Table 2.

Table summarising the main characteristics of the qualitative studies

First author and title of study	Context and main focus	Sampling and participants	Spirituality concept	Methodology	Main results and conclusions	Barriers/facilitators
Cocksedge, S. Doctors’ perceptions of personal boundaries to primary care interactions: a qualitative investigation (Cocksedge and May 2009)	UK, 2009. The boundaries of GP care in relation to touch and spiritual care. Both these aspects of care had arisen as significant themes from a previous qualitative study by the authors	Semirural Northern English GPs. Convenience/geographical sample. 28 GPs in this area invited. 23 accepted	Author uses Murray definition 2003 “The needs and expectations that all humans have to find meaning, purpose and value in life”. Many respondents clearly connote religious affiliation with this and respond in relation to this	Qualitative: Recording, verbatim transcription, thematic analysis using constant comparative method (Strauss and Corbin 1998). Coding involved 2 researchers	Spiritual needs may need to be addressed but there are differences in perception of how often these present. Religiously affiliated GPs report seeing more and are more confident in dealing with this. Those without faith report less presentations of spiritual problems and may be less keen, or unwilling to address these. Three reported no instances of spiritual issues presenting in primary care	Personal lack of the awareness of spirituality may create functional boundaries to discussion with patients. One practitioner “acts” a religious perspective where it seems the patient might wish this
Craigie, F. C. Spiritual perspectives and practices of family physicians with an expressed interest in spirituality (Craigie et al. 1999)	USA 1999. Views of family practitioners on spirituality An open ended empirical enquiry in relation to patient encounters, personal practice and medical education	Intentional sampling of interest group. 12 word of mouth/snowballing invitations to PCPs “with a significant interest in discussing spirituality” Participants were heterogeneously religious	Not explicitly stated, implicitly existential, meaning based, sometimes religious	Qualitative: Convenience sample. Data collection to theoretical saturation. Qualitative interviews, transcriptions, 7 stage phenomenological analysis based on Colaizzi (1978)	Spirituality personally highly significant for the practice of medicine, Need to respect patients own beliefs. Participants report spirituality underpins the vocation of many of them and they see a vital goal of PCPs as encouragers of a patient’s own spirituality. Dialogue, respect and mentoring important aspects of spirituality teaching	Barrier: time. Facilitators; ongoing, genuine and respectful relationships. Comments about personal, clinical and organisational axes of spiritual care. Section on future research including” collecting stories about physicians experiences of spirituality”
Ellis, M.R. What do Family Physicians think about spirituality in clinical practice? (Ellis, Campbell, Detwiler-Breidenbach, and Hubbard 2002)	USA 2002 Views of spirituality and attitudes about provision of spiritual care	13 family practitioners from Missouri. Purposive sampling to locate diversity of age, sex, rurality and religious/non-religious background. Mostly Christian, some agnostic and atheist	Not defined but functionally dealt with as broad inclusive concept including and perhaps most closely related to Judeo-Christian ideas. Clearly includes religious belief but not exclusive to this	Qualitative: Semi-structured interviews with 13 Family Physicians. Audiotaping and use of “Ethnograph” textual analysis software. Preconceptions noted by researchers before analysis started to reduce bias. 6 stated Christian and 2 Agnostic or Atheist. Purposive sampling in regard to demographics and religious affiliation. Thematic analysis as per Miles and Huberman (1994)	Participants ranged from those who felt spiritual issues must be addressed as a scientific imperative, and those that felt its “primacy in life” justified this. Most PCPs saw a vital role of PCPs as encouragers of patients own spirituality but not necessarily as spiritual counsellors. One reported being opposed to addressing spiritual issues with patients because of issues about role definition and invasion of privacy. Some contexts more likely to prompt spiritual discussion, e.g. new diagnosis of a serious illness. Unique theme is modelling of spiritual maturity by the physician and that spirituality may be important for its own sake, not as a means to a health end	Family practitioners are more likely to address spiritual issues in terminal diagnosis, admission to intensive care and mental health. Concerns about imposing beliefs on patients. Physician and patient factors important. Physician factors include upbringing and culture, spiritual awareness, belief of failure to effect patient’s illness or lives
Grant, E. Spiritual issues and needs perspectives from patients with advanced cancer and non-malignant disease (Grant et al. 2004)	Scotland 2004. The attitudes and insights of GPs regarding spiritual care in the context of palliative care	Terminally ill patients and their GPs Likely to be but not stated to be similar to Scottish religious demography	“The needs and expectations which humans have to find meaning, purpose and value in their life”. Such needs can be specifically religious, but authors assume that even people who have no religious faith or are not members of an organized religion have belief systems that give their lives meaning and purpose”	Qualitative: Purposive sampling to ensure diversity in patients participants but not necessarily GP participants. In depth qualitative interviewing (Mays and Pope 1996). Taped, coded, analysed in iterative way	Spiritual care is important to patients in the palliative care context. GPs feel they lack time and skill to deliver this, though the paper shows that some are clearly delivering some components of religious care. Doctors who develop good relationships with patients may inadvertently provide spiritual care. Tentatively suggest lack of spiritual care may increase health care usage and propose mechanism for this. Patients can often meet their spiritual needs if this aspect is validated by professionals	Yes, see left box. A few GPs felt it would be inappropriate to raise such intimate issues
Kelly, B. General Practitioners’ experiences of the psychological aspects of care of the dying (Kelly et al. 2008)	Australia 2007. GPs experiences of the psychological aspects of caring for dying patients	A convenience sample of 15 doctors was recruited for the study at the point of referral of their patient to a hospice/home care specialist palliative care service	No definition offered—authors and participants definitions seem to have differed significantly	Qualitative: Interviews with a consultant psychiatrist as the researcher, audiotaping, thematic analysis	Participants connoted spirituality with religion and many did not think this was part of their role. These participants reported existential issues are some of the most difficult to broach. GPs’ reported leaving it to patients’ initiative to bring up prognostic or spiritual matters and implicated patients’ stoicism and wishes not to engage with these issues as limiting factor, rather than any personal characteristic of the GP	Predominantly barriers, no facilitators discovered or discussed
Murray, S. A. General practitioners and their possible role in providing spiritual care: A qualitative study (Murray et al. 2003)	Scotland 2003 GPs’ views of spirituality and attitudes to being spiritual care providers	Convenience sample: 40 GPs of patients with palliative care patients, their patients and their carers	Defined spiritual needs as the “needs and expectations that all human beings have to find meaning, purpose and value in life”	Qualitative interviews with 2 explicit research questions. Do family practitioners perceive a role in providing spiritual care and what might hinder them in assessing spiritual needs or providing spiritual care? Telephone interviews with experienced social scientist, taping, transcription, NVIVO thematic analysis	Most family practitioners have a high awareness of the spiritual needs of their dying patients and feel that they have a role in providing spiritual care but lack time and appropriate strategies to introduce this. These GPs conceptualise patients’ spiritual needs as broader than simply religious needs	Barriers—some GPs felt patients could be “the wrong type” of person for this approach. Time constraints
Olsen, M. M. Mind, body, and spirit (Olson, Sandor, Sierpina, Vanderpool, and Dayao 2006)	USA 2006. An exploration of family practitioners’’ beliefs and attitudes regarding integration of spirituality in patient care	Southwest US medical school. Convenience sample: 17 third-year family medicine residents	None explicitly offered. Implicitly existential//theistic/religiously pluralistic concepts of spirituality	Qualitative: Phenomenology/grounded theory (Strauss and Corbin 1990). Taping, transcription, coding, independent analysis multiple researchers	Family practitioner–patient relationships. Some report struggling with language and concepts to describe existential suffering. Concerns expressed to not try and infringe on other people’s personal beliefs and the possible misuse of medical power	Barriers such as initial reluctance, time constraints, ambiguity, and degrees to which some residents’ religious and spiritual orientations differ from those of patients
Saba, G. W. What do family physicians believe and value in their work? (Saba 1999)	USA,1999 For PCPs in training what core values are important to them in their work. Spirituality arises as a significant theme	Convenience sample or 143 Family medicine residents of a San Francisco hospital. Residents are ethnically a mixture of white, Hispanic and black Religious affiliation not recorded	Author does not adopt any position, but relates the definition and understandings of the participants, which are heterogeneous	Qualitative: Focus group with field notes, some videotaping. Group reflections on beliefs and values. Grounded theory related thematic analysis	Philosophical and religious values give meaning and moral direction to decisions that doctors make, and the decision to pursue medicine. Beliefs and values of residents about meaning, suffering and spirituality are essential to who they are and what they do as family practitioners	Not a concern of this paper
Vermandere M. GPs’ views concerning spirituality and the use of the FICA tool in palliative care in Flanders: A qualitative study (Vermandere et al. 2012)	Belgium 2012. Attitudes to use of a spiritual needs screening tool in palliative care	Convenience/geographical sample. 23 Belgian GPs in the vicinity of Leuven University	Uses Puchalski 2009 definition, as modified by the European Association of Palliative Care. multidimensional—existential, value based, religious/theistic	Qualitative: GPs chosen by location—Surrounding the Catholic hospital of Leuven, 12 researchers, 11 open ended questions. Verbatim recording and transcription. Line by line coding. Descriptive and interpretive themes developed	Opinions about the role of GPs in spiritual care were divided. Some reported this to be task for relatives or professional spiritual care providers. A majority felt spiritual care important but only half would initiate a discussion. PCP viewed the use of the FICA screening tool as a useful guide but should not be used prescriptively	Barriers: Lack of time, privacy or knowledge about the patients’ beliefs. Lack of spiritual education and of a shared spiritual language with the patient. Western societies discomfort with spiritual language and concern about disruption to relationship with patient