Iranian nurses' perception of spirituality and spiritual care: a qualitative content analysis study.

The purpose of the present study was to explore nurses' perception about spirituality and spiritual care. A qualitative content analysis approach was conducted on 20 registered nurses interviewed using unstructured strategy in 2009. Three themes emerged from the data analysis: 1) "meaning and purpose of work and life" including 'spiritualistic view to profession', 'commitment and professional responsibility', and 'positive attitude'; 2) "religious attitude" including 'God approval', 'spiritual reward', 'taking advice', 'inner belief in the Supreme Being', 'faith-based interactions and altruism'; 3) "transcendence-seeking" including 'need for respect' and 'personal-professional transcendence'. Therefore, the spirituality produces maintenance, harmony and balance in nurses in relation to God. Spiritual care focuses on respecting patients, friendly and sympathetic interactions, sharing in rituals and strengthening patients and nurses' inner energy. This type of spirituality gives a positive perspective to life and profession, peaceful interactions, a harmonious state of mind, and acts as a motivator among nurses to promote nursing care and spirituality.

Introduction

Spirituality is particularly an intangible (1), highly subjective and multidimensional concept (2) manifested in the human lifestyle (3). It is recognized as a key to people health. It has been adopted by the World Health Organization (WHO) as a principle of promoting health (4).

There is no consensus on the definition of spirituality (2, 5, 6), but it is generally agreed that spirituality is a highly subjective, personal, and individualistic concept. Integrative reviews of spirituality concept analysis have identified some themes such as meaning, purpose, connectedness, relationship, transcendence, hope, existential experiences, power, force and energy (7).

Spirituality and religiousness are two separate concepts (2), but they are used interchangeably (8). Many authors identified a fusion between spirituality and religiosity (9). It is suggested that spirituality can be seen as the summation of our values, which determines the process of how we interact with the world; whereas religion is seen as a pathway to follow practices and thoughts that are appropriate to God or Gods of a particular faith (10).

While spirituality may be related to religion for certain individuals, for others it may not be; for example, the spirituality of an atheist or an agnostic may be centered on a strong belief in significant relationships, self-chosen values and goals instead of a belief in God (8).

In addition, spirituality has rarely been discussed from nurses’ perspectives (11–13).

Mc Sherry et al. interviewed 12 nurses in a study. They described spirituality as a universal concept that applied to both religious and non-religious matters and a force that permeated every aspect of their life and human being (14).

The concept of spirituality depends on cultures and beliefs that are important in the understanding of meanings and dimensions of spirituality. Hence, it is essential to accomplish a qualitative investigation in regard to nurses’ spirituality views. Consequently, the findings clarify the themes and may help in the promotion of spiritual nursing care in the concerned context. It also helps to develop spiritual conceptions for nurses and spiritual care.

Nurses’ spiritual needs at work

Spirituality is important to staff nurses. It can be used as an intervention strategy and a supportive force at work and in the care of clients (12).

Nurses are exposed to many stressors related to the workplace such as work overload, rotating shifts, high work demands, conflict at work, sudden death, unexpected and rapid changes in patients’ conditions, patients’ violence and daily physical and verbal abuse that may lead to physical and psychological problems (15, 16).

Ebadi et al. suggested that spirituality is a coping method which could be a source of comfort, strength and support during stress (17). Hence spirituality helps nurses by harmonizing and balancing their inner resources (17, 18).

Spittles found that maintaining a spiritual practice clearly enhances physiological, psychological, intellectual and creative functioning. It was correlated with improved work performance, improved relations with coworkers and supervisors, increased work satisfaction and decreased turnover propensity (19).

Nurses’ perception of spirituality can directly affect how they behave, how to deal with their patients and how to communicate with them in regard to the provision of spiritual care (18).

According to the literature, nurses’ knowledge about their own religious, spirit, and attention to such needs are limited and further research about religious and spiritual aspects in different cultural contexts is needed (20).

The suggestion that nurses ought to explore their own spirituality has also been made by many authors. Being in touch with one’s own spiritual dimensions may be the first step in being able to recognize and support the spiritual nature of the others (21). Although some nurses are willing to pay attention to patients’ spiritual needs, there is lack of agreement in nurses’ interpretation of spirituality and spiritual care (18). Therefore, the extension of knowledge of spirituality in different cultural contexts should be explored.

Moreover, the interpretation and understanding of spirituality among Iranian nurses may not be similar to other cultures, because of differences in nurses’ background and clinical context. Therefore, the purpose of this study was to explore nurses’ perception of spirituality and spiritual care.

Iranian background

Iran is a religious (Muslim) society (10) and, the majorities of nurses are Muslim and believe in God. Almost 2% percent of Iranians belong to the religions of Judaism, Christianity, Zoroastrianism, etc, who believe in God as well.

Although the majorities of nurses have accepted the spirituality as a valuable element in their lifestyle, there are a few studies on nurses’ perception of spirituality and spiritual care for patients in Iran, which one of them reported that nurses ordinarily spent their time for managing their routine tasks and performing religious activities (22).

Method

This qualitative study was a part of an extensive investigation about nurses’ lifestyle by using conventional content analysis approach. Qualitative content analysis is the analysis of the content of narrative data, and it is a flexible method to identify prominent subthemes and patterns among themes (23, 24). At the conditions of lack of enough knowledge about a phenomenon (such as spirituality) or knowledge fragmentation, the inductive approach is recommended (24) in order to explain and interpret the data and elaborate the dominant and major themes of participants’ experiences (25).

Setting and participants

The participants were selected by purposeful sampling because it was suitable for conducting a qualitative study. The participants were registered nurses; (14 female and 6 male). The majority of them (45%) aged between 25 and 35 years old. They had the experience of working as nurses from 3 to 29 years in different hospital wards. All of participants were Muslim. The study was carried out in 2009 in Iran. Data gathering was done in three teaching hospitals in Gorgan city (Iran). The interview was carried out in free and relaxed environment according to nurses’ preferences (in hospitals). Data collection was continued until no new data was gathered, and the researchers reached to the point of saturation.

Data collection

Unstructured interviews were conducted as the data gathering tool. The major foci of the questions were “Can you explain the spirituality in your professional lifestyle?” The interviews lasted between one and half an hour in average. Some participants were interviewed twice, (in two separate parts, in order to improve the depth of data gathering). It means that according to the findings, the next interview was carried out to the point of completing the data. The total number of participants was 20 nurses, but totally, 24 interviews were performed. The first participant was selected by the hospitals’ supervisors in order to facilitate the selection of the participants followed by using snow ball method for selecting the nurses. The maximum variation of sampling was considered with the participants’ gender, age, nursing experiences and nursing wards.

The interviews were subsequently transcribed, read, re-read, and analyzed by the team of researchers.

Ethical considerations

The study was approved by the research council of Medical Sciences Faculty, Tarbiat Modares University, which corroborated its ethical consideration. The study ethical considerations were anonymity, informed consent, withdrawal from the study, and recording permission. Prior to the study, the nurses were informed verbally about the aim of the study. It was mentioned that they could withdraw from the study at any time without being penalized. Then informed consent was obtained from the nurses who willingly participated in the study. To protect the privacy, confidentiality and the identity of the participants, interviews were conducted only with the participation of the interviewer and the interviewee.

Data analysis

The interviews were recorded on tapes. The interviews were subsequently transcribed, read, reread, and analyzed by the research team. The overt and covert messages and transcribed texts were analyzed by qualitative content analysis approach. The approach focuses on subject and context, differences and similarities within categories and themes (26, 27).

Inductive content analysis was made in different steps. At first, the content of each interview (the text) was repeatedly read to obtain an overall understanding of the data and to gain ideas for further analysis. Then all the texts were divided into meaning units (each one containing several words, sentences and phrases) related to the aim. Then the meaning units were condensed into open coding (26, 28).

The data was organized in the next step. This process included open coding [notes and headings were written in the text while reading it (extracted from meaning units)], and creating categories and themes. The written text was read through again, and as many headings as necessary were written down in the margins to describe all aspects of the content. The headings were collected from the margins onto coding sheets and categories were generated at this stage (24). The lists of categories were grouped under higher order headings. Categories were grouped as main categories or themes. The purpose of creating categories was to provide a means of describing the phenomenon, to increase understanding and to generate knowledge (28, 29). At this stage, we obtained 11 sub-themes and three final themes. All researchers were engaged in the process of analyzing and synthesizing the data. Throughout the entire analysis process, subcategories, categories and themes were compared with the original texts until consensus among all authors was attained.

Therefore, the total process of analysis was briefly carried out as transcribing each interview, and dividing it into meaning units, open coding, subcategories and themes (Table 1).

Table 1:

The trend of condensation-abstraction process for themes (sample)

Meaning units (instances)	Open coding (Condensed meaning units)	Subcategories (sub-theme)	Main Categories/themes
“Truthful nursing is very difficult. I think it is a divine blessing, I don’t suppose it is only a job” [Nurse 2].	Nursing is a divine blessing	Spiritualistic view to profession	Meaning and purpose of work and life
“I’ve got a job and I’m responsible for the patient’s life. So, I suppose to be responsible in the other world” [Nurse 3].	Feeling of commitment and responsibility to God.	Professional commitment and responsibility
“There is some delay in my overtime work payment, but I think I have to care well of patients, this is my problem, not for patient”[Nurse 15].	Care of patients without being affected by delay in payment.	Positive attitude (positive view)

Credibility of the data was established through member checking. The report of the analysis was given to the participants in order to get assurance that the researchers were presenting their ideal worlds. In addition, nursing faculty members performed member checking of the transcripts, subcategories, and final categorization or themes. Maximum validation of sampling helped to establish dependability and credibility of the data.

Results

Three themes emerged from the data analysis: 1) “meaning and purpose of work and life” including ‘spiritualistic view to profession’, ‘commitment and professional responsibility’, and ‘positive attitude’; 2) “religious attitude” including ‘God approval’, ‘spiritual reward’, ‘taking advice’, ‘inner belief in the Supreme Being’, ‘faith-based interactions and altruism’. 3) “transcendence-seeking” including ‘a need for respect’ and ‘personal–professional transcendence’.

Meaning and purpose of work and life

This theme consisted of three sub-themes (Table 1).

Spiritualistic view to profession

This sub-theme involves affective-spiritual responses of the nurses to caring, acceptance of nursing as a sacred profession and effect of the job on their lives. The participants described nursing as a divine blessing.

A participant said: “Nursing is an effective job, a spiritual job; actual nursing is very difficult, but, I think it is a divine blessing; I don’t suppose that it is only a job.” [Nurse 2] Another one said: “In my opinion, spirituality is the foundation of nursing; I selected this profession due to the spiritual issues.” [Nurse18]

Commitment and professional responsibility

According to the nurses’ views, they are responsible to God for their practices. They believe that someone who is religious should work exactly, carefully and correctly. According to a participant: “However, the individuals who are more faithful and believe in God should be more responsible for the client, because they are God-fearing and don’t want bad things to occur to God’s creatures.” [Nurse15]

Therefore, they believed that the spirituality is a kind of internal commitment. The internal commitment is related to God or conscience.

“I always remember I must work in a manner that reveals my commitment to the people.”[Nurse 17] “I’m responsible to God about the patient’s life. So, I suppose to be responsible to God in the future life. [Nurse 3]

Positive attitude (Positive view)

Positive view was the other sub-theme mentioned. A participant said “I attempt to have a positive view in my life, I think positive to what occurs to me. My ward was changed, now I am working in a new one, it is better to me. I think the chief nurse in the new ward will be match with me.” [Nurse 16] Another one said “I have a good life; I think it is due to my job, I always attempt to resolve patients’ problems”

Religious attitude

This theme contains six sub-themes:

God approval (Approval of the spirituality)

God approval is based on the personal practice (behavior) and naturally depends on individual’s behavior, honest working, and ritual practice for clients and so on. A participant said: “I made an effort to do my duty honestly for God approval; furthermore, it may increase my supervisors respect. I work so hard, but my intention isn’t to enjoy the attention or encouragement of the supervisor at all, rather I want to gain God approval.” [Nurse 3] Also, they supposed nursing equal to worship, so a participant said:

“Now, I am happy; that is, if I get another job offer, I will certainly prefer nursing as my job. I always give thanks to God.” [Nurse 2] Although nurses are facing with many problems, he still has a tendency to remain in the job.

Another one said,” I always say a sentence of Allameh Tabatabaie (a philosopher and worshipper scholar) to my colleagues, who said, “I never exchange the value of taking care of a patient during a night with seventy years of worship“; it means how worthy and important nursing care near god is.” [Nurse 17] “The nurse needs to be patient to gain God approval.” [Nurse 16]

Spiritual reward

The nurses stated that they will be rewarded in different ways by God which consists of being helped in life in secret and so on. A participant said:

“It has been ascertained that everybody who performs his/her duty very well, God does not bring loss to him and helps him.” [Nurse 6]

“When I am working honestly for patients and people, obstacles in my life will be removed; God will help me in many circumstances.” [Nurse 2]

Taking advice

This subtheme focused on advice in relation to the patients’ problems. Nurses observe patients’ problems, then, they will perceive the value (importance) of health and conclude that health is a gift of God. Therefore they must be thankful of God and attempt to protect health.

“You know that these events may occur to you –it is easy for God-; therefore, you will attempt to understand and find out the power of God and spirituality in these events.” [Nurse 7]

Inner belief in the Supreme Being

Some of the nurses believed that internal motivation with religious context is helpful in caring for patients.

“The religious beliefs have created a situation in which I do my duty well. I became more responsible for patients” [Nurse 4].

According to nurses’ opinions, the Supreme Being permanently supervises over everyone’s actions. Although, they try to help recovery of the patients, but results depend on the willing of God.

“I do care for patients, I use all of my power to care, but the results depend on God’s willing, ultimate healing comes from God.” [Nurse 7]

“I do my duty, because I know there is a permanent supervisor. He (God) pays attention to me all the time …” [Nurse17]

Thus, the belief that there is a kind of supervision over human beings everywhere and every time produces a confidence and precision in performing one’s duty.

Faith-based interactions

The participants said that nurses interact with patients, families and others in a friendly manner, but those nurses who are religious and prayerful, interact in a more friendly and sympathetic manner. One participant said: “The nurses that are religious and prayerful are better in practice and behavior toward patients.” [Nurse 2] Another nurse said the following about faith-based relationship: “I communicate friendly with my colleagues and patients’ family. I like ill persons as much as I like my family members; I attempt to have a sympathetic relationship. Of course, the relation of a nurse with a patient depends on his/her nature and beliefs.” [Nurse 7]

Praying is usual in the community and clients would like to pray when encountering problems, but most of the time, it is impossible in the ward. Therefore, the nurse as a providing spiritual care says: “I prefer to keep the ward quiet, so I could talk with my patients about themselves and their problems. I like to pray with the patients altogether on Friday night. This brings calmness to the patient and me.” [Nurse 14]

Altruism

The last subtheme was altruism. A nurse said “It must be done as an affair, an action that you are able to do, because the patient is a trust (and the nurse is a trustee). Therefore you must do your duty honestly.” [Nurse 15] The patient is a human, I like all people, therefore, if I am permitted, I would work to the utmost within my ability.” [Nurse 7]

This subtheme is a general view, but it is important and prominent in the nurses’ spirituality. A participant said: “The nurse must love patients. He/she must know that the patient, who is the present client, as a human needs support and help.” [Nurse 8] “You must spend energy and time, you must honestly work for a man (human) and spend time to save him/her…I think working for an ill person, an elderly, is worship, and induces a good feeling.” [Nurse 19]

Transcendence seeking

The third theme has two subthemes:

A need for Respect

Feeling transcendence influences the interpersonal interactions, personal quality of working, mental and spiritual calmness. A participant said: “I attempt to have a good communication with my colleagues. Interpersonal respect is very important to me.” [Nurse 15]

Personal –professional transcendence

Nurses work in a dynamic environment. They learn and achieve new professional experiences and knowledge. That leads to personal–professional excellence. A nurse said: “I always try to learn everything, do all works …, this produces a good feeling in me.” [Nurse 3]

Also a nurse who was eager to self development said “From the scientific viewpoint, I always study, I teach students, and I participate in instruction and clinical education.” [Nurse 18]

Discussion

In this qualitative study, the participants were Muslim nurses. In general, Iran is almost a religious society; therefore, a usual person performs religious rites. Moreover, there were no non-Muslim nurses in the hospitals in this study. However, three themes emerged that is disputable.

The first theme was meaning and purpose of work and life. It consisted of three subthemes. One of them was spiritualistic view to profession. According to the participants, nursing was an effective job and a divine blessing. Naturally, this view of nurses caused honest and satisfactory delivering of services to patients. Moreover, such a nurse would tolerate the difficulties in caring and role performance. His/her mood would not quickly deteriorate due to complaints. It seemed that spirituality was an obstacle to relinquishment of job for the mere reason of a high level of stress. When a nurse assumes nursing as a “divine blessing” then he/she keeps his/her calmness and copes with problems.

Rays and McGee stated that spiritual health organizes values, relationships, meaning and purpose of our lives (12). Moreover, spirituality provides a personal sense of meaning and life purpose, which is not confined to the beliefs and practices of a particular religion (18, 30). However, spirituality can play a positive role in coping with changes and life-altering events (12).

Also, it is argued that spiritual needs are met through the individual’s relationship with God, and we are still far from having a universal agreement as to what is meant by the concept of spirituality; also, it is argued that spirituality is possible without the concept of God (31).

The second sub-theme was responsibility. The nurses were responsible for the patients, but they were basically responsible to God. They would be audited ultimately in this world and the next world. This perspective induces nurses self control at work and in life. However, the spirituality and religion have been mixed by nurses life, so that, all of the nurses’ intentions and functions are to gain God approval and, consequently, patients satisfaction. Therefore, the more faithful nurse is the more responsible to patients.

Spirituality is important to staff nurses. It increases quality of work and care of clients (12). Religion provides the content for spirituality. It shows us the character of God, the meaning of life, and how we are to live (7).

The second theme was religious attitude. In this theme, God approval and spiritual satisfaction was related to the individual’s behavior such as honest working, ritual activities for clients and spiritual satisfaction that provided enjoyment and calmness for the nurses. The nurses who believed nursing is equal to worship of God, sought God approval and their own enjoyment. The nurse, patient and community would benefit from this belief. So that, the Iranian philosopher “Tabatabaie” had said about the reward of a night caring for a patient near God: “I never exchange the value of taking care of a patient during a night with seventy years of worship”; this indicates that patient care is very valuable. Hence, a nurse that has achieved such a belief undoubtedly cannot be affected much by problems of the work and daily life. They are less involved in disharmony or mental disorder. But they would be happy, fresh and pleased with their work.

Wong et al. stated that for Christians and Muslims, spirituality is directly related to religion (18).

Nurses’ perception of spirituality can directly affect how they behave, how to deal with their patients and how to communicate with them in regard to the provision of spiritual care. He or she listens to a patient’s spiritual thoughts and concerns with spiritual feelings.

Spiritual reward was a subtheme. According to Islam, God is free of need but He donates reward in this world and the next world to someone who gives service to humans (32). The participants believed that positive and good events in their life had been due to their compassion and honesty. God helps everyone who is beneficent. This idea prevents from any damage to clients even though the boss neglects employees’ rights. Of course, a nurse must be praised by head nurse or supervisor when he/she tries truthfully.

Another subtheme was “to take advice” from events. However, the nurses could not completely control occurrence of the events and sickness. A nurse, who believes in a divine entity, supposes that many calamities and illnesses do not come to him/her because of God’s kindness. That is, if someone is ill, it may happen to everyone. Then a nurse must be grateful of God that he/she is healthy and does not suffer from illness. Someone, who is conscious of the human life, will take advice for correction and improvement of his/her life.

Tongprateep found that the beliefs shaped patterns of thinking and practices in daily life. The participants believed that good or evil actions are related to cause some effects not only in the present life but also in the future life. They hoped that, if they accumulated meritorious acts in their lives, they would get good results both in this life and the future life (33).

Inner belief in the Supreme Being, one of the subthemes, is necessary for action; because it is a motivator and produces energy for performing. Indeed, inner belief must be present for the sense of spirituality. Also, according to participants, inner belief leads to more responsibility. The belief in the presence of the Supreme Being and a permanent supervisor helps nurses to have a supportive power that everything depends on his/her willing. “Ultimate healing comes from the Almighty”.

Thus, the belief that there is a kind of supervisor everywhere and every time produces confidence in nurses.

Pesut et al. stated that spirituality, for us, begins with recognizing God, whose spirit infuses and sustains all creatures, but who has the capacity to exist independently of the creation. The character of God is what dictates the ideal life. We agree that spirituality is a form of power but, its origin is located within the Almighty. Daily, we make choices that bring our power closer to or further away from that character of goodness (7).

Altruism was another subject and since participants were Muslims, it is necessary to identify human value in Islam. Human is the highest creature in the world. According to Islam, human is a great, valuable entity and very important (32). Hence, a nurse is responsible for care of such an entity. If a nurse loves God, he/she will love this highest creature as well. A nurse is responsible for human care.

The participants mentioned that “The patient is a trust, the patient is a human, I like all people, I love patients.” These statements indicated that the humans are very important for nurses. Therefore, they honestly spend energy and time to save them.

The third theme was transcendence-seeking with two subthemes. Basically, increasing the human excellence enhances spiritual feeling. Doing honor and respecting others and ourselves is a virtue that is related to human spirituality. A nurse, willing to achieve new experiences, skills, and knowledge, gets away from stagnation; consequently, he/she excels in life and at work. It seems that these help growth of spirituality in nurses.

Also Rays and McGee stated that self-development helps nurses in feeling well about themselves (12). It is a way that promotes human fulfillment (18).

Finally, while the findings of some investigations indicate that spirituality is related to religion, but some others do not agree. For example, they focus on the purpose of life. In this study, “professional commitment and responsibility related to God” and “God approval (spiritual satisfaction)” were the new sub-themes that were not present in other studies. Both themes lead to a harmonious state of mind in nurses and peaceful interactions with others.

Conclusion

Spirituality is a dimension of human health. In this survey, the connection between the concepts of spirituality to religious believes was found. The spirituality produces maintenance, harmony and balance in nurses in relation to God approval and inner belief in the Supreme Being. This type of spirituality creates a positive perspective in life and profession, peaceful interactions, harmonious state of mind in all situations and connectedness with God. Under the religious and, consequently, spirituality influence, the nurses are motivated to deliver care, especially spiritual care. Therefore, professional problems and adversity would be sustainable and acceptable to nurses. Spirituality prevents from abandonment of job.

Therefore, according to the nurses’ view, spirituality is meaning and purpose of life, honest care of patients, attainment of God approval and patient’s satisfaction, and attempt to achieve transcendence. Also, spiritual care focuses on respect for patients, friendly and sympathetic interactions, sharing in rituals and strengthening patients and nurses’ inner energy.

Spirituality in nurse’s lifestyle has also implications for the nurse him/herself, other healthcare providers and ultimately people as clients, probably other Muslims or other people who believe in God. It is necessary to investigate in different cultures and beliefs throughout the world to identify similarities and differences and, ultimately, establishing local and general models to recommend proper behavior.