Received: 20 Nov. 2010 Accepted: 1 Jan.

2011

Original Article
Spiritual care in hospitalized patients

Hojjatollah Yousefi *, Heidar Ali Abedi **

Abstract
BACKGROUND: Spiritual needs are among an individual’s essential needs in all places and times. With his physical and
spiritual dimensions and the mutual effect of these two dimensions, human has spiritual needs as well. These needs are an
intrinsic need throughout the life; therefore, they will remain as a major element of holistic nursing care. One of the great-
est challenges for nurses is to satisfy the patients’ spiritual needs.
METHODS: This is a qualitative study with hermeneutic phenomenological approach. Data were collected from 16 patients

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hospitalized in internal medicine-surgery wards and 6 nurses in the respective wards. Data were generated by open-ended
interview and analyzed using Diekelmann’s seven-stage method. Rigorousness of findings was confirmed by use of this
method as well as team interpretation, and referring to the text and participants.
RESULTS:

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In final interpretation of the findings, totally 10 sub-themes, three themes including formation of mutual relation
with patient, encouraging the patient, and providing the necessary conditions for patient’s connection with God, and one
constitutive pattern, namely spiritual need of hospitalized patients.
CONCLUSIONS: Spiritual needs are those needs whose satisfaction causes the person’s spiritual growth and make the person
of
a social, hopeful individual who always thanks God. They include the need for communication with others, communica-
tion with God, and being hopeful. In this study, the three obtained themes are the spiritual needs whose satisfaction is poss-
ible in nursing system. Considering these spiritual aspects accelerates patient’s treatment.
KEY WORDS: Spiritual needs, hospitalized patients, phenomenology.
ive

IJNMR 2011; 16(1): 125-132

O
ne of the greatest challenges of a nurse Patients enter an unfamiliar environment, so
is to provide comfort for patients. In the care system must assign a person for this
ch

recent years, with scientific advances in purpose and give him/her the essential train-
health care society, belief in the significance of ings. Patients must be aware of the existence of
human spiritual nature has increasingly become a person who can help them.3 When a patient
more complex especially regarding health and gets engaged in therapeutic activities, he/she
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disease. Researchers have recently come to the has a great deal of time to think about the
point that the real and complete health care is meaning of life and the disease experience.
possible through being sensitive to patients’ Physical engagement may remarkably cause
spiritual needs.1 Holistic nursing believes in the spiritual changes in patient’s past and his/her
relationships among body, mind, and spirit. future attitudes and behaviors.1 It is common in
Nursing therefore requires considering all of every group and culture to connect to God and
these dimensions and the relationships among power sources which can make clear the goal of
them. In chronic diseases, in addition to endur- the patient’s life by which the patient would
ing physical discomfort the patients are dis- tolerate the discomfort caused by the disease;
turbed by spiritual stress and frequent change only the power sources to which attention is
of behavior.2 paid may be different.4 The Holy Quran states:
* PhD, Assistant Professor, Department of Surgical Nursing, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran.
** PhD, Associate Professor, Department of Health, Faculty of Nursing and Midwifery, Khorasegan Branch, Islamic Azad University, Isfahan, Iran.
Correspondence to: Hojjatollah Yousefi, PhD.
E-mail: Yousefi@nm.mui.ac.ir
This article was derived from PhD thesis in the Isfahan University of Medical Sciences.

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Spiritual care in hospitalized patients Yousefi et al

“You humans are always dependent to the such as nervousness, sadness, the problems
needless God.” This need always accompanies caused by diseases which threaten the life, or
human and is expressed more during disease. family problems.9 On the other hand, the high-
God in another verse states: “And when they est level of dissatisfaction in hospitals relates to
board a ship, they supplicate Allah, sincere to communication.10 Though disease may change
Him in religion. But when He delivers them to the life course of the patients, they never get
the land, at once they associate others with disappointed and every patient is yet hopeful;
Him” (Sura Ankabut, 65).5 As a result, nurses this is however in the form of “silent hope”.11 In
should accept the religiousness of human socie- this hermeneutic phenomenological work, we
ty in order to provide health behavior of the pa- studied the experience of hospitalized patients
tients.6 According to Leininger, human care is a regarding their spiritual needs, which is pre-
universal phenomenon; however, its expres- sented in the form of a constitutive pattern as
sions, process, and care patterns differ among the spiritual needs of hospitalized patients.
the cultures. In his mind, care is meaningful in

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spiritual context.7 Methods
There may be problems in saying prayers This is a qualitative research with hermeneutic

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during acute situations. In such cases, blessing phenomenological approach. Hermeneutics (in-
for the patients and his/her attendants can be terpretive, Heideggerian) emphasizes under-
an important spiritual care intervention. One of standing more than description and is based on
the most useful prayers is to request God for interpretation.12 Since the aim of this study was
patient’s needs, fear and hope, and reminding to know the nature of spiritual needs of hospita-
of
that God is able to meet the patient’s demands lized patients, qualitative method with pheno-
in these circumstances. Prayer and religious menological approach was employed.
traditions must be performed in appropriate
conditions so as not to have negative effect.1 Access to the study environment
ive

Attending the patient in hospital has a gen- After obtaining the required permissions from
eral meaning. From the patient’s viewpoint, at- the faculty, the researcher visited the study en-
tending includes considering all his/her care vironment and got permission from hospital’s
issues. So, respecting the patient and taking into manager, nursing officials, and the patients’
consideration his/her humanistic dimensions is nurse. Participants were chosen from hospita-
ch

a part of attending; also, chatting with and lized patients. Especially in ICU, the researcher
communicating with the patient is a part of made interview with some of nurses. The ne-
nursing and attendance. Holistic nursing em- cessary information about the project and its
phasizes respecting the patient’s viewpoints goals was provided to them and their written
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and demands. Nurses should get assured that consent to participate in the research was ob-
they accomplish case based upon what the pa- tained. Then they were interviewed in a quiet
tient requests, rather than what the nurse room.
wants.8 In the patient-nurse relationship, com-
munication is a significant part of nursing daily Data collection
performance. Communication is the foundation Conducting a phenomenological research in-
of the relation between them. The power of ef- volves acquiring rich explanations of a pheno-
fective attendance is reinforced and improved menon and its collections; this was accom-
by good communication. As nurses possess a plished in the present study via depth interview
specific position in health care system, they and note-taking. The goals of study and inter-
spend much time in speaking with patients and view were first explained to the participants.
listening to their concerns, feelings, and needs. We made nondirective open interview so that
Some of these conversations are difficult for the participants could state their experiences as
nurses and are accompanied by serious feelings narration. In this stage, they were requested to

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Spiritual care in hospitalized patients Yousefi et al

express their experienced needs. All interviews searchers based upon meaning, quotations, and
were recorded on tape with the participants’ interpretations provided. Conceptual codes
consent. The research was directed based on were then extracted from this resultant text.
data obtained from the participants and the When other interviews continued, the related
next samples were chosen according to these themes were formed through induction of the
data. Each interview was assigned a code, for conceptual codes; so the previous themes were
anonymity of the participants. This code was made more obvious, and possibly some themes
written down along with the interpretations were removed or new themes could come into
yielded from each interview. As soon as possi- existence. This was accomplished through con-
ble, the interviews were listened and written versation of the team members. During finding
down. the themes, interpretations and patterns were
formed as well.
Data sources Panel 1. Analytic stages using Diekelmann’s
The objective of qualitative sampling is to un- method

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derstand the phenomenon under study; there- 1. Reading the transcript interviews to acquire a
fore, qualitative study is based upon purposeful general understanding of the text;

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sampling. Samples are chosen according to re- 2. Extraction of implicit and explicit meanings;
searcher’s judgment and study goals, and we 3. Writing the hermeneutic summary and ex-
look for those who have experience about the tracting the codes and meanings;
phenomenon under study. In the present re- 4. Extension of sub-themes and themes by team
search, samples were chosen from among the work;
of
hospitalized patients in different units of the 5. Determination of patterns related to the
hospital. Boyd considers 2-10 participants or themes;
study samples sufficient to reach saturation.13 6. Confirmation of the constitutive pattern by
Sampling in this study was purposeful. Infor- referring to the interpretive team, the text, and
ive

mation saturation was reached after interviews the participants;

with 16 patients and 6 nurses, and sampling 7. Use of quotations and interpretations in the
was stopped at this stage. final pattern.

Data analysis Rigorousness of data

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Researcher’s goal of data analysis in phenome- In qualitative studies, validity and reliability of
nological study is to discover and generate a the research and its findings are confirmed
description of the live experience. Practical through using systematic methods and proce-
steps for reaching this goal are different accord- dures, triangulation (simultaneous use of sever-
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ing to the approach followed by researcher. The al research methods, and data collection for
current study was performed using Diekel- confirmation), peer debriefing, and member
mann’s seven-stage method (Panel 1). After checking.14 Systematic methods of data collec-
each interview, it was transcribed and the text tion and information analysis were used in the
was first reviewed by the researcher. The re- present study as mentioned above. Using Di-
search team included two PhD students and a ekelmann’s method, team interpretation, and
nursing associate professor. The team members referring to the text (which included revision of
extracted the quotations as well as implicit and interview transcript in different interpretation
explicit meanings from the interview written stages) and participants, rigorousness of find-
texts. These meanings not only involved the ings was confirmed.
participant’s statement, but also included the
interview atmosphere and how the participant Ethical considerations
responded the questions. The hermeneutic The following ethical considerations were ob-
summary of interviews was written by the re- served: To enter the research environment and

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Spiritual care in hospitalized patients Yousefi et al

conduct the study, approval was taken from the by merging the sub-themes according to the in-
faculty, and the officials of the hospital and terpretive team’s opinion, and finally the consti-
wards were consent for the researcher’s pres- tutive was yielded (Table 1). In this section, the
ence in the environment and conducting the resultant themes are explained.
study. Written consent was also taken from the
participants. They were assured that their in- Hopefulness
formation will be kept secret and the research It is sometimes neglected that the aim of estab-
results will be published without mentioning lishing a hospital and collecting the medical and
their names. To observe this issue, all names care team is the patient. The concerns of the pa-
were changed into codes during transcription of tient from being hospitalized and the patient’s
interviews and the participants were referred ambiguous information during the course of
only by those codes during data analysis and
treatment are sufficient to make him/her very
statement of the results. By giving the phone
anxious and even desperate. The feeling of be-
number and address of the researcher to the
ing lonely in hospital is perhaps the strangest

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participants, it was possible to have communi-
atmosphere for the hospitalized patient.
cation if further information was needed, as
well as to provide the participants a copy of the “It would be better to have good communi-

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paper resulted from the study, if they liked. The cation. I have fear when the doctor comes. For
study steps were approved by research board of example, I fearfully asked whether the patient
the faculty with regard to observing the ethical should eat his tablet or not. They face us very
considerations.15 seriously.”
“I tell them that I take refuge to you. I have
of
Results pain. I have come here to take refuge to you.”
Based upon analysis using Diekelmann’s me- Imperious behavior of medical team mem-
thod, the conceptual codes were induced and so bers toward the patient causes the patient to
smaller classifications or sub-themes were hesitate about remaining in hospital. This indi-
ive

reached. Subsequently the themes were formed cates that the patient has trusted the medical

Table 1. Sub-themes, themes, and constitutive pattern.

Sub-themes Themes Constitutive pattern
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Need to refuge

Need to a familiar person Hopefulness

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Need to hope

Need to esteem

Need to verbal communication Comprehensive relation

Spiritual needs of hospitalized
patients
Need to sympathy and attendance

Need to connect to God

Need to worship conditions

Performing religious practices
Need to being familiar with religious laws

Need to keep respect the patient’s beliefs

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Spiritual care in hospitalized patients Yousefi et al

team to alleviate his/her pain and disturbance, “Currently I dislike life and have no feeling
and requires a refuge for him/herself. By being about it. I only count the days to go to dialysis
hospitalized, the patient tends to alleviate and then sleep. This is my life.” After being
his/her physical and spiritual problems some- hospitalized, patients need many spiritual sup-
how and trust the members of medical team. A ports, such as being encouraged and receiving
nurse mentions the patient’s need to refuge as hope. Hope is a significant condition for contin-
following: uation of human life, and being desperate ex-
“The patient likes to alleviate his/her spirit; presses many negative feelings, even suicide, in
for example something has happened to the patient. This is reflected especially for the
him/her and he/se has been then hospitalized case of diseases such as renal failure. Getting
before telling others the event. Through telling hopeful again can bring back the life to these
others about that event, the patient would like patients.
to lessen the spiritual burden…”
Familiarity of the attendant with the patient Comprehensive relations

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often lightens his/her fear and anxiety. It is Entering the hospital, the patient feels that
usually observed that the patients who are hos- he/she has lost his/her social roles.
pitalized several times in the same hospital

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“Though I wear patient’s clothes, I am not a
would like that their previous nurse attends low person. They don’t care these things…”
them. Considering the nursing system in Iran, He/she feels not to be paid enough attention
small ratio of nurses to patients, and allocation and negligence has occurred for him/her. Pa-
of activities which are based on case or perfor- tients need to admit them as they were before
of
mances, most nurses do not have much time for getting sick and respect their social roles.
supporting aspects; they often perform the rou- Attendance and sympathy cause the state-
tine activities in the ward and neglect suppor- ment of patient’s problems and his/her spiri-
tive care toward patients. On the other hand, tual relief.
the patients are satisfied by supportive care and
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“Last night the nurse had a very hopeful

require a nurse to support and attend them. personality. When I was discomfort, she told
“I expect the nurses to understand the pa- me not to worry. What would happen if they
tient. They should not think that the patient has
attended us? Treatment is not the only impor-
come to be hospitalized and his/her place will
tant thing. It was good if they could talk to us
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be changed to another patient in future days.

sometimes. Perhaps a word by them could calm
They should collaborate with sympathy. We
us, but when the patients speak, they only
have much pain in our body.”
watch and don’t listen and go…”
The patient has compulsorily come to hos-
The patient in solitude and disease expects to
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pital. He/she would like to be paid attention,

find a person to relieve his/her spiritual prob-
rather than being considered as the patient No.
lems and considers this sympathy even better
(). The ward nurse states that: “In the emergen-
cy ward, the patients like to see somebody fa- than medication. Though listening to the patient
miliar and they introduce that person. Probably and paying attention to him/her may not alle-
they believe that they will receive more atten- viate the disease problems, this calms the patient
tion if they know somebody there. I myself al- spiritually. Communication and answering the
ways explain that I try to do my best.” questions are among important nursing respon-
Even when patients enter the emergency sibilities and it should receive attention since it
ward, they look for a person who recommends causes that the patient’s problem are expressed
them. Our interpretation in this section was as during this communication and the ambiguities
“need to a familiar person”. in the patient’s mind can be elucidated.
Often patients visit hospital to relieve their “They are busy and have no free time to talk
physical pains, but physical engagement causes with a person like me. I see that they go and
spiritual and mental engagement. come, or they write something. I see that they

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Spiritual care in hospitalized patients Yousefi et al

don’t spend their time coming to me and talk to connect to God have higher intensity in the
with me.” patient. Saying prayers is obligatory for Muslim
The only information resource of the patient adults in every condition; however it has specif-
in hospital is generally physician and nurse. ic conditions in different situations and the pa-
Since the nurse spends more time with the pa- tient must know it or be informed about it. A
tient, so the patient expects him/her to answer patient says: “Since the day I was hospitalized, I
the questions so the patient can feel more calm- have quitted saying my prayers, because there
ly by resolving the ambiguities. Statements of is sprinkle here when I go to wash my hand,
patients indicate that they need verbal commu- which causes me not to feel good for saying my
nication and expect more from nurses, com- prayers, and I have quitted it to say it whenever
pared to other personnel of hospital. arrive my home. I know that saying prayers
Respecting the patient, attendance and sym- must be done in all conditions, but I don’t feel
pathy, and correct verbal communication are good.” Such statements indicate the patient’s
issues which are satisfied in a comprehensive unfamiliarity with flexibility of religious laws

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relation with the patient. Resolving the prob- for saying prayers. Informing the patient is to
lems which disturb these issues will sustain the some extent effective to calm him/her. The
practical strategy in performing the religious

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spiritual need of the patient.
practices considering the specific situations can
Performing religious practices assist the patient in performing them, while un-
A significant aspect of patients’ spiritual need is familiarity to it causes discomfort of the patient
performing religious practices. Doing these and not performing these practices.
of
What does not change with patient’s hospita-
practices is obligatory for adults and if the con-
lization is his/her cultural identity. “There are
ditions for doing these practices are not suita-
some situations that we cannot tell them to fe-
ble, the patient gets anxious. On the other hand,
male nurses and it would be better if the nurse
performing these practices is the patient’s re-
was male. If the nurses are male, I chat with
ive

quest for more rapid cure and makes disease

them; otherwise, I don’t chat.” The patient
and its accompanying problems to be tolerated
needs to maintain his/her beliefs and this ex-
easier. This has a specific position in Shia beliefs
tends even to gender of the nurse, such that the
which will be mentioned later. “Certainly I get
patient prefers a nurse of the same gender.
angry, very angry. I tell God why I have be- From sub-themes including need to connect to
ch

come patient while others are still healthy. I see God, need to worship conditions, need to being
others laughing. I have much pain, but I say familiar with religious laws, and need to keep
that God tests people differently, and this is my respect the patient’s beliefs, the extracted theme
test. I tell God to give me patience to tolerate the was “performing religious practices”.
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pain.” Looking for the cause of their disease,

patients pay attention to origin of existence. Discussion
They feel the need to connect to God. An ICU In the current study, patients expressed their
nurse states that: “For example they frequently spiritual needs as hopefulness, comprehensive
give us written prayers and green bands, and relations, and performing religious practices. In
request us to tie them to the patient’s bed. This Kolcaba’s opinion, patients’ needs for comfort
is their belief and culture, and we respect it.” include physical, psychospiritual, sociocultural,
Our religious beliefs for recourse (Tavassol) and environmental needs. Spiritual needs re-
are of importance from the viewpoint of patient garding the presence of a familiar person in
and him/her attendants, such that it is followed hospital and comprehensive relations are in ac-
with different intensities in the hospital when cordance with Kolcaba’s psychospiritual and
the patient is hospitalized. This has also differ- sociocultural needs. Juybari has stated the pa-
ent aspects and originates from Shia culture. tients’ comfort in physical, psychospiritual, and
Recourse (Tavassol) in this culture and the need cultural dimensions as well as environmental

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Spiritual care in hospitalized patients Yousefi et al

factors and organizational issues.16 The themes sive relations. This was not observed in some
yielded in our study are in agreement with Juy- cases for the patients under study and the pa-
bari’s findings concerning the presence of a fa- tients were seriously disturbed by negligence of
miliar person in hospital and comprehensive their privacy and dignity. Baillie’s study about
relations. The theme “performing religious the impact of urological condition on patients’
practices” is a different finding. dignity indicates that these methods threaten
the patient’s dignity; however, being in an envi-
Theme 1: Hopefulness ronment next to similar patients as well as pa-
Patients tend to be hospitalized in a familiar en- tient’s attitude and nurse’s proper behavior can
vironment and especially encounter persons influence the observing of patient’s dignity in
who are familiar to them; this acquaintance can threatening situations, and providing a private
assure them. Johnston in a study reported the environment helps in this regard.19
perceptions of nurses and patients regarding In our study, patients emphasized issues
expert palliative nursing care. In the theme such as attendance and verbal communication

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“meet my demands”, a sub-theme is “he/she is of nurses with them. It seems that attendance
beside me” in which patients speak about the was meant to encompass all aspects of care, and
presence of nurse besides them, especially when when answering the question “What do you
they feel anxious. Some patients and nurses
have also mentioned the theme “being accessi-
ble and being beside the patient”.17 It should be
noticed that looking for a familiar person in
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need?” patients frequently mentioned it. There-
fore, communication and being respondent are
a kind of care which shows that the medical
team are responsible when confronting the pa-
of
hospital has become a routine, which is differ- tients.
ent from the mentioned study.
Theme 3. Performing religious practices
Theme 2: Comprehensive relations Sincere and practical belief of Muslims in God
as well as performing divine practices leads to
ive

Comprehensive relations with patient in hos-

pital cause the decrease of patient’s discom- complete comfort in individuals, especially in
fort and bring back the hopeless patients to patients. This has been explicitly mentioned in
life. Hope has a fundamental role in life and is Holy Quran that “without doubt in the remem-
brance of God do hearts find satisfaction” (Sura
especially an essential dimension to success-
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Al Ra’d, 28) and also “Seek (God's) help with

fully confront the disease and getting pre-
patient perseverance and prayer: It is indeed
pared for death.18 In a hermeneutic phenome-
hard, except to those who bring a lowly spirit”
nological study with Ricœur approach, the
(Sura Al Baqarah, 45).5
aim was to show the experiences of patients
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In a study by Narayanasamy et al conducted

with spinal cord injury from hope and hope-
with the aim of exploring the nurses’ role in
fulness; they interviewed 10 patients with
sustaining the spiritual needs of older people as
spinal cord injury. The results with the theme
well as the structure of this care, the findings
“power of hope” indicated that the hope ex- revealed that the spiritual needs of patients
perience is of importance for all patients and were factors such as religious beliefs and prac-
provides energy and power for the trying tice (prayer); absolution; seeking connectedness,
process, since hope is necessary for personal comfort and reassurance, healing or searching
advancement and development.11 In our for meaning and purpose. Also, the interven-
study, patients with chronic diseases were tions to meet patients’ spiritual needs included
seriously desperate and this hopelessness respect for privacy; helping patients to connect;
caused them to wait for death instead of pay- helping patients to complete unfinished busi-
ing attention to future. ness; listening to patients’ concerns; comforting
Respecting the patient’s personality and pri- and reassuring; using personal religious beliefs
vacy is another important aspect of comprehen- to assist patients and observation of religious

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Spiritual care in hospitalized patients Yousefi et al

beliefs and practices.20 Our study as well refers Conclusions

to specific points with regard to performing re- Sustaining the spiritual needs of hospitalized
ligious practices, such that though the patient is patients requires forming trust and sympathy
dependent on routine treatments in hospital, with patient, providing desirable environment,
requests cure from God and talks with his/her appropriate communication of medical team
own words with God. The patient would like with patient, and respecting the patient’s digni-
that in addition to his/her disease to be treated, ty and beliefs. These issues can receive suffi-
his/her spirituality and privacy would not be cient attention from nursery team and be pro-
disturbed. The patient wants to perform the ne- vided according to the patient’s demand. There-
cessary religious practices and requests the pre- fore, it is suggested that in addition to general
requisite conditions. Another important issue in evaluation of patients, their spiritual needs in
our patients which has not been mentioned in hospital would also be taken into consideration.
similar studies is their recourse (Tavassol) as The authors declare no conflict of interest in
well as belief in avow and charity, which is this study.

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deeply connected to Shia beliefs and culture,
and it exists with its exclusive characteristics in
Iran.21

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