Catalysts to Spiritual Care Delivery: A Content Analysis


Monir Ramezani 1 , Fazlollah Ahmadi 1 , * , Eesa Mohammadi 1 , Anoshirvan Kazemnejad 2

1 Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, IR Iran

2 Department of Biostatistics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, IR Iran

How to Cite: Ramezani M, Ahmadi F, Mohammadi E, Kazemnejad A. Catalysts to Spiritual Care Delivery: A Content Analysis, Iran Red Crescent Med J. 2016 ; 18(3):e22420. doi: 10.5812/ircmj.22420.


Iranian Red Crescent Medical Journal: 18 (3); e22420
Published Online: March 1, 2016
Article Type: Research Article
Received: August 4, 2014
Revised: September 7, 2014
Accepted: September 28, 2014




Background: Despite the paramount importance and direct relationship of spirituality and spiritual care with health and well-being, they are relatively neglected aspects of nursing care.

Objectives: The aim of this study is to explore Iranian nurses’ perceptions and experiences of the facilitators of spiritual care delivery.

Materials and Methods: For this qualitative content analysis study, a purposive maximum-variation sample of 17 nurses was recruited from teaching and private hospitals in Tehran, Iran. Data were collected from 19 individual, unstructured interviews. The conventional content-analysis approach was applied in data analysis.

Results: The facilitators of spiritual care delivery fall into two main themes: living to achieve cognizance of divinity and adherence to professional ethics. These two main themes are further divided into eight categories: spiritual self-care, active learning, professional belonging, personal and professional competencies, gradual evolution under divine guidance, awareness of the spiritual dimension of human beings, occurrence of awakening flashes and incidents during life, and congruence between patients’ and healthcare providers’ religious beliefs.

Conclusions: The study findings suggest that the facilitators of spiritual care delivery are more personal than organizational. Accordingly, strategies to improve the likelihood and quality of spiritual care delivery should be developed and implemented primarily at the personal level.


Spirituality Nursing Care Professional Ethics Qualitative Research

Copyright © 2016, Iranian Red Crescent Medical Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License ( which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Background

Spirituality is a human dimension which contributes significantly to health and well-being (1). Although health generally is viewed as having only physical and psychosocial aspects, Russel and Osman (2) recommend including a spiritual dimension to the concept of health. Approximately a quarter of a century ago, the World Health Organization faced the issue of whether to include a spiritual dimension in the definition of health (3). A few years later, WHO defined spiritual health as one of four dimensions of health and “Health Promotion Journal” popularized the concept of spiritual health. More recently, the Bangkok Charter for Health Promotion emphasized the importance of the spiritual aspects of health (4). Accordingly, the concept of health is defined as encompassing the physical, psychosocial, and spiritual dimensions of humans.

Simultaneous to the paradigm shift in defining the concept of health, the concept of care has been expanded to encompass patients’ and families’ spiritual needs. Assessing and fulfilling patients’ and families’ spiritual needs is considered a core component of care. The professional ethics codes of most universities worldwide require nurses to provide care based on patients’ physical, psychosocial, and spiritual needs. The goal of nursing, thus, is to help people gain harmony among their body, mind, and spirit and to find meaning in their existence and experiences (4). This process of creating harmony and discovering meaning should increase individuals’ self-knowledge, self-control and self-healing regardless of health condition (5).

Spiritual care is a unique aspect of care which integrates all other dimensions (6). Despite its great contribution to individuals’ health and well-being (7, 8), spiritual care, along with spirituality, is often neglected by health care professionals (9). Previous studies have shown that many nurses rarely provide spiritual care (10-12). Given the increasing importance of the concept of spiritual care, many studies have been conducted in this area. However, previous research has mostly explored nurses’ perceptions of and attitudes toward spiritual care (13-15) and aimed to identify the barriers to providing spiritual care (10). Several studies have also investigated nurses’ experiences of providing spiritual care (16-18).

However, little is known about the facilitators of spiritual care delivery. In particular, to the best of our knowledge, Iranian nurses’ perceptions of the facilitators of spiritual care delivery have not yet been studied, even though Iran has a specific cultural and religious context. Comprehensive knowledge of the facilitators of spiritual care delivery could help nurses and other healthcare providers apply the concept of spiritual care in practical situations and their daily nursing practice. This study was conducted to fill these research gaps.

2. Objectives

The aim of this study is to explore Iranian nurses’ perceptions and experiences of the facilitators of spiritual care delivery.

3. Materials and Methods

3.1. Design

A qualitative content analysis design was selected for this study. Content analysis is a systematic approach to the analysis and interpretation of textual data. It goes beyond extracting the objective contents of the data and includes the identification of latent themes and patterns in participants’ experiences (19).

3.2. Participants

A purposive sample of 11 female and 6 male nurses working at 3 teaching and 2 private hospitals in Tehran, Iran, was recruited. The inclusion criteria were at least 6 months of work experience and interest in participating in the study. A maximum variation sample was recruited to include a wide range of experiences in the study. The range of participants’ age and work experience was 25 - 45 and 3 - 20 years, respectively. Twelve nurses held bachelor’s degrees, and 5 had master’s degrees in nursing. Participants were recruited from different clinical settings, including emergency wards and coronary, intensive, oncology, cardiac, pediatric, and neurology care units (Table 1).

Table 1. Demographical Characteristics of Participants
ParticipantsGenderAgeEducationWork Experience, YClinical Setting
P. 2M40MSN15Cardiac
P. 6F30BSN8Pediatric
P. 7M28BSN6Neurosurgery
P. 8F42BSN15Cancer
P. 9F35BSN12Cancer
P. 10M34BSN11Emergency
P. 11F32BSN9Cancer
P. 12M30BSN10Emergency
P. 13F42BSN20Emergency
P. 14F34BSN11CCU

3.4. Data Analysis

The data were analyzed simultaneously with data collection according to the conventional content-analysis approach (21). The interviews were transcribed verbatim immediately after they were concluded, and the transcripts were read several times to gain an accurate understanding of the data. In the last round of reading, the meaning units (sentences and paragraphs relevant to the topic studied) were identified and coded. The primary codes were categorized according to their similarities and differences. These categories were compared and grouped into higher-level categories and themes (Box 1). MAXQDA 10.0 was used for data management.

Box 1. Themes and Main Categories from Content Analysis of the Facilitators of Spiritual Care Delivery
Themes/Main Categories
Living to achieve cognizance of divinity
Gradual evolution under divine guidance
Spiritual self-care
Awareness of the spiritual dimension of human beings
Occurrence of awakening flashes and incidents during life
Congruence between patients’ and healthcare providers’ religious beliefs
Adherence to professional ethics
Personal and professional competencies
Active learning
Professional belonging

3.5. Trustworthiness

The credibility of the study findings was strengthened by the use of such techniques as peer- and member-checking and prolonged engagement with the data. All analytic activities were documented step by step for auditing purposes. The transferability of the study findings was increased by recruiting a maximum variation sample.

3.6. Ethical Considerations

The ethics committee of Tarbiat Modares University, Tehran, Iran (No. 52/112234) approved this study, and the necessary permissions were obtained from the administrators of the study setting. Participants were informed of the study aim, interview process, the confidentiality of personal data, and their absolute right to participate in or withdraw from the study at any point. Participants were also ensured that their data would be managed and reported anonymously. Each participant was assigned a code number used to analyze and report the data. Written, informed consent was obtained from each participant before the interviews.

4. Results

Participants’ experiences and perceptions of the facilitators to spiritual care delivery are classified into 2 main themes, 8 main categories, and 34 sub-categories. The two main themes are living to achieve cognizance of divinity and adherence to professional ethics. These themes and their corresponding categories and subcategories are explained in this section.

4.1. Living to Achieve Cognizance of Divinity

This theme reflects the goal of living to gain insight into divinity and the transcendent dimension of human beings. The five categories of this theme are spiritual self-care, gradual evolution under divine guidance, awareness of the spiritual aspect of human beings, occurrence of awakening flashes and incidents during life, and congruence between patients’ and healthcare providers’ religious beliefs.

4.1.1. Gradual Evolution Under Divine Guidance

This category refers to nurses’ moral and spiritual development over time. Such concepts as obtaining spiritual insight, changing behaviors through religious practices, believing in divine mercy and retribution, and believing in the divine management of the world fall into this category. Participating nurses reported that they changed and developed their views and attitudes by paying attention to and obeying God: “God says, ‘Avoid defrauding.’ You know, a transaction is like a treaty. … You need to respect others’ rights. My attitude changed and developed over time because of God’s favor. Now, I’m living with this new attitude. I strive to protect and respect patients’ rights and avoid shirking my responsibilities to gain patients’ confidence” (P. 2).

Nurses gradually acquired considerable comprehension and logical- and rational-thinking skills which they employed in their daily lives and practices. They sought to never make patients feel indebted or to hold them to certain expectations. Nurses believed that care provision enriched their lives and earned God’s blessing. Along with their feelings of achievement, they attributed their abilities to manage problems and to make important decisions to God’s favor and believed that God manages the world. Finally, they emphasized that patients’ life, death, and recovery are all dependent on God’s will. Accordingly, they believed that they deal with God and need to obey His will: “When you choose the way of obeying God’s will, you can understand the meaning of many events. This way, you won’t consider worldly criteria as that important anymore because the only criterion of supremacy is piety” (P. 2).

4.1.2. Spiritual Self-Care

This category consists of the concepts of adopting a divine approach to life, practicing theological virtues, reading and reflecting on the Quran, praying to God, and acting to please God. Participating nurses strove to establish a strong, committed relationship with God, obey Him, and avoid violating His will: “I strive to obey God and prefer His will over my own. I try to abstain and avoid doing wrong things. When dealing with patients, I scrutinize my behavior to better care for their souls and preserve their dignity. I avoid saying any trivial thing merely to make patients happy” (P. 2).

Participants were also thankful to God in all their life and work situations. They could transfer the kindness they received from God to their patients and had a great sense of happiness at attending and providing care to patients. Their main aim of working was to be accepted by God. Accordingly, they attempted to meet patients’ needs and work in a way pleasing to themselves, their patients, and God: “When we feel that we are receiving God’s kindness, we have the ability to transfer this kindness to patients. Accordingly, I visit patients and provide care to them with a deep, inner feeling of joyfulness. When I’m in such a cheerful mood, I can provide effective care to my patients” (P. 2).

4.1.3. Awareness of the Spiritual Dimension of Human Beings

This category is comprised of nurses’ awareness and recognition of the great strength of spirituality as an important dimension of human beings. Participants saw nursing as providing care to humans as dignified beings and unique creatures of God. Nurses viewed caring as looking after patients’ bodies, minds, and souls. They valued patients’ dignity and referred to them as creatures with divine spirits: “It [nursing] is really an important job. We do not focus merely on patients’ bodies; rather, our work deals with their bodies, minds, and souls” (P. 3). “The patient is not a vegetative being on whom we merely perform mechanical tasks” (P. 13).

The nurses recognized the great abilities of the human soul and considered it to be the origin of science, thought, wisdom, and intention. They believed that the soul can even surpass the natural abilities of human beings and facilitate recovery: “The soul possesses so great abilities and powers that it can advance its owner to the highest degrees of perfection, provided that the owner recognizes its importance” (P. 2).

4.1.4. Occurrence of Awakening Flashes and Incidents During Life

According to participants, another facilitator of spiritual care delivery is the awakening flashes and incidents that happen during life. Awakening flashes and incidents include events which promote nurses’ spiritual awareness, such as suffering terrible losses, caring for terminally ill patients, and being directly involved in a disease affecting one’s own family members. Incidents, such as the complete recovery of severely ill patients and the sudden death or significant loss of consciousness by a recovering patient, taught about participants the unpredictability of life and increased their spiritual awareness: “I saw with my own eyes that a stable patient died in a few minutes, and his final wish remained unfulfilled” (P. 17).

4.1.5. Congruence Between Patients’ and Healthcare Providers’ Religious Beliefs

Participants emphasized that the congruence between patients’ and healthcare providers’ religious beliefs helped providers accurately understand and effectively fulfill patients’ spiritual needs: “If a patient and I have shared beliefs, the effects of my talks with the patient will then increase” (P. 16).

4.2. Adherence to Professional Ethics

The second main theme of the study is nurses’ adherence to the principles of professional ethics. According to participants, nurses’ moral and professional accountability is another facilitator of the provision of spiritual care. The three categories of this theme are personal and professional competencies, active learning, and professional belonging.

4.2.1. Personal and Professional Competencies

One of the most important facilitators of the provision of spiritual care is nurses’ personal and professional competencies, particularly positive psychological attributes, accurate sensory perception, empathizing ability, and good professional conscience. Participants saw positive affects from defining human attributes, such as patience and enthusiasm for learning and self-improvement, on the provision of spiritual care: “I pay special attention to spiritual care because I am interested in and study spirituality” (P. 16). Having a great empathizing ability helped participants exhibit great empathy for patients, understand their conditions, and perceive their and others’ negative and positive energies: “I can understand patients’ conditions, pains, and sufferings so clearly that it sounds like being in their shoes” (P. 11). Nurses were also aware of and competent in their professional roles and recognized patients’ right to receive high quality care: “Having mastery over my work and providing patients with adequate information increase their calm, as well as confidence in my competence” (P. 15).

4.2.2. Active Learning

Active learning is another facilitator of spiritual care delivery and consists of nurses’ active engagement in study, reflection, and social learning. Participants acquired better understanding of holistic care and the different dimensions of human beings through reading about great individuals’ and human beings’ mystical powers and through reflecting on role models’ faults and shortcomings, such as their inability to establish relationship with patients. Nurses viewed social learning as the process of learning by observing the desirable personality traits and behavioral characteristics of colleagues, instructors, role models, and patients: “I’ve seen how my colleagues, particularly the experienced ones, can establish relationships with patients and create a pleasant environment for themselves and patients. Indeed, such a pleasant environment alleviates their own and patients’ stress. These colleagues have been good role models for me and attract my attention” (P. 3).

4.2.3. Professional Belongings

Another facilitator of spiritual care delivery is professional belonging, which includes an interest in and sensitivity to nursing and its professional image, a love of the profession and patients, the honor of providing service to patients, and the desire for professional development: “I like nursing very much because I want to reach its pinnacle” (P. 4). Participants were sensitive to, reflected on, and strove to improve the public image of nursing: “Each nurse is a mirror for other nurses; in other words, your good professional practice reflects on my good practice. We need to be sensitive to each other’s behaviors, as well as the public image of nursing” (P. 13).

5. Discussion

This study is aimed at exploring Iranian nurses’ perceptions and experiences of the facilitators of spiritual care delivery. The study findings reveal that the main facilitators of spiritual care delivery are living to achieve cognizance of divinity and adherence to professional ethics. Nurses’ awareness of spirituality and the spiritual aspect of human beings is found to help them accurately identify and properly meet patients’ spiritual needs. Previous studies have also shown that nurses’ transcendent awareness is an essential prerequisite to spiritual care delivery (6, 22). Spiritual care delivery also reflects nurses’ attention to each patient’s uniqueness and reality (6). The present findings also demonstrate that the occurrence of awakening flashes and incidents during life affect nurses’ spiritual awareness and insight. Generally, previous spiritual experiences, problems, and crises (23, 24) increase awareness of the transcendent aspects of life.

Nurses’ religious beliefs and practices are also found to contribute to the provision of spiritual care. Similarly, it has been reported that nurses’ organized or non-organized religiosity, spiritual well-being, meaningful spiritual experiences, and faith in God and an afterlife significantly affect their spiritual care attitudes and practices.22 Nurses’ religious inclinations can facilitate the identification and fulfillment of patients’ spiritual needs (14). Encouraging nurses to strengthen their religious beliefs and increase their spiritual awareness can improve their ability to provide spiritual care (25). However, some studies have clearly differentiated spirituality from religiousness and defined it from an existential perspective (26).

The present findings show that nurses’ personal and professional competencies and moral and professional accountability are among the facilitators of the provision of spiritual care. Previous studies have suggested that nurses’ accountability (27, 28), competences (29), accurate sensory perception, (30) and ability to understand and accept others’ feelings and behaviors are among the prerequisites to meeting patients’ spiritual needs. Finally, this research finds that nurses’ positive psychological attributes, such the desire for critical self-evaluation and self-improvement, greatly contribute to spiritual care delivery. This finding has been reported in other research (31).

5.1. Conclusions

The study findings suggest that the facilitators of spiritual care delivery are more personal than organizational. Accordingly, strategies to improve the likelihood and quality of spiritual care delivery should be developed and implemented primarily at the personal level. Such strategies include but are not limited to encouraging nurses’ active engagement in self-learning, increasing their personal and professional competencies, promoting their adherence to the principles of professional ethics, and introducing spirituality and spiritual-care concepts into nursing curricula and in-service continuing education programs to raise spiritual knowledge and awareness.

5.2. Limitations and Recommendations

This qualitative study explores factors facilitating the provision of spiritual care in Iran. Accordingly, the findings might have limited transferability. Further studies investigating the facilitators of spiritual care delivery in other contexts and settings are needed.

5.3. Implications of the Findings

Providing spiritual care to patients can significantly improve the quality of nursing care. However, few studies on spiritual care and its facilitators have been conducted. Nursing managers and policy makers can use the findings of the present study to develop and implement strategies to facilitate the provision of spiritual care. Moreover, the findings suggest that a lack of formal, university-based spirituality and spiritual-care education is a major barrier to the provision of spiritual care. Accordingly, the study findings can be used to develop and revise nursing curricula to integrate spirituality and spiritual-care concepts.




  • 1.

    Bussing A, Balzat HJ, Heusser P. Spiritual needs of patients with chronic pain diseases and cancer - validation of the spiritual needs questionnaire. Eur J Med Res. 2010; 15(6) : 266 -73 [PubMed]

  • 2.

    Russel NR, Osman PM. Spiritual health: out of the closet. J Health Edu. 1992; 23(4) : 221

  • 3.

    Spiritual health is important, say our readers. WHO Chron. 1979; 33(1) : 29 -30 [PubMed]

  • 4.

    Vader JP. Spiritual health: the next frontier. Eur J Public Health. 2006; 16(5) : 457 [DOI][PubMed]

  • 5.

    Watson J. Human Caring Science. 2012;

  • 6.

    Ramezani M, Ahmadi F, Mohammadi E, Kazemnejad A. Spiritual care in nursing: a concept analysis. Int Nurs Rev. 2014; 61(2) : 211 -9 [DOI][PubMed]

  • 7.

    Yousefi H, Abedi HA. Spiritual care in hospitalized patients. Iran J Nurs Midwifery Res. 2011; 16(1) : 125 -32 [PubMed]

  • 8.

    Yuan H, Porr C. Integrating Spiritual Care into a Baccalaureate Nursing Program in Mainland China. J Holist Nurs. 2014; 32(3) : 240 -3 [DOI][PubMed]

  • 9.

    Bussing A, Zhai XF, Peng WB, Ling CQ. Psychosocial and spiritual needs of patients with chronic diseases: validation of the Chinese version of the Spiritual Needs Questionnaire. J Integr Med. 2013; 11(2) : 106 -15 [DOI][PubMed]

  • 10.

    Carr TJ. Facing existential realities: exploring barriers and challenges to spiritual nursing care. Qual Health Res. 2010; 20(10) : 1379 -92 [DOI][PubMed]

  • 11.

    Ross L. Spiritual care in nursing: an overview of the research to date. J Clin Nurs. 2006; 15(7) : 852 -62 [DOI][PubMed]

  • 12.

    Balboni TA, Balboni M, Enzinger AC, Gallivan K, Paulk ME, Wright A, et al. Provision of spiritual support to patients with advanced cancer by religious communities and associations with medical care at the end of life. JAMA Intern Med. 2013; 173(12) : 1109 -17 [DOI][PubMed]

  • 13.

    Wu LF, Lin LY. Exploration of clinical nurses' perceptions of spirituality and spiritual care. J Nurs Res. 2011; 19(4) : 250 -6 [DOI][PubMed]

  • 14.

    Stranahan S. Spiritual perception, attitudes about spiritual care, and spiritual care practices among nurse practitioners. West J Nurs Res. 2001; 23(1) : 90 -104 [PubMed]

  • 15.

    Tiew LH, Drury V. Singapore nursing students' perceptions and attitudes about spirituality and spiritual care in practice: a qualitative study. J Holist Nurs. 2012; 30(3) : 160 -9 [DOI][PubMed]

  • 16.

    Bailey ME, Moran S, Graham MM. Creating a spiritual tapestry: nurses' experiences of delivering spiritual care to patients in an Irish hospice. Int J Palliat Nurs. 2009; 15(1) : 42 -8 [DOI][PubMed]

  • 17.

    Dunn LL, Handley MC, Dunkin JW. The provision of spiritual care by registered nurses on a maternal-infant unit. J Holist Nurs. 2009; 27(1) : 19 -28 [DOI][PubMed]

  • 18.

    Ross L, van Leeuwen R, Baldacchino D, Giske T, McSherry W, Narayanasamy A, et al. Student nurses perceptions of spirituality and competence in delivering spiritual care: a European pilot study. Nurse Educ Today. 2014; 34(5) : 697 -702 [DOI][PubMed]

  • 19.

    Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005; 15(9) : 1277 -88 [DOI][PubMed]

  • 20.

    Elo S, Kyngas H. The qualitative content analysis process. J Adv Nurs. 2008; 62(1) : 107 -15 [DOI][PubMed]

  • 21.

    Krippendorff K. Content Analysis: an introduction to its methodology. 2004;

  • 22.

    Sawatzky R, Pesut B. Attributes of spiritual care in nursing practice. J Holist Nurs. 2005; 23(1) : 19 -33 [DOI][PubMed]

  • 23.

    Burkhart L, Hogan N. An experiential theory of spiritual care in nursing practice. Qual Health Res. 2008; 18(7) : 928 -38 [DOI][PubMed]

  • 24.

    Tanyi RA. Towards clarification of the meaning of spirituality. J Adv Nurs. 2002; 39(5) : 500 -9 [PubMed]

  • 25.

    Wright MC. The essence of spiritual care: a phenomenological enquiry. Palliat Med. 2002; 16(2) : 125 -32 [PubMed]

  • 26.

    Burkhart L, Schmidt L, Hogan N. Development and psychometric testing of the Spiritual Care Inventory instrument. J Adv Nurs. 2011; 67(11) : 2463 -72 [DOI][PubMed]

  • 27.

    Dyson J, Cobb M, Forman D. The meaning of spirituality: a literature review. J Adv Nurs. 1997; 26(6) : 1183 -8 [PubMed]

  • 28.

    Chan MF, Chung LY, Lee AS, Wong WK, Lee GS, Lau CY, et al. Investigating spiritual care perceptions and practice patterns in Hong Kong nurses: results of a cluster analysis. Nurse Educ Today. 2006; 26(2) : 139 -50 [DOI][PubMed]

  • 29.

    Carr T. Mapping the processes and qualities of spiritual nursing care. Qual Health Res. 2008; 18(5) : 686 -700 [DOI][PubMed]

  • 30.

    Clark PA, Drain M, Malone MP. Addressing patients' emotional and spiritual needs. Jt Comm J Qual Saf. 2003; 29(12) : 659 -70 [PubMed]

  • 31.

    Puchalski C, Ferrell B, Virani R, Otis-Green S, Baird P, Bull J, et al. Improving the quality of spiritual care as a dimension of palliative care: the report of the Consensus Conference. J Palliat Med. 2009; 12(10) : 885 -904 [DOI][PubMed]