Spiritual Well‐Being, Religious Coping and Care Burden in Relatives of Intensive Care Unit Patients: A Mixed‐Method Study

ABSTRACT

Background

Intensive care unit (ICU) admission is an extremely stressful experience that can increase the burden of care among patients' relatives.

Aim

This study aimed to examine the relationships between spiritual well‐being, religious coping and burden of care among the relatives of ICU patients.

Study Design

This convergent mixed methods study was conducted between February 2023 and December 2025 in the ICU of a university hospital. Quantitative data, the Spiritual Index of Well‐Being Scale, the Muslim Religious Coping Scale and the Zarit Burden Interview were used. Qualitative data were collected through semi‐structured interviews with 10 participants and analysed using the thematic analysis method.

Results/Findings

Quantitative data were collected from a total of 313 ICU patients' relatives. Higher levels of spiritual well‐being and religious coping were associated with lower burden of care (β = −0.190, p = 0.028 and β = −0.128, p = 0.042, respectively). In hierarchical regression analyses, spiritual well‐being remained significantly correlated with the burden of care. The qualitative findings revealed that family members who have a relative in intensive care are affected psychologically, physically, socially, and economically. The participants reported that they used spiritual and religious practices, social support, and professional psychological support as coping resources during the intensive care process.

Conclusions

Among the relatives of ICU patients, spiritual well‐being and religious coping were associated with a lower burden of care. In addition, the qualitative findings showed that spiritual, religious, social and psychological resources can play important roles in helping family members cope with the challenges of admitting a loved one to the ICU.

Relevance to Clinical Practice

Healthcare professionals should adopt a holistic and family‐centred approach that recognizes the emotional, social and spiritual needs of ICU patients' relatives and facilitates access to appropriate support resources.

Impact Statements

• What is known about the topic

  • ○
    Admission to the intensive care unit (ICU) is an extremely stressful experience that can increase the burden of care for both patients and their relatives
  • ○
    Spirituality and religion are important resources that individuals can turn to when coping with stressful life events, uncertainty, and crises.
• What this paper adds

  • ○
    Among relatives of ICU patients, higher levels of spiritual well‐being and religious coping were associated with a lower care burden
  • ○
    In hierarchical regression analyses, spiritual well‐being remained significantly associated with burden of care, whereas the association between religious coping and burden of care weakened and ceased to be statistically significant after spiritual well‐being was included in the model
  • ○
    The qualitative findings showed that the ICU experience affected many aspects of the daily lives of patients’ relatives in the psychological, physical, social and economic domains.
  • ○
    The relatives of the ICU patients identified spiritual and religious practices, social support and professional psychological support as important resources for coping with the challenges associated with critical illness.

1. Introduction and Background

Intensive care units (ICUs) are specialized settings where critically ill patients are continuously monitored and receive advanced medical treatment [1]. Having a loved one admitted to an ICU is an unexpected and distressing experience for family members, leaving them facing psychological, social and emotional challenges. Relatives of ICU patients often experience uncertainty about the prognosis, fear of the death of their family members, communication difficulties, restricted participation in care and pressure related to treatment decisions. Recent studies have consistently shown high levels of anxiety, stress, depressive symptoms, emotional distress and uncertainty among family members of ICU patients and have emphasized that critical illness affects not only patients but also their loved ones [1, 2, 3, 4, 5].

A burden of care may also arise when care does not directly involve medical tasks [6]. In ICUs, family members often take on the responsibility of making decisions, coordinating family roles, maintaining communication with healthcare professionals and dealing with uncertain outcomes. These responsibilities can pose a unique burden, characterized by emotional exhaustion, helplessness, uncertainty, impact on daily life, social constraints and financial strain. Research findings on this topic indicate that family members of ICU patients typically experience anxiety, depressive symptoms, psychological distress and long‐term adverse outcomes, which are collectively referred to as the Post‐Intensive Care Syndrome‐Family (PICS‐F) [2, 5].

Individuals facing major health crises employ various coping strategies to manage their uncertainty and emotional distress. These strategies may include problem‐focused coping, emotion‐focused coping, seeking social support, professional psychological help and meaning‐focused coping processes [7, 8]. Among the relatives of ICU patients, coping responses are often shaped by prognostic uncertainty, disruption of family roles, emotional tension and caregiving demands [1, 9]. Recent studies have shown that family members often seek communication with healthcare professionals, social support, psychosocial interventions, and family‐centered care resources to manage ICU‐related stress [10, 11, 12]. Effective communication, psychosocial support, and supportive relationships with healthcare professionals have all been associated with improved family well‐being and reduced emotional burden [2, 12].

In addition to social and psychological resources, spirituality and religion can also be used as important coping mechanisms during times of crisis. Spirituality generally refers to an individual's search for meaning, purpose, connection and inner harmony, while religious coping involves the use of religious beliefs, practices and resources to understand and manage stressful experiences [13, 14]. While conceptually distinct, these constructs are closely related and can interact through meaning‐making processes. Religious coping can contribute to spiritual well‐being by helping individuals maintain hope, interpret the pain they are experiencing and find meaning in adverse circumstances, while a sense of spiritual well‐being can allow individuals to effectively use religious and existential resources during stressful experiences [8, 14, 15].

Previous studies have shown that spirituality can play an important role in psychological adjustment among the relatives of critically ill patients. Having spiritual resources available has been linked to resilience, emotional adjustment, hope and improved psychological well‐being in families facing critical illness [16, 17, 18]. However, religious coping may not always be beneficial. Negative religious coping methods, such as feelings of spiritual abandonment, punishment by God, anger against a higher power, or the feeling of being engaged in a religious struggle, have been associated with worse psychological outcomes and greater distress in stressful health situations [14]. Therefore, examining both spirituality and religious coping methods can provide a more comprehensive understanding of how relatives of ICU patients adapt to caregiving‐related stress.

Although the family experiences, level of psychological distress, spiritual needs, resilience, and coping strategies of the relatives of ICU patients have all been examined [10, 12, 19, 20, 21], there is limited evidence on how spiritual well‐being and religious coping strategies are correlated with caregiver burden. Most of the existing studies rely primarily on quantitative or qualitative approaches, limiting the understanding of both statistical relationships and lived experiences. Very little is known about how the spiritual and religious resources available to them affect the burden on caregivers and how these experiences impact the daily lives of their loved ones in the ICU. A mixed‐methods approach can provide a more comprehensive understanding by integrating statistical relationships with contextualized descriptions of lived experiences [22].

1.1. Purpose

The quantitative component of the study aimed to examine the relationship between spiritual well‐being, religious coping and burden of care among relatives of ICU patients. The qualitative component aimed to determine how patients' relatives experience the burden of care during the intensive care process and the coping strategies they use in response to these challenges. By integrating quantitative and qualitative findings, the study aimed to provide a more comprehensive understanding of the role of spiritual and religious support in the care experiences of ICU patients' relatives.

1.2. Research Questions

The study sought answers to the following questions:

1. Is there a relationship between spiritual well‐being, religious coping and the care burden?

2. What are the effects of the care burden on the relatives of ICU patients?

3. What are the coping strategies used by the relatives of ICU patients?

1.3. Conceptual Framework

The conceptual framework of this study is based on Park's Meaning‐Making Model [8], which describes how individuals interpret and adapt to highly stressful life events. According to the model, psychological distress occurs when stressful experiences challenge an individual's overall beliefs, goals, values and sense of meaning. To mitigate this distress and restore coherence, individuals engage in meaning‐making processes that help them reinterpret and adapt to stressful circumstances [8].

The admission of a loved one to the ICU represents a highly stressful and potentially traumatic experience, characterized by uncertainty, fear of loss, emotional strain, disruption of daily life, and the burden of caregiving. Family members often experience concerns about their relative's prognosis, treatment decisions, communication with healthcare professionals and changes in family roles [1, 4, 9]. According to the Meaning‐Making Model, an individual's ability to maintain meaning, purpose and coherence can influence how these challenges are perceived and managed [8].

In this regard, spiritual well‐being and religious coping can be considered significant sources of meaning. Individuals with a higher degree of spiritual well‐being may be more successful in integrating stressful experiences into a coherent life perspective and maintaining psychological stability during crises [13, 15, 23]. Religious coping refers to the use of religious beliefs, practices and communities to understand and manage stressful situations. Activities such as prayer, reading scripture and participating in religious communities, as well as trusting in God's will, can provide emotional comfort, hope and perceived control during times of uncertainty [14, 24].

Religious coping can support meaning‐making efforts and contribute to maintaining or enhancing spiritual well‐being during crises. Individuals with a stronger sense of spiritual well‐being may be more likely to draw on religious and existential resources when faced with adversity [8, 14]. Through these interconnected processes, spiritual well‐being and religious coping methods can have an impact on how relatives of ICU patients perceive and manage the burden of care. The meaning‐making model can guide qualitative research into how family members of patients engage in meaning‐making in order to cope with the stress and care challenges related to the ICU, based on the quantitative assumption that a higher degree of spiritual well‐being and a greater range of religious coping strategies are associated with a lower care burden. This study hypothesizes that spiritual well‐being and engaging in religious coping may be associated with a lower perceived care burden among family members of ICU patients.

2. Methods

2.1. Study Design and Sampling Method

The study used a convergent mixed methods design to obtain a comprehensive understanding of the burden of care, spiritual well‐being and religious coping strategies of the relatives of ICU patients. In a convergent mixed methods design, quantitative and qualitative data are collected and analysed separately but are interpreted together to gain a more comprehensive understanding of the phenomenon under study [22]. The quantitative component examined the relationships between spiritual well‐being, religious coping strategies, and burden of care, while the qualitative component investigated the experiences of patients' relatives regarding the burden of care and the coping strategies they used during the intensive care process. The quantitative and qualitative findings were synthesized during the process of interpretation. In this approach, findings addressing the same research questions were compared and interpreted together to develop a comprehensive understanding of the experiences of the family members of ICU patients.

The study was conducted between February 2023 and December 2025 in the ICUs of a university hospital located in the Central Black Sea Region of Türkiye. Sample size estimation was performed using G*Power version 3.1.9.7 [25] for hierarchical multiple regression analysis (fixed model, R ² increase). Assuming a small to moderate effect size (f ² = 0.08), a significance level of α = 0.05, and 95% statistical power (1 − β = 0.95), the required minimum sample size was calculated to be 263 participants. During the data collection process, 313 relatives of ICU patients were reached. The statistical power of the study was also assessed post hoc using the G*Power 3.1 [25] software. Consistent with the initial analysis, the coefficient of determination (R ² = 0.029) obtained for the care burden variable in the post hoc power analysis was used; this value was converted to a correlation coefficient (r = 0.170) and included in the analysis. According to this value, the power of the study was calculated as 85.8% (1−β = 0.858) as a result of the post hoc power analysis based on a 95% confidence level (α = 0.05) and the sample size of 313 participants. The fact that the power value obtained was above the recommended minimum level of 80% [26] indicated that the study had sufficient statistical power to determine the observed effect.

The inclusion criteria were being 18 years of age or older, being literate, being a primary caregiver relative of an ICU patient, providing care without compensation, not having any cognitive or communication disabilities, and being willing and able to give informed consent. Researchers informed the relatives of patients who met the inclusion criteria about the study during visiting hours in the ICU and invited them to participate in the study on a voluntary basis. Exclusion criteria included failing to communicate effectively, failing to complete questionnaires, being under 18 years of age, refusing to give informed consent, and caring for a patient for a fee.

For the qualitative component, purposive sampling was used to select participants who could describe their experience in depth. Data saturation was continuously assessed throughout the interview process. After the eighth interview, no significant new codes or themes emerged. Two additional interviews were conducted to validate that themes were being repeated and ensure that saturation had been reached. The qualitative data collection was thus completed after 10 interviews.

Since the study explored spirituality and religious coping, the contextual characteristics of the study environment were also considered. Although the hospital has a prayer room for patients' relatives, there are no specific spiritual care providers, chaplains, imams or structured spiritual care programmes explicitly designed for family members of ICU patients. Furthermore, the healthcare professionals working in the ICU had not received formal training in providing spiritual assessment or spiritual care for family members.

2.2. Data Collection

Quantitative data were collected using the Patient Relative Information Form, the Spiritual Index of Well‐Being Scale [27], the Muslim Religious Coping Scale [24] and the Zarit Burden Interview [6]. The study data were collected between May 2024 and July 2025. Before data collection, the survey form was tested in a pilot study involving five relatives of ICU patients to assess its clarity, comprehensibility and feasibility. Since the participants reported that they had no difficulty understanding the items, no changes were necessary. Data obtained during the pilot study were not included in the final analyses. The questionnaires were administered face‐to‐face by the first researcher before or after intensive care visits according to the preferences and routines of the participants. This approach was adopted to minimize disruption to patient care and reduce the participants' burden during their experience of the ICU.

The semi‐structured interview form was developed based on the relevant literature and Park's Meaning‐Making Model, which formed the conceptual framework of the study. The interview questions were designed to explore the participants' experiences regarding the burden of care, the emotional and practical challenges they faced and the strategies they used to cope with these challenges. Open‐ended questions were used to encourage participants to describe their experiences in their own words. Before data collection, the interview form was reviewed by two experts experienced in qualitative research and intensive care nursing to assess its relevance and comprehensibility.

Both researchers had received training in qualitative research methods. Detailed face‐to‐face interviews with the patients' relatives were conducted by the first researcher in a private and quiet room. In the qualitative interviews, the intensive care experiences of the patients' relatives, their perceived burden and their coping strategies were examined. Permission was obtained from the participants before the meeting to audio‐record the interviews. To ensure privacy, identifiers such as ‘Participant 1’ and ‘Participant 2’ were used instead of personal data. The duration of the interviews varied between 30 and 45 min.

2.3. Measures

2.3.1. Patient's Relative Introductory Information Form

The introductory information form for the patient's relatives consisted of questions about the sociodemographic characteristics of the patient's relatives (age, gender, marital status, education level, employment status, having/not having children, degree of closeness with the patient and religion).

2.3.2. Spirituality Index of Well‐Being (SIWB)

The SIWB was developed by Daaleman and Frey [27]. The Turkish validity and reliability study of the scale was conducted by Sarıçam [28]. The 5‐point Likert‐type scale consists of a total of 12 items. The SIWB has two sub‐dimensions: Self‐Efficacy (items 1, 2, 3, 4, 5 and 6) and Life Plan (items 7, 8, 9, 10, 11 and 12). The lowest score that can be obtained from each of the sub‐dimensions is 6, whereas the highest score is 30. An increase in the score obtained from the Self‐Efficacy sub‐dimension indicates an increase in self‐efficacy in the spiritual context, and an increase in the score obtained from the Life Plan sub‐dimension indicates an increase in life planning in the spiritual context. An increase in the score obtained from the overall scale indicates an increase in the spiritual well‐being levels of individuals. In the original study of the scale, Cronbach's alpha reliability coefficient of the overall scale was 0.79, while it was 0.77 for the Self‐Efficacy sub‐dimension, and 0.86 for the Life Plan sub‐dimension [27]. In this study, the Cronbach's alpha reliability coefficient of the SIWB was found to be 0.93, while the Cronbach's alpha reliability coefficients of the Self‐Efficacy and Life Plan sub‐dimensions of the scale were found to be 0.87 and 0.92, respectively.

2.3.3. Muslim Religious Coping Scale (MRCS)

The MRCS was developed by Adam and Ward [24]. The Turkish validity and reliability study of the scale was conducted by Künüroğlu and Sevi Tok [29]. The 5‐point Likert‐type scale consists of a total of 19 items. The MRCS has three sub‐dimensions: the Cognitive Religious Coping sub‐dimension (items 1, 2, 3, 4, 5, 6, 7 and 8), the Behavioural Religious Coping sub‐dimension (items 9, 10, 11, 12, 13, 14 and 15), and the Social Religious Coping sub‐dimension (items 16, 17, 18 and 19). A high score obtained from the scale and its sub‐dimensions indicates that a particular coping strategy is more frequently used. There is no reverse‐scored item on the scale [29]. In the original study, the Cronbach's alpha reliability coefficient of the Cognitive Religious Coping sub‐dimension was 0.92, the Cronbach's alpha reliability coefficient of the Behavioural Religious Coping sub‐dimension was 0.92, and the Cronbach's alpha reliability coefficient of the Social Religious Coping sub‐dimension was 0.85 [24]. In this study, the Cronbach's alpha reliability coefficient of the MRCS was 0.92, and the Cronbach's alpha reliability coefficients of the Cognitive, Behavioural and Social Religious Coping sub‐dimensions were 0.90, 0.93 and 0.90, respectively.

2.3.4. Zarit Burden Interview (ZBI)

The ZBI was developed by Zarit et al. [6]. The Turkish validity and reliability study of the scale was conducted by İnci and Erdem [30]. The 5‐point Likert‐type scale consists of a total of 22 items. The score that can be obtained from the scale varies between 0 and 88 points. A high score from the scale indicates that the distress experienced is high [30]. In the Turkish validity and reliability study, the Cronbach's alpha reliability coefficient of the scale was found to be 0.95 [30]. In this study, the Cronbach's alpha coefficient of the ZBI was found to be 0.92.

2.4. Data Analysis

2.4.1. Quantitative Analysis

The data were analysed using the IBM SPSS 25 software. Descriptive statistics (mean, standard deviation, frequency, percentage) were calculated. Hierarchical multiple regression analysis was performed to examine the extent to which spiritual well‐being and religious coping methods explained the variance in burden of care. Before regression analyses, assumptions were evaluated using normality, skewness and kurtosis values. Multicollinearity was examined using variance inflation factor (VIF) values. Residual graphs were examined to assess linearity and homoskedasticity. The results showed that all the assumptions required for hierarchical regression analysis were met. The selection of predictive variables was made in line with the conceptual framework and study objectives. In the first step, the religious coping method was included in the model. In the second step, spiritual well‐being was added to determine its additional contribution to explaining the burden of care. Statistical significance was set at p < 0.05.

2.4.2. Qualitative Analysis

The qualitative data were analysed using Colaizzi's [31] phenomenological method. This approach was chosen because it provides a systematic and rigorous framework for identifying, organizing and defining the meanings associated with participants' lived experiences. The method was deemed especially suitable for examining the experiences, perceptions and coping strategies of the relatives of ICU patients. The analysis involved reading the transcripts repeatedly, extracting key phrases, formulating meanings, clustering themes, developing comprehensive descriptions and integrating the findings into a coherent structure.

To improve reliability, the criteria proposed by Lincoln and Guba [32] were applied. The reliability was supported by the audio recordings and verbatim transcriptions of all the interviews. Reliability was enhanced through the systematic application of Colaizzi's analytical procedure. Validation was enhanced through the independent coding and development of themes by the two researchers, followed by discussion until consensus was reached. Transferability was supported by providing detailed descriptions of the study's context, its participants and the data collection procedures. Qualitative findings were reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) guideline [33].

2.5. Ethics Statement

Ethical approval was obtained from the Ethics Committee of Ondokuz Mayıs University (Approval Date: February 24, 2023; Decision No.: 2023/62). All participants were informed about the purpose of the study, the fact that participation was voluntary, the procedures regarding confidentiality, and their right to withdraw at any time without any consequences. Verbal informed consent was obtained before participation in both the quantitative and qualitative phases of the study. The study was carried out in accordance with the principles of the Declaration of Helsinki.

3. Results and Findings

3.1. Participants' Characteristics

A total of 313 relatives of ICU patients participated in the quantitative phase of the study. The majority were male (58.5%), married (67.4%), university graduates (55.3%) and employed (85.6%). Most of the participants were parents of the patients (72.8%), and all were Muslim (100%). The mean age was 37.25 ± 11.24 years.

3.2. Scale Scores

The mean SIWB score was determined to be 41.65 ± 10.58, the mean MRCS score was 73.16 ± 13.21, and the mean ZBI score was 46.81 ± 14.76 (Table 1).

TABLE 1.

Total and sub‐dimension scores for the Spiritual Index of Well‐Being (SIWB), Muslim Religious Coping Scale (MRCS) and Zarit Burden Interview (ZBI).

Scales	Mean ± SD
Spirituality Index of Well‐Being (SIWB)
Self‐efficacy sub‐dimension	20.02 ± 5.39
Life plan sub‐dimension	21.65 ± 5.94
Total	41.65 ± 10.58
Muslim Religious Coping (MRC) Scale
Cognitive religious coping sub‐dimension	32.94 ± 6.13
Behavioural religious coping sub‐dimension	28.79 ± 5.81
Social religious coping sub‐dimension	11.43 ± 4.61
Total	73.16 ± 13.21
Zarit Burden Interview (ZBI)	46.81 ± 14.76

Abbreviation: SD, standard deviation.

3.3. Determinants of Care Burden

Hierarchical regression analyses were performed to examine the contributions of spiritual well‐being and religious coping methods to the burden of care. Both spiritual well‐being and religious coping methods were significantly associated with the burden of care (β = −0.190, p = 0.028 and β = −0.128, p = 0.042, respectively) (Table 2). However, when both variables were included in the regression model, the association between religious coping and burden of care was seen to weaken and was no longer statistically significant. The final model explained 2.9% of the variance in burden of care (R ² = 0.029) (Table 3). Although statistically significant associations were observed, the explained variance rate was relatively low.

TABLE 2.

Hierarchical regression analysis for predicting the caregiver burden (ZBI).

Model	Predictor	B a (95% CI)	S.E	β b	t	p	r 1	r 2	VIF
1	Constant	55.969 (49.374: 62.565)	3.352		16.697	< 0.001
	SIWB	−0.223 (−0.377: −0.070)	0.078	−0.161	−2.863	0.004	−0.161	−0.161	1.000
2	Constant	59.347 (49.754: 68.941)	4.876		12.172	< 0.001
	SIWB	−0.190 (−0.358: −0.021)	0.086	−0.136	−2.214	0.028	−0.161	−0.125	1.205
	MRCS	−0.065 (−0.200: 0.070)	0.069	−0.059	−0.954	0.341	−0.115	−0.054	1.205

Model	Predictor	B a (95% CI)	S. error	β b	t	p	r 1	r 2	VIF
3	Constant	56.029 (46.842: 65.215)	4.669		12.001	< 0.001
	MRCS	−0.128 (−0.252: −0.004)	0.063	−0.115	−2.038	0.042	−0.115	−0.115	1.000
4	Constant	59.347 (49.754: 68.941)	4.876		12.172	< 0.001
	MRCS	−0.065 (−0.200: 0.07)	0.069	−0.059	−0.954	0.341	−0.115	−0.054	1.205
	SIWB	−0.190 (−0.358: −0.021)	0.086	−0.136	−2.214	0.028	−0.161	−0.125	1.205

Abbreviations: r ¹, Zero‐order correlation; r ², Partial correlation; VIF, variance inflation factor.

^a Unstandardized regression coefficient.

^b Standardized regression coefficient.

TABLE 3.

Model fit and variation statistics for hierarchical regression analyses.

Model	R 2	Adjusted R 2	Change statistics			Model significance
			R 2 change	F change	p	F	p
1	0,026 a	0023	0026	8199	0004	8199	0004
2	0.029 b	0.022	0.003	0.911	0.341	4.554	0.011
3	0.013 c	0.010	0.013	4.153	0.042	4.153	0.042
4	0.029 d	0.022	0.015	4.901	0.028	4.554	0.011

Note: Dependent variable: ZBI.

^a Independent variables: (Fixed), SIWB.

^b Independent variables: (Fixed), SIWB, MRCS.

^c Independent variables: (Fixed), MRCS.

^d Independent variables: (Fixed), MRCS, SIWB.

3.4. Qualitative Findings

The thematic analysis identified various interrelated themes that defined the participants' experiences while their relatives were in the ICU (Table 4). In general, the burden of care was experienced as a multidimensional phenomenon that affected psychological, physical, familial, social and economic areas. Participants stated that fear, uncertainty, helplessness, emotional exhaustion, fatigue and sleep disturbances were the main consequences of having a relative admitted to the ICU. In response to these challenges, the participants reported using various coping resources, including spiritual and religious practices, social support and professional psychological support.

TABLE 4.

Categories and subthemes related to intensive care experiences, their effects and coping mechanisms.

Categories	Subtheme	Representative quotes
Impact of the ICU Process on Family Members	Psychological and cognitive distress	I am very worn out psychologically. I wake up every morning with the fear that something will happen. Every time the phone rings I feel afraid that something has happened. This wears people out. My stress and anxiety levels have increased. (P3)
	Physical burden	My sleep pattern was disturbed. Having insomnia leads to people feeling weak and exhausted. I can't get enough rest. I constantly experience physical problems such as bodily aches and headaches during the day. (P6)
	Changes in family life	Our family relations have become stronger. With regard to illness and care, everyone has started to communicate better with each other. We didn't get together that often before this illness. (P7)
	Occupational burden	My professional life has been greatly affected; There's a lot of work to be done. Right now, I'm just going in and out of class. But there's a lot of paperwork waiting for me to do. Other than that, my colleagues and managers are very understanding. My friends do a lot of my work. (P8)
	Financial and social burden	We live in the outskirts. The hospital's in the city center. We go to the city center and the hospital every day. We eat and drink out, and our travel expenses are high. This is putting a financial strain on us. (P1)
Coping Strategies	Religious and spiritual coping	The first thing I turned to in order to cope with difficulties was praying and having faith. Both the good and the bad that happen to us come from Allah. I try to cope by accepting this. Spirituality relaxes people psychologically. I think faith is one of the most fundamental things that keeps people alive. (P1)
	Social support	Our family ties are very strong. I try to relax by spending time with my family. I've never been alone in this process. Their presence gives me strength. (P3)
	Professional support	In this process, I have received psychological support and I take medication. My mother is in a bad situation, so I need to be strong. I only share my feelings with the therapist. I don't share them with those in my environment, my family, or my friends. (P2)
Experiences Related to Intensive Care	Institutional policies and rules	Visiting hours are very short. We know that these are my father's last few minutes. We want to see him, but they don't allow all of us to visit. We want to see him for a longer amount of time. (P4)
	Experiences with healthcare personnel	We get clear answers to the questions we ask about our relative. They give detailed information about our their condition and what has been done. We're very pleased with the physicians and other healthcare personnel. (P5)

Spiritual and religious coping strategies included prayer, reading the Quran, trusting in a higher power, and engaging in personal spiritual contemplation. The participants described these practices as sources of comfort, hope, emotional release and strength during times of uncertainty. In addition, the participants emphasized the importance of support from family members, healthcare professionals and psychological services. The participants also reported that ICU visiting policies, communication with healthcare professionals and concerns about privacy affected their experiences in the ICU.

Overall, the qualitative findings helped contextualize the quantitative results. Themes related to meaning, hope, faith, emotional support and social connection provided insights into how spiritual well‐being and religious coping mechanisms may relate to caregiver burden. In addition, themes related to communication difficulties, uncertainty, economic hardship and emotional exhaustion indicated that caregiver burden was influenced by multiple factors beyond spirituality and religious coping (Table 5).

TABLE 5.

Integration of quantitative and qualitative findings.

Quantitative findings	Qualitative findings
Higher spiritual well‐being was associated with a lower burden of care.	Participants identified prayer, faith, hope, acceptance and finding meaning as important sources of coping.
While religious coping strategies were associated with a lower burden when examined separately, this association became insignificant after spiritual well‐being was included in the analysis.	Religious practices are generally embedded within broader experiences of meaning, hope, and emotional harmony.
The last regression model was able to explain only 2.9% of the variance in burden of care.	Participants identified multiple factors that contributed to the increased burden, including uncertainty, communication difficulties, financial strain, professional difficulties and emotional exhaustion.

4. Discussion

This mixed methods study examined the relationship between spiritual well‐being, religious coping and burden of care among the relatives of ICU patients and investigated how family members experience and manage the challenges associated with critical illness. The quantitative findings showed that higher levels of spiritual well‐being and religious coping were correlated with a lower burden of care. However, when both variables were examined simultaneously, spiritual well‐being remained significantly correlated with burden of care, while the correlation between religious coping and burden of care weakened and lost its statistical significance. The qualitative findings complemented these results by showing that family members often turned to their religious faith, prayer, a sense of acceptance, feelings of hope, social support and professional psychological resources as they coped with the emotional and practical challenges of the intensive care experience.

One of the most striking findings is that once spiritual well‐being was included in the regression model, the correlation between religious coping and caregiving burden became insignificant. This finding should be interpreted with caution. Rather than suggesting that spiritual well‐being is more important than religious coping, the results may suggest that these structures are closely related and partially overlap. While spiritual well‐being involves broader perceptions of meaning, purpose, inner harmony and existential coherence, religious coping represents one of the specific strategies individuals can employ when responding to stressful situations [8, 14, 15]. Some of the beneficial effects associated with religious coping may come into play through more extended meaning‐making processes that contribute to spiritual well‐being. This view is consistent with Park's Meaning Formation Model, which suggests that individuals adapt more effectively to stressful life events when they can maintain or recreate a sense of meaning and consistency [8]. Similar findings have been reported in recent studies on this subject, stating that spiritual resources can support resilience, emotional adjustment and psychological well‐being among critically ill patients' relatives [16, 17].

Although statistically significant correlations were observed, the regression models explained only a small fraction (2.9%) of the variance in burden of care. This finding shows that the burden of care among the relatives of ICU patients is a multidimensional phenomenon affected by a wide range of psychological, social, clinical and contextual factors other than spirituality and religious coping. Previous studies have identified family functioning, financial concerns, uncertainty about prognosis, emotional distress, communication with healthcare professionals, resilience, social support and the patient's clinical condition as significant contributors to family burden during critical illness [9, 18, 19, 20, 21, 34]. Therefore, the present findings should be interpreted not as a comprehensive explanation of the burden of care, but rather as representing one component of a much broader and more complex experience of spiritual well‐being and religious coping.

The qualitative findings provide an important context for understanding the multidimensional nature of the burden of care. Participants described the ICU experience as psychologically challenging and characterized by fear, uncertainty, helplessness, emotional exhaustion and concerns about the patient's prognosis. Many participants also reported sleep disturbances, impaired concentration, an affected family and social life, professional difficulties and financial difficulties. These findings are consistent with previous studies showing that family members of critically ill patients hospitalized in the ICU often experience significant psychological and social difficulties [1, 2, 3, 5]. The qualitative findings also helped explain why regression models explain only a limited fraction of the variance in the burden of care. By identifying numerous stressors beyond emotional concerns, the participants highlighted the complex and multifactorial nature of the family burden in intensive care settings.

This study also demonstrated the importance of spiritual and religious resources in times of uncertainty and emotional distress. Participants often identified prayer, reading the Quran, trust in God, patience and acceptance as important sources of comfort, hope, and emotional strength. Although the study examined religious coping mechanisms primarily within a Muslim population, the concept of meaning‐making may also apply, in a broader sense, to different faith traditions and secular worldviews. The findings may also hold significance beyond a specific religious context. Across different faiths, spiritual beliefs and religious practices can often serve as sources of meaning, hope, comfort and emotional support during times of crisis [14, 35, 36]. Similarly, in secular or non‐religious communities, similar functions can be fulfilled through existential meaning‐making, personal values, family ties, social relationships or philosophical worldviews [8, 37]. Therefore, the correlation observed between spiritual well‐being and burden of care may reflect broader meaning‐oriented coping processes rather than solely religious‐specific mechanisms [8, 14].

Participants identified their coping mechanisms not only with their religious practices but also with the social and psychological resources available to them. This finding is consistent with previous studies [7, 37] that highlight the multidimensional nature of coping among family members of critically ill patients. Participants often stated that they received support from family members, friends, healthcare professionals and, in some cases, professional psychological services. These findings suggest that the coping processes of relatives of ICU patients are multidimensional in nature and involve the interaction of spiritual, social, psychological and interpersonal resources. Similarly, previous studies have also emphasized the importance of family‐centered care, effective communication, psychosocial support and supportive relationships with healthcare providers in helping family members of critically ill patients cope [10, 11, 12]. The combination of quantitative and qualitative findings suggests that spiritual resources may contribute to adaptation, but that they operate within a broader network of coping resources that collectively influence the family experience.

Integrating quantitative and qualitative findings strengthens the results of the study. The quantitative analyses illustrate correlations between spiritual well‐being, religious coping, and burden of care, while the qualitative findings provide insight into the mechanisms of these correlations. The themes related to meaning, hope, faith, emotional support and acceptance help contextualize these correlations. In addition, themes related to communication difficulties, uncertainty, financial concerns and emotional exhaustion highlight a broader range of factors that contribute to the burden of care. These findings support the need for a holistic understanding of family experiences during critical illness and reinforce the value of mixed methods approaches in ICU research.

Given the social, emotional, psychological and spiritual challenges experienced by relatives of critical care patients, healthcare professionals should adopt holistic and family‐centred care approaches. Nurses are particularly well‐positioned to assess family members' emotional and spiritual concerns, facilitate access to psychosocial support services and promote effective communication between families and healthcare teams. Nurses, at the request of family members, can contribute to a more supportive ICU environment, creating opportunities for spiritual practices, facilitating access to psychological support and strengthening family‐centered communication strategies. Previous studies have reported that healthcare professionals often do not feel adequately prepared to address spiritual concerns due to limited training and institutional guidance [37]. Recent studies have also highlighted the importance of structured family support interventions, communication programmes and psychosocial care initiatives in ICU settings [10, 12]. Educational initiatives, institutional policies and clinical protocols that support holistic family care can help healthcare workers better address the various needs of relatives of ICU patients.

The mixed methods design used in this study allowed for the examination of statistical relationships alongside detailed descriptions of participants' life experiences, thereby providing a more comprehensive understanding of the burden of care among relatives of ICU patients. The integration of quantitative and qualitative findings offers insights into the potential mechanisms underlying the observed correlations, highlighting the complex interplay between spiritual, religious, social and psychological resources during critical illness. The simultaneous examination of spiritual well‐being, religious coping and the burden of care adds to the limited literature addressing these constructs in ICU settings and provides a broader perspective on the resources family members turn to during highly stressful experiences.

4.1. Strengths and Limitations

This study has several strengths. First, the convergent mixed methods design enabled the integration of quantitative relationships with in‐depth descriptions of participants' life experiences, offering a more comprehensive understanding of the burden of care among relatives of ICU patients. Second, the simultaneous examination of spiritual well‐being, religious coping and the burden of care has filled a significant gap in the ICU literature. Third, the use of valid measurement tools and rigorous qualitative procedures, including purposive sampling, data saturation, independent coding and adherence to COREQ guidelines, has enhanced the methodological robustness of the study.

Despite these strengths, the study also has some limitations. First, because the study used a cross‐sectional design, causal inferences cannot be drawn from the correlations observed. Second, the study was conducted at a single university hospital; this may limit the generalizability of the findings to other intensive care settings and health care systems. Third, all data were based on participants' own reports and subjective experiences; these may also have been affected by recall bias.

Fourth, although spirituality and religious coping were central to this study, no information was collected on the broader cultural characteristics that may have influenced participants' perceptions of caregiving, spirituality and religion. In addition, all participants identified themselves as Muslims. Consequently, the transferability of findings to populations with diverse religious affiliations, cultural backgrounds or secular worldviews must be carefully considered. Future studies involving culturally and religiously diverse populations will strengthen the understanding of the correlations between spirituality, religion and the burden of care.

Fifth, the data were collected in a single session, based on the participants' availability. Some relatives filled out the questionnaires before visiting the patient, whereas others completed them after the visit. Since emotional responses may vary with the timing of ICU visits, this variability may have influenced the patient's relatives' perceptions of the burden of care, spiritual well‐being and religious coping. Furthermore, since the questionnaires and interviews were administered only once, they may not have fully reflected the dynamic nature of patients' caregiving experiences in the ICU. Longitudinal studies are needed to better understand how the burden of care, psychological well‐being and religious coping strategies evolve during hospitalization in the ICU and in the post‐discharge period [19, 21].

Sixth, the regression analyses focused specifically on spiritual well‐being and religious coping methods in accordance with the conceptual framework and objectives of the study. However, the burden of care is a multidimensional phenomenon influenced by a multitude of demographic, clinical, psychological, social and contextual factors. Thus, the relatively low proportion of the variance explained may reflect the contribution of variables that have not been included in existing models. Future studies should include a wider range of predictive variables to provide a more comprehensive understanding of the burden of care among relatives of ICU patients.

Seventh, the study assessed general religious coping methods primarily by using a scale that measures positive religious coping strategies. Negative religious coping strategies—such as spiritual struggle, a sense of being abandoned by God, or religious conflict—were not studied, and this may also have affected how the patients' relatives coped with the stress associated with a critical illness. Future studies should explore both the positive and negative dimensions of religious coping.

Finally, the analyses were performed using the total scale scores. Future studies examining the individual contributions of spiritual well‐being and sub‐dimensions of religious coping may provide a more nuanced understanding of their relationship to the burden of care.

From a qualitative point of view, several strategies were employed to enhance reliability, including researcher triangulation, verbatim transcription, iterative analysis and the application of Lincoln and Guba's criteria. However, the findings reflect the participants' experiences at a single point in time. In addition, since the participants were drawn from a single institution and represented a relatively homogeneous cultural and religious background, transferability may be limited. Multicentre and longitudinal studies involving culturally diverse populations could be conducted to strengthen the reliability and transferability of the evidence.

4.2. Implications for Clinical Practice

The findings of this study support the adoption of holistic and family‐centered approaches that take into account the emotional, social, psychological and spiritual challenges experienced by relatives of ICU patients [12, 16]. Nurses and other healthcare professionals should routinely assess not only patients' informational and psychosocial needs but also their spiritual concerns, religious preferences and coping resources when appropriate. Given that many participants described spirituality and religion as an important source of comfort and support, healthcare professionals should be prepared to identify and address spiritual needs in a respectful and culturally sensitive manner [17, 23, 38]. Facilitating access to spiritual resources and creating opportunities to engage in the desired spiritual or religious practices will contribute to more individualized familial support.

The findings also highlight the importance of effective communication and psychosocial support during the intensive care process. Family‐centred communication strategies, clear information sharing and supportive interactions with healthcare professionals can help reduce uncertainty and emotional distress among patients' relatives [10, 12]. Facilitating access to psychological counselling and psychosocial support services can further strengthen coping and adaptation during periods of critical illness [11]. To support this practice, healthcare organizations should consider educational initiatives, clinical guidelines and institutional policies that can enhance healthcare professionals' competence and confidence in addressing the psychosocial and spiritual needs of patient relatives. Such initiatives will contribute to providing more comprehensive and person‐centred support for the relatives of ICU patients.

5. Conclusion

This mixed methods study shows that higher spiritual well‐being among the relatives of ICU patients was associated with a reduction in the burden of care; however, once spiritual well‐being was included in the regression model, the relationship between religious coping and the burden of care weakened and was no longer statistically significant. However, the relatively small proportion of the variance explained suggests that the burden of care is influenced by a multitude of psychological, social, clinical and contextual factors beyond mere spirituality and religious coping. The qualitative findings revealed that the intensive care experience affected patients' relatives psychologically, socially, physically and economically. The participants stated that they benefited from various coping resources, especially spiritual and religious practices, social support and professional psychological help, when coping with the difficulties faced by families with a loved one in the ICU. The findings highlight the multidimensional nature of the burden of care and suggest that spiritual well‐being is one of several sources that support adaptation during critical illness. The integration of the quantitative and qualitative findings emphasizes the importance of considering the emotional, social, psychological and spiritual dimensions when providing support to relatives of ICU patients.

Author Contributions

Cansu Atmaca Palazoğlu: conceptualization, methodology, validation, formal analysis, investigation, writing – original draft, Writing – review and editing, supervision. Zeliha Koç: conceptualization, methodology, validation, formal analysis, investigation, writing – original draft, writing – review and editing, supervision.

Funding

The authors have nothing to report.

Ethics Statement

The study began after approval had been received from the Ethics Commitee of Ondokuz Mayıs University (Date: February 24, 2023/Decision No.: 2023‐62). Verbal informed consent was obtained from all participants before the data collection process. In this study, the principles of the Declaration of Helsinki were followed.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

These research data have never been used in an article before. The datasets used during the current study are available from the corresponding author upon reasonable request.