Spiritual needs of cancer patients: A qualitative study
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0973-1075.150190 Clinical trial registration none
Source of Support: None, Conflict of Interest: None
Clinical trial registration none
Introduction: Diagnosis of cancer can cause huge spiritual crisis in a person and affect different aspects of life. At this stage, patients have certain spiritual needs.
Keywords: Cancer, Cancer patients, Palliative care, Spirituality, Spiritual needs
Spirituality is the essence of human existence  and causes a human being to experience transcendence and consistency with existence beyond his own, or find bonding with others. Either way, he establishes vertical connection (with a better existence), and horizontally (with other humans), beyond "self." This experience provides direction in life and meaning for death. , People's spirituality is more displayed when in need and in crisis. These crises could be disease, illness, loss, and deprivation. 
Today, cancer is considered one of the most important health problems worldwide, including Iran.  According to the World Health Organization estimates in 2012, 14.1 million new cases of cancer have been reported.  There are 1.7 million deaths due to cancer annually in Europe,  and it is anticipated that prevalence of cancer will double by 2020.  Diagnosis of cancer can lead to feelings of fear, anxiety, depression, and despair and can cause doubt in performing future plans. , Cancer can significantly increase patient's spiritual needs, since self-esteem and spiritual faith are endangered, personal relationships are impaired due to lack of confidence, previous adoptive mechanisms seem inadequate hospitalization may induce feeling of loneliness, and ultimately spiritual crisis emerges in them. , This crisis leads to imbalance of thought, body, and soul.  In dealing with critical diseases, like cancer, patients develop special needs, the most important being spiritual needs. These patients rely on the spiritual aspect, and spiritual adjustment is the strongest method they use to deal with their disease.  Tendency toward religion, faith, and spiritual sources can be used as a psychosocial adaptive approach post diagnosis. 
According to Florence Nightingale's philosophy of care, spirituality is inherent in humans and is the deepest and strongest source of healing. Thus, one of the nurses' responsibilities is attention to spiritual dimensions of care and providing a healing ambience for patients.  As part of a holistic care, care providers are required to acquire necessary skills to detect spiritual needs of patients  and provide care beyond mere physical needs; since when facing the diagnosis, changes in status of the disease, or end-of-life problems, cancer patients may be more at risk of spiritual stress.  Hence, attention to spiritual needs is a necessary part of holistic care in nursing.  Yet, most of the patients do not receive the required spiritual care by the care givers,  and response to spiritual needs of cancer patients has been minimal or neglected.  Failure to meet spiritual needs is associated with reduced quality of care, patient satisfaction, and quality of life. 
Nurses' understanding of spiritual needs of patients can affect the relationship and spiritual care of patients. Vagueness in understanding the concept of spirituality and ambiguous nurses' responsibility to provide spiritual care is considered an ethical issue. Given that experiences of patients and care providers can play an important role in explaining nursing spiritual care, and since recognizing spiritual needs is considered a vital element in providing cultural care,  it is necessary to obtain a better understanding of nature of spiritual needs. Considering religiosity of Iranian people, religious dimension may be more important in assessment of spiritual health, which requires further investigation. According to ethical codes of most universities, nurses are expected to provide care on the basis of physical, psychological, social, and spiritual needs and status of patients, and play an active role in meeting their spiritual needs.  Despite the necessity of attending to patients' unmet needs  , so far there have been few studies to describe cancer patients' spiritual needs in Iran.
The object of present study is to determine the spiritual needs of Iranian patients with cancer.
In this qualitative content analysis study, participants were selected using to purposive sampling from referrals to the Cancer Institute of Imam Khomeini Hospital in Tehran (the main center for cancer patients in Iran). Participants were selected from patients with definitive diagnosis of cancer, aware of their diagnosis, able to communicate, without history of severe psychological disorders like schizophrenia, and with minimum of 6 months since their diagnosis. There are no criteria or rules for determining sample size in a qualitative study prior to commencement, and sampling continues until data saturation in all categories (when new data are no longer produced).  In this study, data saturation occurred after 18 interviews.
Data were collected using semi-structured interviews. Interviews were recorded with permission of patients. Each interview began with an open, general questions such as, "How has the disease affected your feelings, behaviors, or needs?" and continued with "What things do you think you need more since your illness?" "Has your illness had any impact on your communication with God?" "Could you describe a related anecdote?" "What makes you happy during illness?" Attempts were made to have minimal interference in the process of interview. Deviation from study path was prevented with appropriate questions, and progressive questions guided interviews toward objectives of study. Next, follow-up questions were asked according to information disclosed by the participant to clarify the subject matter. Also, in-depth questions such as "Can you explain more? What do you mean? Could you give an example, so I can understand you better?" were asked, appropriate to responses. Interviews were completely transcribed and analyzed after completion. To this end, recorded information was written verbatim immediately, after being listened to repeatedly, and analyzed simultaneously with process of data collection. This was equally performed for all 18 interviews. Then, to ensure accuracy and rigor of data transferred onto paper, all data were reviewed while listening to interviews. Interviews lasted between 30 to 90 minutes each.
In this study, conventional content analysis approach was used for data analysis, in which categories are directly extracted from textual data.  Conceptual units were identified in the form of sentences or paragraphs from interview statements and texts, and initial or open codes were extracted from them. For the ease of detecting what statement belonged to which interview, interview number was written by the statement. After extracting conceptual units, these statements were reviewed again to obtain themes. For rigor and acceptability of data, the following methods were used (a) prolonged engagement, in which researchers used simultaneous analysis and collection of data, thereby providing possibility of feedback. Also, sufficient time was allowed for interviews, (b) selecting main informants: Patients with ability and inclination to cooperate, and ability to maintain effective communication were interviewed, (c) use of time triangulation, which meant use of "interview in two sessions" to make feedback possible, (d) peer check, in the form of use of complementary views of colleagues and experts, so that all interviews and extracted themes were reviewed by two researchers. Member check was also used as another means of increasing rigor of data and to increase transferability, researchers tried to describe the study accurately and step-by-step to provide possibility of follow-up process for other researchers.
To comply with ethical considerations and to protect participants' rights, the researcher obtained permission from hospital and ward authorities, introduced himself to participants, explained objectives of the study, obtained their informed consent, assured them of confidentiality of data, and emphasized that they could withdraw from study as and when they wished. They were also assured that their names not be disclosed.
Participants were 18 patients, including 9 men and 9 women within the age range 22-72 years and with cancers of the gastrointestinal tract, liver, lung, leukemia, lymphoma, Hodgkins, breast, uterus, and ovary.
Analysis of manuscripts about participants' understanding of spiritual needs led to formation of 1850 initial codes, 85 subcategories, and 12 categories, with 4 themes of "connection", "Seeking peace", "meaning/purpose", and "transcendence." [Table 1] [Table 2] [Table 3] [Table 4] present themes, categories, and some of the participants' narratives.
An important human need is contact with others.  Relationship is considered the social dimension of spiritual needs, which is expressed in the form of love, belonging, and contact with others.  In the study by Bussing and Koenig, a problem experienced by cancer patients was considered communication with family and friends. 
Cancer patients spend huge amounts of energy in dealing with diagnosis, treatment, and feeling of instability due to possibility of relapse, death, complications, and financial problems, and often reach a point where they feel they are in an uncertain and highly desperate position.  Cancer causes loss of hope and dreams and affects not just the body but the soul  and leads to such disorders as loneliness, depression, and failure to adapt.  Family members have a considerable role in fulfilling spiritual needs and providing hope and peace for patients with cancer.  Family members are concerned about their patient's calm and providing facilities for him and reporting any sudden change.  In this study, participants rated prayers of others very highly. Participants in Alcorn study also desired prayers of others for themselves and considered the results positive.  In the present study, participants expected others to treat them normally and not constantly talk about the disease. Studies have shown that one of the dimensions of coping with the disease is people's attitude and feeling of pity toward the patients, which leads to patients' hiding their disease from others. Some patients do not want excessive attention and kindness and expect normal behavior from others. 
In a study by Rahnama et al., participants cited appropriate relationship of medical team including nurses.  Although nurses' duty is to treat patients with respect, since this study was conducted in Iran, their religious backgrounds may have helped nurses in providing patient care with respect. Studies have shown that in Iran, nurses have a spiritual attitude toward their profession, believe in spiritual rewards for their job, and because of their religious attitude, do their job to please God. ,
Patients tended to spend some time alone to pray to God. They believed that they could obtain peace in this way. Also, Galek et al. reported the need for peace as one of the emotional needs of patients with cancer.  Rahnama et al. believed that one of the patients' needs is providing an atmosphere of joy and peace. They concluded that patients need some time to be alone for developing a relationship with God and to think about their spiritual belief.  Grant et al. examined nurses' view about spirituality and the type and time of spiritual treatment, where almost all nurses believed that spirituality grants inner peace to patients. 
Samson and Zerter raised the point that in cancer patients, being ready to help others increases the meaning and hope in their life and yet brings hope to others.  In a study by Stephenson et al. (2003) titled "The experience of spirituality in hospitalized patients", they concluded that more than 93% of patients with cancer believed that spirituality helped them to strengthen their hope.  Researchers emphasize the importance of the relationship with God as an aspect of spirituality that may provide some hope, optimism, and inner strength in adapting to stress. 
Spiritual health will lead to a purposeful and meaningful life. The life of these people will change from a material life to a spiritual life. The whyness of person's life is a part of his existential goal that gains from his life, and this part itself constitutes the spiritual dimension of life.  In the study by Rahnama also, participants experienced changes in value in the form of more appreciation for blessings granted by God, decreased attention to the worldly affairs, and increased attention to another world after death, gaining a positive outlook towards life and future.  In the study by Samson and Zerter, experiences of cancer patients also indicated that their transformation led to changes in their values and priorities and they found a new perspective on life. All of these lead the individual to a position where his life is meaningful and useful for others.  In the current research, a number of patients coped with their disease, accepted it, and were content with their fate because most cancer patients in Iran had this religious belief that they became sick as a result of God's will and the disease was a divine fate. Some believed that the disease was a divine test to measure their faith. However, if God's dominance is considered negatively, for example, it is thought that God inflicted the disease as punishment for sins, the patients may experience more stress.  Taleghani et al. found that most patients they reviewed believed that their disease was a divine test, and they should attempt to pass this test,  which is in line with the results of the current study.
The belief in God and the appeal for his support in most patients was stronger than before. Rahnama et al. state that spiritual and religious resources can lead to an overall sense of hope and optimism toward life.  McClain et al. also mentioned that spiritual well-being can be an obstacle to the creation of end-of-life disappointment in patients whose death is imminent.  Rahnama et al. concluded that participants had a sense of strength, hope, peace, and confidence through a relationship with God and religious beliefs.  Several studies showed positive beliefs of Iranian Muslim patients. ,
Another spiritual need outlined in the theme of transcendence was relationship with God. Participants stated that from the onset of disease, their relationship was closer to God and Imams. In the current study, religion had a strong role. Researchers emphasize the importance of the relationship with God as an aspect of spirituality that may provide some hope, optimism, and inner strength in adapting to stress.  In this study, praying, including saying prayers and performing religious rituals, formed the basic needs of patients with cancer. Spirituality with religious rituals, such as praying, plays an important role in accepting diseases.  Praying has an important role in coping with cancer and helps the patients to improve their spiritual health when they are sick. , In the current study, the performance of religious rituals by participants was very strong. They requested the Imams to pray for their peace or cure their disease. As Iranians based on cultural conditions are religious, they turn to religion more often to cope with critical situations. However, in the current study, some patients did not visit religious places because of their physical changes and people's peculiar way of looking at them. Participants in the study of Taleghani et al. also believed that the awareness of other people about their disease was a problem and affected their welfare. 
This study showed that Iranian Muslim patients seek help from spirituality to accept or cope with their disease. Since understanding the perceptions and spiritual needs of patients with cancer by the medical staff has a great value, the findings of this study can help to prioritize cancer patients' care and the manner of care and interaction with them. Considering the necessity of understanding the spiritual needs of patients by medical staff, need for appropriate plan for interventions, and growing number of patients with cancer, the results of this study can be useful, particularly for nurses, to communicate properly with patients. Also, the results of this study can be used by researchers, managers, and planners to better understand the needs of cancer patients and perform proper evidence-based planning. This study could be replicated in other locations and under different cultural conditions. Meanwhile, this study can be conducted with more and distinct types of cancer patients and based on gender, age, type of cancer, stage of cancer, etc., and spiritual needs according to the above topics can be investigated and reported.
The researchers greatly appreciate the cooperation and assistance provided by the authorities of Shahid Beheshti University of Medical Sciences and the participants without whose participation this research would be impossible. We are thankful to Cancer Institute of Tehran University of Medical Sciences for data gathering.
[Table 1], [Table 2], [Table 3], [Table 4]