Transcendence, the Most Important Spiritual Need of Muslim Older Adults: A Content Analysis Study.

Healthcare providers agree that promoting spirituality among older adults while caring for them increases their quality of life. However, there is little knowledge about the spiritual needs of the elderly, especially in the Muslim community. This qualitative study attempted to explore the spiritual needs of Muslim older adults. Fifteen non-hospitalized Muslim older adults from Hamadan City, Iran, were interviewed. The semi-structured interviews were analyzed using conventional content analysis. After identifying semantic units from the text, related codes were extracted and placed in subcategories and categories based on their similarities. Once the data were analyzed, one theme was formed. The study's findings showed that the spiritual needs of older adults fell into three main categories: religious needs, the need for transcendence, and the need for connection. Religious needs included subcategories of religious practices and beliefs, and the need for transcendence included the search for meaning and purpose in life, and the need for peace and stability and balance. Also, the need for connection included the need to connect with nature and connect with others. Healthcare professionals and family caregivers should be trained in the specific competence of recognizing older people's unmet spiritual needs and fulfilling them.

Introduction

Old age is conventionally defined as 65 years of age or older. Aging is the gradual decay in the body’s structure and organs. Aging occurs over time, causing changes in the structure and function of various body organs (Garza, 2016). The aging population gradually increases worldwide due to increased life expectancy, reduced mortality, reduced birth rates, and improved healthcare. Thus, the elderly population has the fastest growth rate among other age groups (Khodaveisi et al., 2018). Statistics show that in 2015, the older adult population accounted for 15.3% of the total world population, which will reach 20.8% by 2025 (Teerawichitchainan & Knodel, 2018). Also, according to available reports, the population of people over 60 will double from 11% in 2000 to 22% in 2050 (Doetsch et al., 2017).

Older adults need physical and psychological support and to understand the meaning and purpose of life. It is the duty of both families and healthcare providers as caregivers of older adults to facilitate their spiritual growth and development (Forlenza & Vallada, 2018). As the most complete monotheistic religion emerging for more than 14 centuries, Islam attaches great importance to the spirituality and spiritual health of its followers. Spirituality is considered the core of one’s perfection and happiness. In this regard, there is a great emphasis on meeting the spiritual needs of people, especially the elderly. Sönmez and Nazik (2019), in their descriptive study, showed that Muslim older adults had a high level of spiritual needs (Sönmez & Nazik, 2019). Therefore, spiritual growth and development are essential in older people, and if their spiritual needs are met, they may have more insight into the meaning and purpose of life and report more satisfaction with their lives. One of the most critical needs of old age is spiritual needs. Spiritual needs can influence older people's decisions about their health, illness, and quality of life (Oz et al., 2021).

Spirituality is a set of values, attitudes, and hopes, connecting one to a superior being and linking one to well-being. Some researchers believe that spirituality is one of the most critical health components in old age in all cultures, and older people are more inclined to religious and spiritual practices. Leaving these tendencies unattended can lead to spiritual distress for the elderly (Ali et al., 2015; Chan et al., 2016; Monod et al., 2010). In addition, according to the eighth stage of Erikson's theory of psychosocial development, “ego integrity versus despair,” one tries to give meaning to one’s life and thus copes with death, loss, and many other issues (Gross, 2020). Also, Frankl (2005) believes that human beings need to meet existential needs to achieve happiness and perfection, including three philosophical concepts of freedom of will, the will to meaning, and meaning in life (Frankl, 2005).

Harrington (2016) believes that although the spiritual evaluation of the elderly may sometimes irritate them, caregivers must consider spirituality in the elderly and the spiritual duties of aging to perform therapeutic interventions. He also introduces the spiritual evaluation of the elderly as one of the essential duties of nurses. He believes that the first step to this end is to know the spiritual dimension of the elderly (Harrington, 2016). In their randomized controlled trial, Wu and Koo (2016) found that the spiritual needs of older adults were not given much notice, which could reduce the overall quality of care in these clients (Wu & Koo, 2016).

Understanding spirituality as an adjustment mechanism or a social support intervention enables nurses in charge of elderly care to provide more effective care for older adults (Bulduk et al., 2017). A longitudinal study by Cowlishaw et al., (2013) indicated the effect of spirituality on life satisfaction over time. They suggested that spirituality may influence older adults' experience and perception of life events, leading to a more positive appraisal of these events (Cowlishaw et al., 2013). Therefore, caregivers and nurses should be oriented about the spiritual needs of older adults with any culture and provide the necessary spiritual care based on these needs themselves or through other competent professionals, such as clergymen.

Despite the significant correlation between spiritual needs and aging, these needs have not been well studied. Therefore, it is necessary to conduct extensive studies to examine the spiritual needs of the elderly population. Moreover, since the population of older adults is increasing daily and will form a significant part of society in the near future, their spiritual needs must be addressed to help implement spiritual care in the population. Therefore, this study was designed to explore individuals' perceptions of the spiritual needs of non-hospitalized older adults.

Methodology

Design

This study aimed to explore older people’s perceptions of their spiritual needs using conventional content analysis. Conventional content analysis systematically transforms a large amount of text into a highly organized and concise summary of key results. Analysis of raw data from verbatim transcribed interviews, forming categories or main theme, is a further abstraction of data from the manifest and literal content to latent meanings at each analysis step (Hsieh & Shannon, 2005).

Participants

Fifteen Muslim older adults residing in Hamadan City, western Iran, were selected using purposive sampling. The participants included nine women and six men with a mean age of 76.8 ± 4.48 years. The demographic characteristics of the participants are summarized in Table 1. One of the researchers identified the participants by attending public urban spaces, such as parks, mosques, shopping malls, and banks in Hamadan. Data collection continued until data saturation was ensured, and the categories were formed after 13 interviews. Subsequent interviews were conducted, but data analysis yielded similar results and confirmed the emerging categories. The inclusion criteria were residence along with family members, age above 65 years, absence of any acute physical and mental diseases, such as cancer and kidney failure, the ability to hear and speak, sufficient time to participate in the interview, and the ability to communicate and cooperate with the researchers.

Table 1

The participants’ demographics data

Participant	Age	Sex	Education	Marital status	Previous job	Lifestyle (alone or with others)
1	74	M	Diploma	Married	Employee	With wife
2	81	F	Illiterate	Widower	Housewife	Alone
3	79	M	Primary	Married	Shopkeeper	With wife
4	73	F	Diploma	Widower	Housewife	With children
5	89	M	Primary	Married	Driver	With wife
6	71	F	Illiterate	Widower	Housewife	With a child
7	69	F	Illiterate	Married	Housewife	With husband
8	70	M	Diploma	Married	Military	With wife
9	83	F	Primary	Widower	Housewife	With children
10	76	F	Illiterate	Widower	Housewife	Alone
11	84	M	Primary	Married	Worker	With wife
12	75	M	Academic	Married	Employee	With wife
13	82	F	Primary	Married	Housewife	With husband
14	78	F	Illiterate	Widower	Housewife	With a child
15	68	F	Academic	Married	Teacher	With husband

Data Collection

The primary data collection tool was individual semi-structured interviews. The interview guide and field notes were used in the interviews. The corresponding author conducted the interviews after introducing himself, stating his goals, and emphasizing the confidentiality of information. Informed verbal consent was obtained after face-to-face visiting each participant in an environment where they felt comfortable. The interviews were performed starting with general, open-ended questions. Other questions included: “What does come to your mind by the phrase ‘spiritual needs’?,” “What do you know about spirituality?,” “As an elderly person, what shortcomings do you feel in your life?,” “What steps are you taking to address these shortcomings?,” “How is your relationship with God?,” “How do you communicate with others?,” and “How do you interact with your surroundings?”.

Based on the participants’ responses, they were asked to provide further clarification with phrases and questions, such as “Please explain more” and “What do you mean?” At the end of each interview, the participants were encouraged to provide more explanations with questions, such as “Is there anything that you want to say?” Given the participants’ responses and by considering the research questions, each interview was followed individually. All the interviews were recorded with the consent of the participants. The duration of the interviews was between 38 and 59 min (45.5 min on average). After each interview, the researcher listened to the recorded conversations several times and carefully transcribed them in the shortest possible time. This procedure was done to increase the accuracy of the implemented information and provide the researcher with more control over the data.

Data Analysis

Data analysis was performed with the participation of all the authors. Conventional content analysis was used to analyze the raw data. Accordingly, semantic units were first identified, and relevant codes were then extracted and placed in subcategories based on their similarities. Subcategories also became categories, and eventually, main theme was formed. In order to further explain the categories and subcategories, the participants' statements were presented about each of them. Field notes were also coded and entered into the analysis process. The steps of data analysis are shown in Table 2. MAXQDA software version 2010 was used for data analysis. MAXQDA is a qualitative software to analyze mixed methods data and qualitative findings from texts, videos, and photographs. The software is used for explaining and theoretically analyzing social and cultural phenomena (Kuckartz et al., 2019).

Table 2

Steps of data analysis

Step 1	Identify and collect data
Step 2	Determine Coding Categories
Step 3	Code the Content
Step 4	Check Validity and Reliability
Step 5	Analyze and Present Results

Rigor

The four criteria of Guba and Lincoln were used to increase the accuracy and credibility of the data (Cypress, 2017). This study was conducted by researchers familiar with qualitative research who had an average of more than ten years of experience in qualitative studies and working with older adults. The credibility of the collected data was also confirmed through long-term involvement with the data, the in-depth analysis of the data, the combination of information sources, and the employment of multiple data collection methods, such as interviews, field notes, and member checking by colleagues and participants.

The researcher asked two individuals with similar demographics to the study population to confirm the obtained information to ascertain the transferability of the findings. The researcher carefully recorded and reported the study process and the path of decisions and provided the possibility of any follow-up for others to ensure the confirmability of the findings. The researcher employed two external observers to determine any similarities or differences in interpreting the data to evaluate the consistency of the findings.

The content validity of questions asked in the interviews was ascertained from the literature review. Also, face validity was assessed using the semi-structured interview questions with a targeted group of laypeople (not included in the study) to ensure they understood what was being asked.

Ethical Considerations

The Ethics Committee of the Hamadan University of Medical Sciences approved this study (code: IR.UMSHA.REC.1398.553), and the Vice-Chancellor for Technology and Research of the Hamadan University of Medical Sciences issued the certificate. The participants were reassured of the confidentiality of their information, and verbal consent was obtained from them before enrollment.

Findings

Findings from the analysis of the interviews led to the formation of three categories: religious needs, the need for transcendence, and need for connection, and eight subcategories, including religious practices, religious beliefs, the meaning of life, purposefulness, peace, stability and balance, connect with nature, and connect with others. The process of emergence of theme, categories, and subcategories is shown in Table 3.

Table 3

The emergence process of themes, categories, and subcategories

Theme	Category	Subcategory1	Subcategory2	Codes
Spiritual Needs	Religious needs	Religious beliefs		Believing in God's existence, the Prophets and Imams, and the Hereafter
		Religious practices		Offering prayers and supplications, worshipping, reciting the Qur'an at home, and fasting
	Need for transcendence	Meaning of life	Life Satisfaction	Being satisfied with life, loving life, and tolerating life
			Happiness	Enjoying a happy environment, laughing, being happy with family members, and participating in celebrations
			Independence	Not interfering with the elderly's affairs and consulting with the elderly in doing things related to them
			Self-esteem	Not insulting the elderly, not underestimating the elderly, and immediately meeting the elderly’s financial needs
		Purposefulness	Hope	Hoping for the future, the Hereafter, and life
			Foresight	Living with a look to the future, thinking about the future, saving some money for the future
		Peace	Providing privacy	Having privacy for personal matters and spending hours in private
			Security	Providing financial security, life and psychological security, and freedom from fear of insecurity
		Stability and balance		Maintaining the place of residence, Maintaining the furniture of the house, and preserving personal belongings
	Need for connection	Connect with nature		Going to green spaces, traveling, and caring for flowers, plants, and birds
		Connect with others	Socializing	Commuting, going to parties, having parties at home, and contacting family members
			Loving	Expressing love to children, grandchildren, and others
			Empathy	Hearing the love of children, seeing love from children, seeing love from relatives Listening to older people, giving them feedback, sympathy
			Support	Providing financial, physical, emotional, and psychological support

Religious Needs

Religious Beliefs

Here, belief in God's existence, the Prophets and Imams, and the Hereafter and transcendental subjects was introduced as a subcategory. All the participants in the study expressed that the acceptance of these values by the family and others can lead to peace of mind. They also believed that consulting with knowledgeable people could help know about these values. A participant in this regard said:

“Our parents have taught us godliness and love for the Prophet and the Infallibles since childhood” (Participant No.2).

Another participant said:

“My parents always prayed for Muslims to die, that is, to believe in God, the Qur'an, the Prophet, the Imams, and the Infallibles. They do not believe in them, and I cannot tolerate unbelievers, even for a moment” (Participant No.14).

Religious Practices

All the participants considered religious practices as one of their most important daily spiritual needs. They considered that meaning in their lives as Muslims depended on performing these practices. These religious practices include individualistic and collective practices. Individualistic religious practices include offering prayers and supplications, worshipping, reciting the Qur'an at home, and fasting, and collective religious practices include offering congregational prayers and supplications, worshipping in the mosque, going on pilgrimage, and attending religious places. In this regard, a participant said:

“Muslims are familiar with the Qur'an and supplication, and praying and fasting are among their common duties” (Participant No.4).

Another participant said:

“Life is meaningless without praying, fasting, and going on pilgrimage. Without such practices, how are humans and non-humans different?” (Participant No.5).

The Need for Transcendence

Meaning of Life

This critical subcategory consisted of many other subcategories. Life satisfaction, happiness and vitality, independence and autonomy, and respect and self-esteem were introduced as the subcategories of this concept.

Life Satisfaction

The participants in this study acknowledged that life would be meaningless if they were not satisfied with life. A participant said:

“You’d better die if you are not satisfied with your life. Not that whatever you wish should come true, but you should be at least somewhat satisfied with life” (Participant No.3).

Another participant who was a widow living with her child said:

“Thank God I am very happy with my life. Although I lost my husband when I was young, my children never let me feel his absence” (Participant No.6).

Happiness

According to the participants in this study, although life has many ups and downs and grief and joy are intertwined, happiness and vitality can motivate one to live a meaningful life. A participant said:

“Overall, I am a happy person. I have always laughed at problems so far. I do not bother myself, which is why I have not grown too old. I used to be a cheerful person at work, although it was very difficult” (Participant No.15).

Independence

The elderly participants considered independence essential in life that should be noticed by caregivers and families while caring for the elderly. A participant, who was a married woman, emphasized this point as follows:

“In my opinion, one should die if one is a burden to others at old age, so that others need to put food in one’s mouth or change one’s diapers. I’d like to take care of my affairs myself. Of course, I consult with others, but I do not allow my children or others to interfere in my life” (Participant No.15).

Self-esteem

Another essential need that was evident in the interviews was the need for self-esteem. The participants believed that caregivers and family members of older adults should be careful not to tarnish their dignity and self-esteem while caring and providing for the physical and mental needs of older adults. They said that in some cases, older adults might not express their needs. In these cases, their relatives should try to provide for older adults before expressing their needs, which helps maintain dignity and self-esteem in the elderly. A participant who was a widow mentioned this need as follows:

“The younger ones should not behave in a way that makes older adults feel humiliated and inferior to others. They should try to preserve the dignity of older adults. Older adults should feel loved by others, and their dignity should be preserved” (Participant No.2).

Another participant described respect as one of the essential needs of old age:

“People become irritable and sensitive at old age. Children and younger people should more respect older adults so that they do not feel inferior to others. I do not believe that children should obey the elderly blindly, but children should treat the elderly with respect so that they do not get upset” (Participant No.5).

Purposefulness

One of the essential aspects of spiritual health from the participants' point of view was having a purpose in life. Therefore, according to them, one of the spiritual needs is that people do not consider their lives aimless.

Hope

The participants expressed that human life depended on hope for the future and that human life was doomed without hope, which was doubly important in old age. They believed that old age was the final stage of the human life cycle and was associated with several shortcomings. They also believed that spending this stage of life with peace and enjoying the last years of life depended on hope, which could be achieved through earthly life and spiritual practices. A participant said:

“One feels that death gets closer at old age. But in this period, one also hopes that one’s life will end well and one’s children and grandchildren are happy and successful. Actually, one hopes one has a dignified life in one’s last years” (Participant No.7).

Foresight

The participants believed that human beings were purposeful and aimed to achieve futuristic goals. This notion is also true in old age, and the elderly, although often retired and disabled, need to live with a look to the future. A participant in this regard said:

“Everyone believes that older people should only live in the past and forget the future. However, as long as one is alive and living, one should think about the future. Older people should also save some money for the future and plan and manage their income and expenses” (Participant No.11).

Peace

The participants stated that one of the basic needs in old age was peace. They believed that older adults had little capacity for stresses and problems in life. Therefore, providing a life with peace was one of the crucial aspects of their spiritual needs.

Providing Privacy

Some of the participants believed that although they needed to be with their children and family members, they also needed to spend hours of the day and night alone. An older widow living with her child said in this regard:

“I live with my sons. Thank God they are very good and take care of me. However, we sometimes do not feel good about living together. After all, one sometimes needs to be comfortable, to lie down, to sleep, and to be alone with oneself” (Participant No.14).

Security

The participants stated that aging was a period that required a sense of security. Financial security and life and psychological security were some of the topics discussed in the interviews. In this regard, a participant who was a widow living alone said:

“I've been lonely since my husband died. I get very scared, especially at night. Things I hear about thieves and murders for money and gold scare me more. But what can I do? I have to calm myself down somehow” (Participant No.10).

Although all human beings need security, it seems that older adults living alone, especially older women, need to feel more secure. Older adults feel fear and panic at certain times due to the loss or disability of a spouse and a decrease in their physical and mental abilities, which can be overcome by securing this group of adults. A participant who was a widow living alone stated in this regard:

“I am afraid to sleep some nights. At night, I put a pillow on the floor and pull a blanket over it so that if anyone comes, they will think that one is asleep. I turn on the lamp in one of the rooms to reduce my fear. My grandchildren sometimes stay the night with me so that I am not alone. But I get very scared when they are not around” (Participant No.10).

Stability and Balance

Although the participants believed that change was one of the inevitable aspects of human life, they also thought that older adults needed to maintain stability and balance in life more than others. They claimed that changes that could bring joy and diversity to the lives of young people were sometimes annoying for the elderly. They wanted to live their lives with the slightest change and the highest stability. A participant stated in this regard:

“My children sometimes tidy up the house and move my belongings. I feel angry and nervous for a long time, as I cannot find my stuff. It takes me a long time to get acquainted myself with the new locations of my belongings. I keep asking my children to leave my stuff alone, and they don’t care” (Participant No.1).

Older adults tend to have stability and balance in all aspects of their lives.

The Need for Connection

The participants believed they needed to communicate with nature and others to maintain and promote their spiritual health.

Connect with Nature

Many of the participants emphasized the need to interact with nature to gain vitality and refresh the spirit. Going to green spaces, traveling, and caring for flowers, plants, and birds were some of the examples the participants gave in this regard. The participants also pointed out that factors, such as loneliness, lack of physical strength, and financial deficiencies, prevented them from having a proper connection to nature, and they called for facilities to enjoy more natural attractions. For example, a participant said:

“When I was young, I always went to the mountains and plains. It was fun and really made me fresh and energetic. Now, I barely can walk. I wish there was at least one person to take me to the park so that I could refresh myself” (Participant No.12).

Connect with others

Communication with others was another manifestation of the spiritual needs of the elderly. Based on the participants’ views, interaction with others included interaction with spouses and children, relatives, friends, neighbors, and others.

Socializing

One aspect of interacting with others is commuting, going to a party, and having a party at home. The elderly need to have intimate contact with their family members; it gives them a sense of life and vitality. A participant acknowledged this point and said:

“Life means these commuting. If these are not there, one will not taste life. At least the children, the grandchildren should come to visit, one day they should come, one day we should go. Of course, it's hard, but as soon as we sit together, eat, compliment, say and hear, it takes the tiredness out of the body” (Participant No.3).

Of course, socializing with others is manifested in many forms. However, according to the elderly participating in this study, none of these forms could replace family gatherings. A participant said:

“Now, instead of talking to their parents, everyone is calling. Although this is better than nothing, but to sit and talk for an hour or two, prepare food, eat together and go has a different taste. On the phone that you cannot see each other or say everything. Face to face is much better” (Participant No.8).

Loving

From the participants' perspective, one of the human needs was to express love to others, especially their children and grandchildren. They considered their children and grandchildren the fruit of their lives and loved them. A participant who was a widow living with her children said:

“I'm a mother. My children, no matter how old they are, they are still my children. I like to hug and kiss them when I see them. Grandchildren are my heart. I love them more than my own children” (Participant No.4).

Empathy

The older adults stated that they needed others to empathize with them, listen to them, and give them feedback. They believed that this would contribute to their inner peace and maintain and promote their mental and spiritual health. A participant who was a married man stated:

“I want someone to talk to him, I do not want him to do anything to me, just listen, it makes me lighter, I calm down. My wife, who is disabled, neither speaks nor hears. When I do not talk to anyone for a while, it is as if something is stuck in my throat, as if I am suffocating. But as soon as someone comes and I talk to him for a while, I lighten up” (Participant No.12).

Another participant who was a widow living with her children emphasized the importance of this point and said:

“In this period of time, they do not have much strength to hear the word. We do not expect our relatives to take the burden off our shoulders. But at least they can sympathize with us. They should come and listen to us, express a little sympathy, this is not a high expectation” (Participant No.9).

Support

The older adults believed that they had lost some of their abilities and become physically and mentally weak and vulnerable; therefore, they needed the support of those around them. Financial, physical, emotional, and psychological support were some of the critical issues mentioned by the participants. A participant who was a married woman said:

“We took care of the children when we were young, we raised them, we took their hands, now it is the turn of the children to take our hands. Aging and a thousand pains, the old man needs help. The children must help us, come and visit, and take care of us. I do not expect much, but it is said that no matter how much the children serve their parents, they cannot compensate for their efforts” (Participant No.7).

Another participant who was a married woman complained about children's negligence in supporting their elderly parents and said:

“The children do not remember when they were little, we took food from our mouths, we gave it to them, we raised them with a thousand efforts, now they do not come to visit us every month. They do not come to say what is your pain and problem? Do you want help or not? Aren't you procrastinating? Do you have anything I can do for you? They do not know that they will treat us the same way, their children will treat them the same way” (Participant No.13).

Discussion

The study results showed that the spiritual needs of older adults were in the three main categories of religious needs, the need for transcendence, and the need for interaction. Religious needs included subcategories of religious practices and beliefs, and the need for transcendence included the meaning of life, the purpose of life, and the need for peace. Also, the need for interaction included the need to connect to nature and connect with others. In this regard, the study of Gautam et al. (2019) showed that the spiritual needs of older adults were based on psychosocial, religious, and existential constructs. Thus, providing spiritual care for older adults is linked to gathering information, providing religious guidance, maintaining family connections, providing companionship, discussing end-of-life issues, and counseling (Gautam et al., 2019).

An essential part of the needs that all the senior citizens emphasized was religious needs. In this regard, the participants addressed belief in God, the Qur'an, and the Hereafter. They described religion as related to spiritual life and talked about their faith and religious beliefs as essential for spiritual needs. According to them, faith and belief had different meanings for different people. They saw faith in God as a personal philosophy and a source of energy, comfort, and confidence bringing one from darkness to light. This finding is consistent with the results of other studies (Bulduk et al., 2017; Gijsberts et al., 2019; Kim, 2020). All the participants in this study cited religion and spirituality as an essential source of inner energy production for the continuation of life. According to them, meeting religious needs leads to a positive outlook on life and its challenges. This finding is consistent with the results of Forlenza and Vallada’s study (2018), in which participants experienced spirituality as a powerful source of inner energy (Forlenza & Vallada, 2018). In this regard, Sönmez and Nazik (2019) conducted a study on Muslim seniors. They showed that older adults' most significant spiritual needs were religious ones, including praying, reading religious texts, and attending religious services. Therefore, in caring for this population, sufficient attention must be paid to meeting older adults' religious needs (Sönmez & Nazik, 2019).

In addition, the participants in this study performed religious practices, such as offering prayers and supplications, worshipping, going on pilgrimage, and attending other religious places, such as mosques, to seek God. They believed that seeking God through worshipping had a significant role in life and meeting spiritual needs, helping to improve the level of spiritual health and the quality of life in old age. This finding is consistent with the results of a study by Hodge et al. (2016). Participants in their study stated that religious practices such as worshipping often helped people with their spirituality (Hodge et al., 2016). In addition, the present study results are consistent with those of Lima et al.’s study (2020), considering communication with God one of the spiritual needs of older adults (Lima et al., 2020). The concordance of the results indicates that theology forms the basis of religions and cultural differences have little effect on it. Muslims believe that prayer is the best form of worshipping, and if one's prayer is accepted by God Almighty, one's other deeds will also be accepted (Heidari et al., 2019).

Another category of the study was the need for transcendence, as the participants' most critical and widespread need. Having meaning and purpose in life were two essential subcategories of this concept. The participants emphasized that human life would be spent in vain, and life satisfaction would be reduced without meaning and purpose. They believed that one must understand the meaning and purpose of life to achieve existential perfection. This dimension has been expressed as the most prominent spirituality and existential health feature in most qualitative and quantitative nursing studies. Thus, the search for meaning and purpose has been considered the most critical indicator of existential health (Gallardo-Peralta, 2017; Lucchetti et al., 2019; Tiwari et al., 2016). Also, recognizing the purpose and meaning of life is a central part of spirituality in the holistic nursing theory approach, which shows the perfection of individuals and their relationship with a superior strength (Panzini et al., 2017).

The need for peace and solace was another vital subcategory emphasized by all the participants. They believed that due to the lack of physical and mental capacity in old age, there would be a greater need for relaxation during this period to enjoy every moment of life. In this context, Erichsen and Büssing (2013) found in their study that one of the spiritual needs of older adults was the need for inner peace, including enjoying a relaxed environment, enjoying the beauties of nature, and talking to others about their fears and worries. They also stated that the inner peace of this population was more predictable than religious values (Erichsen & Büssing, 2013).

Caregivers should consider the following factors to meet the existential needs of older people: providing a happy and lively environment for the elderly, respecting their experiences and ideas, giving them the right to decide for their affairs, giving them some time alone once in a while and respecting their privacy as much as possible, trying to convey a sense of hope to them by saying hopeful statements, and encouraging them to express their fears and worries to create a sense of security and peace in them (Bolmsjö et al., 2002; Delgado, 2007).

Another important category was the need for interaction, including two subcategories of interaction with nature and interaction with others. Participants in the present study considered interaction with nature to maintain and promote their spiritual health. They believed that wandering in nature, going on trips, and keeping pets would restore vigor to the elderly. In this regard, Asadzandi believes that one’s connection to nature harmonizes one with other beings in the universe and creates in one a sense of servitude to God (Asadzandi, 2019). Another component in this concept was a constructive and healthy relationship with others, which would lead to maintaining and improving spiritual health and a better understanding of the meaning and purpose of life from the older adults’ perspective. They considered socializing, loving, seeing love, making empathy, and providing support examples of interaction with others. According to Palmer et al. (2018), communication with others is most evident in the elderly, and older adults with a high level of spiritual health have the most constructive communication with others and use this capacity for self-transcendence and better adaptation to challenges ahead (Palmer et al., 2018). In his study designed to model the spiritual needs of the elderly, Monood (2010) considered socializing and constructive communication with other human beings the essential components of this model. He also stated that maximum spiritual health capacity could not be achieved by isolation and distance from others. According to him, interacting with others is one of the essential needs of human life, especially in old age. If this need is not met, self-transcendence and understanding the meaning and purpose of life will be difficult (Monod et al., 2010).

In this regard, it is recommended that nurses and home caregivers of the elderly develop the elderly's connection to nature and encourage the elderly to be present among other older people. Things like reminiscing and reading poetry and storytelling can also be helpful in this regard. In addition, maintaining the interaction of the elderly with family members, relatives, and friends can bring them vitality. Also, instilling love in older adults by expressing loving words, listening to the elderly’s concerns and needs, and empathizing with them are other solutions to meet the interactive needs of the elderly (Asadzandi, 2019; Jackson, 2016).

According to the findings of this study, the spiritual needs of Muslim older adults should be met in three areas of religion, transcendence, and interaction. Also, Narayanasamy et al. (2004) and Jadidi et al. (2021) in their study showed that interventions to meet patients' spiritual needs included respecting privacy, helping patients connect to nature and others, helping patients complete unfinished business, listening to patients' concerns, comforting and reassuring, using personal religious beliefs to assist patients, and observing religious beliefs and practices (Jadidi et al., 2021; Narayanasamy et al., 2004).

This study was one of the few studies conducted on Muslim seniors to explain their spiritual needs. Therefore, more studies are recommended to determine how much of these needs are met. In addition, it is necessary to consider the spiritual needs of other older people, such as the elderly of other religions and the elderly living in nursing homes with physical and mental illnesses. It should also be noted that according to the culture of the study community, these findings are most used in a Muslim community and may be more limited in other communities. Further studies are suggested to explore the spiritual needs of older people in other religions and cultures. Also, the effect of meeting these needs on the spiritual health of the elderly should be examined.

Conclusion

According to the findings of this study, older adults have a variety of spiritual needs that can make the last period of life bitter if not met. Family members and rehabilitation nurses should provide a suitable environment to meet the spiritual needs of the elderly. Some of these strategies include providing a suitable place for offering prayers and worshipping, playing pop or ritual music, maintaining the relationship between the elderly and religious and pilgrimage centers, providing privacy, maintaining a happy and peaceful environment, honoring the elderly, helping the elderly walk and perform fun activities, developing the elderly's emotional relationships with others, keeping the elderly in touch with nature, and, if necessary, referring them to counseling services provided by clergymen or religious counselors. Therefore, it is necessary for caregivers of older adults, including family members and nurses, to be oriented about older adults' spiritual needs and take action to maintain and promote spiritual health in this population.

Limitations

The study was conducted in part during the COVID-19 outbreak, restricting the access to regular family contact due to fear and anxiety caused by the epidemic. Other study limitations included a small sample size and limited interpretations.