

Beyond the professional setting, the R/S issues should be understood within society and take into account social, political, and economic difficulties. A pharmacologist said: When I live in a society in which everything is regarded monetarily, how could I adjust my professional activities with spiritual orientation? I could not live a dual life. Another pharmacologist believed that stress imposed by social factors from traffic to economic inflation brings about different conflicts. An excellent care provider is able to do his given duties, let alone options such as spiritual interventions.

Strategies for implementation

Paradigm shift

The existing medical education is based mostly on the biomedical paradigm. This is the dominant but not preferred paradigm. The education system is experiencing a shift to a newer paradigm in which other aspects of human beings particularly his spiritual dimension are considered. An expert in medical education pointed out that the content of textbooks implicitly drives our students to the biomedical outlook that is secular and affects their religious orientation. We should have a solution to maintain and encourage religious sensitivity.

Collaboration

The role of professors in both theoretical and clinical training of the students is outstanding, but it is not limited to them. Development of R/S competencies occurs in a spiritual atmosphere in which everybody is spiritually oriented. Different participants including a female doctor believed that policy-makers, administrators, and managers were among the most influential actors in this process. An expert in religious studies mentioned the inter-institutional collaborations during which universities, institutes, and academies in the field of humanities could share their knowledge and experience with medical universities. An expert in medical education suggested concentrating on peer teaching and mentoring and the involvement of families in the process of competencies development.

Integration

Spiritual competencies are not teachable as a distinct course except for some knowledge and skills. Spiritual competencies are expected to form an atmosphere in which the other parts of the healthcare system find different meanings and interpretations. This worldview should be gained in different parts and instances of medical education, from classes to clinics and bedsides. An expert in medical ethics underscored the role of the hidden curriculum in this regard and believed that the professors and instructors should act as role models. A pharmacologist talked about using arts and different media to convey the necessary concepts to the students. As a whole, the implicit approach and use of extracurricular solutions were emphasized.

Interdisciplinary approach

Though spirituality has been recognized as a dimension of health, it is not a medical topic and thus, it is necessary to address it with the contribution of different disciplines accompanied by critical thinking and reasoning. A medical doctor mentions the distrust between medical experts and religious scholars. She explains that religious scholars do not recognize the doctors'ideas about religion, while on the other hand, medical experts are not willing to accept them in medical fields, because they do not have a precise understanding of health issues, and that their words may seem less accurate and practical.

Consequences

Transcendence

In an R/S context, human beings are capable of growth in a heavenly direction, so that their soul is enhanced and elevated from earthly matters. In light of transcendence, human beings are expanded and gain new opportunities to promote. This personal transcendence could lead to social consequences as well. A medical doctor describes the ultimate transcendent health system as a health system in which everybody entering it, whether a student, a patient, a professor, or a staff member takes a step towards God day by day.

Patient-centeredness

The holistic view of medicine is essentially patient-centered. It considers different aspects of human beings and tries to customize the treatment plan for every patient. The healthcare system with R/S competencies aims to develop and implement a form of medicine that considers the patient as a whole person with unique needs, inner desires, and opportunities for personal growth. In the words of an expert in community medicine, respecting human dignity, providing peaceful conditions for patients, and assisting the patients to make use of their illness as a means of spiritual development were mentioned as the expected consequences of developing R/S competencies.

Accountability

Responsibility and social accountability, adherence to patients'rights, and preferring patients'benefit to personal gain are among the expected characteristics of well-rounded professionals. Developing R/S competencies could foster these characteristics among learners that could in turn provide an accountable healthcare system in the future. An expert in religious studies states that medical students should be aware that they are trained with national funds and budgets. These resources are allocated and spent for them so that they can provide healthcare for people who need their help. This is their duty.

All the processes described here should occur in the context of different layers. The first layer is the intra-institutional context by which we mean the medical education system; the intra-professional context focusing on the healthcare system; the social context that takes into account the different conditions of the country including economic and financial issues; and the global context that exerts its impacts in a globalized world.

Discussion

This study aimed to design a context-sensitive framework for cultivating R/S competencies among medical students in Iran. In an era where holistic, patient-centered care is increasingly valued, truly whole-person medicine cannot be achieved without well-rounded healthcare providers who are sensitive to patients’ spiritual dimensions [23]. To appropriately address the spiritual aspects, healthcare providers need different characteristics in the realm of knowledge, attitude, and behavior. Addressing spirituality is a recognized international need in medical education. There are diverse models, both secular & faith-based institutions such as the George Washington Institute for Spirituality and Health framework [24], NICE guidance on supportive and palliative care [25], and similar models that emphasize holistic care, reflective practice, and patient-centeredness. These models often emphasize multiculturalism and indigenous spirituality and the core rationale across all of them is improving patient care, well-being, and the patient-physician relationship. In some Muslim-majority countries like Malaysia, there are initiatives to integrate Islamic values into medical curricula within a multi-religious society [26]. The framework presented here is distinct given its specific religious and cultural context and its unique focus on character formation as the foundation for sustainable competency.

We identified integrity as the unifying core of all R/S competencies in this model. Integrity is the coherent alignment of one’s values, beliefs, and professional actions and reflects the commitment to embody values in clinical practice [27]. While this model is different from some prior models like Puchalski’s spiritual history-taking that focuses on discrete skills [28], it aligns with Barnard et al.'s conceptualization of integrity encompassing self-motivation, moral courage, honesty, consistency, and responsibility [29]. Moreover, our finding that R/S competencies extend beyond discrete knowledge or communication skills to include the formation of character and inner conviction aligns with medical ethics literature emphasizing virtue development [30], though it is not fully consistent with competency-based approaches that prioritize measurable behaviors over internal states [31].

Developing these competencies is a multi-layered curricular content guided by pedagogical strategies, the hidden curriculum, and particularly the exemplars provided by faculty role models. For instance, role-playing spiritual assessment with standardized patients, and small-group discussions analyzing cases with spiritual distress can actively foster self-awareness and skill integration [32]. This positions spiritual sensitivity as an integral lens through which all training, from didactic sessions to bedside rounds, are reframed [33]. To educate a practitioner attuned to spiritual needs, skilled in assessment and committed to meeting these needs, and willing to provide spiritual care, medical education should foster the students'inner spirituality and focus more on"who you are as a human being"than"what you do as a professional"[34]. This necessitates fostering students’ inner spirituality through reflective exercises, mentorship, and immersive learning environments that reward empathy, altruism, and self-discipline [35]. Such an approach cultivates a well-rounded professional identity, grounded in humanistic values [36].

The re-orientation of medical schools to incorporate the development of spiritual and professional identity requires creating humane learning environments where faculty and students practice mutual accountability and holistic care. While our model emphasizes institutional responsibility, challenges exist: faculty resistance due to discomfort with R/S topics, student skepticism about relevance, and curricular overcrowding [35]. Strategies to overcome these include faculty development workshops on R/S integration, demonstrating R/S impact on clinical outcomes (e.g., reduced patient despair in terminal illness), and embedding R/S content longitudinally within existing ethics/communication courses rather than standalone modules.

Moralities are behaviors judged by virtues, norms, or values and are best cultivated through implicit methods that internalize values [37]. To internalize moral values and provide lasting and consistent moral development, indirect and implicit ways are preferred. Enriching curricula with diverse spiritual perspectives, integrating spiritual dimensions into existing courses rather than relegating them to isolated lectures, and creating a community of accountability, especially in clinical contexts are effective strategies for this aim. Schools need to combine teaching activities with practical activities and comprehensively cultivate the humanistic quality of medical students [38].

In Persian traditional medicine, the spiritual state of therapists and their relation with God and patients are determinants of the efficacy of the treatment and an approach to personalized medicine that is determined by temperament (Mizaj) [39]. Islamic teachings fully address the spiritual aspects and this is true about other religious orientations including Christian mindfulness [40]. This is supported by the idea that human health is an interconnected structure whose physical, social, psychological, and spiritual dimensions influence each other and the overall health.

Successful programs weave spirituality throughout the curriculum and are sensitive and relevant to the specific societal and religious landscape. The Iranian model's strength lies in its deep integration with Islamic values within the national context, contrasting with more pluralistic or secular approaches elsewhere. The model proposed here could potentially contribute to the global discourse, given that R/S competence is manifested in culturally specific ways, but it is informed by worldwide experiences and the cultural adaptability of this framework could make it applicable in other cultural contexts because most of the concepts of the model including embedding values into educational programs are globally accepted [41] and lead to compassionate healthcare with reduced burnout.

Barriers such as conceptual ambiguity and external socioeconomic pressures underline the need for clear definitions, practical guidelines, and supportive institutional policies. Yet, the successful implementation of this model anticipates key outcomes in healthcare. Transcendence of the health system in personal and organizational aspects could lead to better health outcomes. Transcendence involves a connection with God and thus trying to evolve according to God's will and religious instructions thus enhancing the level of healthcare provision. The holistic view is aligned with patient-centeredness, in that all human beings are unique and have their own needs according to their traits and attributes [42]. Accountability, on the other hand, is central to sound medical practice [43]. Teaching, learning, and practicing accountability as a virtue help clinicians to provide better care for their patients and the flourishing of the healthcare systems.

Overall, this framework offers medical educators a roadmap for integrating spiritual formation into professional identity development. Future research should evaluate its applicability across diverse institutions and assess its impact on learner attitudes, clinical behaviors, and patient outcomes.

Implementing the theoretical model in a real-world healthcare system will face practical barriers. There is little acceptance and agreement among the policy-makers and top managers regarding the R/S issues and their serious consideration in medical education and healthcare. Moreover, there are still many academics and health professionals that do not have R/S inclinations because they consider them pseudo-science and this may lead to resistance from faculty members or even students. Lack of textbooks and educational content is a main barrier and the success of this approach in higher education without being prepared in basic stages is doubtful. Thus, the first step to overcoming these barriers is to provide and maintain a consensus regarding this issue. This will facilitate the way to the implementation process and remove the barriers.

Conclusion

Integrity—defined as the seamless integration of one's deepest values, beliefs, and professional actions—constitutes the foundational core of R/S competencies in medical education. Cultivating integrity not only enhances patient care through more empathetic and ethically grounded practice, but also enriches healthcare providers'own well-being and professional fulfillment. The paradigmatic model proposed in this study offers a structured roadmap for embedding R/S competency development across curricular content, pedagogical strategies, and learning environments. Highlighting key enablers, barriers, and contextual layers, can guide medical schools in designing holistic training programs that foster truly whole-person care. Future empirical research should focus on validating this model in diverse educational settings, measuring its impact on learner outcomes, and refining implementation strategies to optimize both educational and clinical effects.

Practical implications

Religious/spiritual aspects of medicine have been highlighted during the recent decades. However, they are not addressed in medical practice appropriately. The main cause of this deficiency is the lack of R/S competencies in healthcare professionals. The model presented in this study provides a base for more practical measures and interventions and offers actionable insights for integrating religious and spiritual issues in medical education. In other words, the model could serve as a practical framework for implementing holistic medical education practices.

Limitations

Despite efforts to maintain objectivity, the interpretation of data and emerging categories may reflect the researcher's subjectivities and prior assumptions. Moreover, as with many qualitative methods, the findings are context-bound and may not be easily generalizable to other settings and contexts. On the other hand, the multi-stage coding process, while methodologically rigorous, may have presented challenges in maintaining consistency and coherence across evolving categories. Also, despite our data saturation during the interviews, we could not claim that we have captured fully all possible variations of the subject of the study. Future research should validate the model across diverse cultural and healthcare settings.

Abbreviation

R/S

religious/ spiritual

Authors’ contributions

All the authors contributed in the design of the study. MH had the main role in the acquisition of data. MH and AA were more involved in the analysis of the data and its interpretation. MH and AH prepared the manuscript draft and the final manuscript was read and approved by all members of the researcher team. All the authors are accountable for the work and the present manuscript.

Funding

This study was funded by the National Agency for Strategic Research in Medical Education (NASR). Tehran, Iran. Grant No. 972424.

Data availability

The data that support the findings of this study are available on request from the corresponding author.

Declarations

Ethics approval and consent to participate

The study was approved by the Iranian National Agency for Strategic Research in Medical Education (NASR) with approval code: 972424. The study was conducted with full adherence to the Declaration of Helsinki. To make sure that the interviewees participated in the study with informed consent, an invitation letter was sent declaring the subject and aims of the study. The interviewees participated in the study voluntarily and the interviews were recorded with their permission. Every necessary measure was taken to keep the anonymity of the participants and the confidentiality of their data. Moreover, the data analysis was carried out with full consideration to maintain objectivity and avoid bias in interpreting the data.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.