Introduction:

Spirituality is a complex concept that has different definitions among different nations¹ and, from the perspective of some scholars, includes non-physical aspects of man, which is experienced through the association of human life with God, himself, others, and nature². Spiritual beliefs are associated with all aspects of the individual's health and illness, guides the daily habits of his life and is the source of support, strength, and recovery for him³. Spiritual health is defined in the context of the relation between body, mind and soul in the context of inner peace, positive and friendly relations with others, as well as relationship with nature and God as the centerpiece of the person's beliefs⁴. In addition, Fisher (2000) considers it as a fundamental aspect of overall health and well-being of the individual, which leads to the integration and coordination of other aspects of health, including his physical, psychological, social and emotional dimensions⁵.

Spiritual care is an important part of nursing practice because nursing is aimed at maintaining and promoting health, preventing the disease, and eliminating the pain and discomfort of patients that spiritual care has an effective role in achieving it^6-8. Paying attention to spiritual needs helps nurses provide comprehensive care for patients¹², and as their perception of spiritual care is greater, they provide more spiritual care for the patient¹³. Vance's study (2001) also demonstrates the relationship between spirituality in nurses and providing spiritual care¹⁴. Therefore, nursing profession that claims the ownership of spiritual care in different dimensions of human, should have the ability to identify and respond to the spiritual needs of patients¹⁵.

Studies conducted by the researchers showed that various studies have been conducted with quantitative and qualitative approaches in relation to the spiritual needs of patients in Iran^16-19, in the vast majority of which variables related to spiritual needs were examined using the statistical population of the patients and with the help of their participation. And despite the key role of nurses in identifying and determining the needs of patients (the first phase and the basis of the care process), experiences, perceptions and especially the views of this group on the spiritual needs of patients have been neglected. And since achieving health and meeting the spiritual needs is possible only when the necessary understanding and collaboration between the patient and the nurse at all stages of the care process, including the need for explanation, happens, the researchers who have years of experience in clinical education and work and have witnessed the neglect or lack of attention to the spiritual needs of the patients and seen that it is becoming more important to meet the patients' physical needs, they got determined to resolve this disadvantage in order to ascertain the spiritual needs of patients from the viewpoint of nurses.

Materials and methods:

In this research, conventional content analysis method was employed, according to the proposed steps of Lundman & Graneheim for 5-monthes period from February to July 2018. Participants included 15 nurses in the Jahrom University of Medical Sciences providing patients with care training. Participants had maximum variation with associate, bachelor and master degree, and holding positions such as staff, head nurse, supervisor, and faculty instructor with rich information in the field and who were eager to participate in the study.

In order to collect data, one of the researchers, as an interviewer, after contacting the participants and attracting his attention to participate in the research, set a time for interviewing them at their work place. After giving explanations about the goals of the study, about compliance with the ethical issues of the research, including keeping the information and anonymity of the participants involved and obtaining permission to record their voice, he commenced to interview. Regarding the male gender of the researcher and the feeling of discomfort of the female participants to attend a private, calm and convenient environment for interviewing, six interviews were conducted by three-people groups (interviewer and two female participants) and in three cases (one case with women and two cases with men), interviews were conducted individually.

The researchers carefully listened to the recorded contents immediately after recording each interview and, after gaining an overview of the contents, they wrote each interview as word-for-word, until the analysis units were developed. They then read the data line by line and important sentences and phrases were identified and their meanings were named (encoded), then similar codes were merged and classified. In the next step, the degradation process continued in data reduction in all the analysis units until the classifications appeared, and thus the overall, conceptual and abstract data were placed in the main category. Before collecting the information and after approval of the proposal by the Research Council of the Faculty of Nursing and Paramedicine, a license to enter the clinical field was obtained from the Ethics Committee of Jahrom University of Medical Sciences. On the other hand, ethical principles in the research such as informed consent, preservation of anonymity, the confidentiality and discretion of participants to abandon the study were complied with. The data collection was conducted through a semi-structured interview so that before the interview began, the purpose of the study and the confidentiality of the information and the recording of the interviews were explained to the participants, then if they wished to participate in the study, interviews started with an open and general question, such as "Please describe your experiences with dealing with patients and behaviors based on their spiritual issues," then follow-up questions were asked. The duration of the interviews was adjusted according to the terms of the participants, which averaged 45 minutes and varied between 30 to 70 minutes.

In order to ensure the accuracy of the data, the criteria proposed by Lincoln and Guba were used so that the validity of the findings of the study increased by allocating sufficient time, good communication, using the combination, using complementary comments from colleagues, and reviewing manuscripts by other colleagues. The acceptance of the data has also increased with the allocation of sufficient time to collect and deeper consideration of them, as well as the reliance on participants' trust, the proper communication that has led to the discovery of more angles of participant experience. In addition, in the present study, a specialist in qualitative studies was asked to re-analyze specific data. Equivalence and validation of the study were also improved by combining the findings and raw data and the extracted and formulated meanings. We tried to use people with different backgrounds and experiences and at the end of the study, the results were shared with a number of similar people who did not participate in the study to comment on the results.

Results:

From the profound and rich description of the participants, the six themes including "expression of opinions", "attention to worship", "compliance with prohibitions", "being protected", "being respected" and "paying attention to rites of the Ihtidar (the presence of death) and death" were achieved (Table 1).

First Theme: Expressing Opinions

• The first theme consists of two subthemes: "communicating with the treatment group" and "having religious symbols". Participants of the research believe that one of the spiritual needs of patients is to communicate with the team of treatment and express their beliefs freely, which is sometimes complemented by confrontational and religious symbols. The importance and need of patients to communicate properly and even emotionally with health-care providers, especially nurses, and their willingness to talk and discuss religious issues, sometimes forces health-care providers to remain silent and makes them to be a listener. One of the participating nurses said:

• "Sometimes the patient needs to talk and we go to him and he starts talking and we listen to her as far as we can"

And the other one said:

• "We had illness who was Dervish and constantly spoke to me about his religious matters ... I did not understand anything from his words, but I allowed him to speak as much as he wanted, because I wanted him to be comfortable because he was ill. He had a heart attack. He explained to me, and as a listener I stood beside his bed, and listened without any judgments."

About the patient's having religious symbols, another nurse said:

• "Sometimes, they fasten the blessed green cloths that have been brought from Imams' shrines to the forehead or arm, sometimes there are prayers in their neck; there are times when the patients' companions bring Zamzam water or the soil of Karbala and ask us to let them give the water to the patient, or rub the soil on the patient's forehead".

Second Theme: Attention to Worship

"The tools required for worship" and "ritual worship" are two sub-elements derived from the theme of "attention to worship". From the perspective of participants, one of the spiritual needs of patients are the availability of conditions, and the availability of the tools necessary for the proper and acceptable ritual worship, because it is believed that the allocation of time for the correct and timely fulfillment of daily and weekly, and occasionally monthly and annual, worship is one of the essential components of the life of every Muslim. According to the nurses, in order to perform such religious rituals as prayer, reading the Qur'an, reading the supplication, resorting to the Imams, telling beads and performing the worship ceremonies such as Wudu, Ghusl and Tayammum, and keeping their body, place and clothing clean. hospitalized patients need collaboration and assistance from hospitals, nurses, and other members of the care team to provide the necessary tools. One of the attending nurses said:

• The major spiritual need for patients to read prayers, Quran and supplication.

And the other one said:

• Many hospitalized patients ask us for Qur'an or Mafatih al-jinan or ask for muhr and Piece of stone for Tayammum and ask for the time of prayers or Qibla direction.

About the expectation of patients to provide proper conditions for worship.

Another participant stated that:

• There was a patient in our ward that said "I cannot pray here because there is blood here and it is Najis, maybe my bed and clothes are also Najis too." He was expecting us to provide a clean environment for his praying.

Another nurse who was working in the CCU ward, stated:

• In each room of our wards, we have Qur'an, Mafatih al-jinan and a Tawdih al-masa'il that provide important religious issues with which patients are confronted in the hospital and they will be in their access at their request or that of their families. In our ward, we also have clean and suitable stone for doing tayammum and pitcher & basin for wudu of patients who are not able to come down from the bed. Sometimes patients ask us to help them do wudu, which we also help them in such cases or if the conditions of the patient and ward are appropriate, we will allow companions to enter the ward and help their patients to do wudu and prayers.

Third Theme: Compliance with Prohibitions

Compliance with religious prohibitions, according to the participants of the study, is another spiritual need of patients and includes three sub-themes of "avoiding contact with the non-mahram", "keeping the hijab (veil)" and "keeping privacy" so that a large number of patients and their families expect health-care providers and treatment staff to provide patients with care by nurses of the same sex as far as it is possible. And, except in cases of emergency or shortage of nurses of the same sex, nurses of the opposite sex will not be allowed to conduct counseling, care and treatment. And this approach becomes more intense when it comes to more private issues and sex organs. Although few patients pass by negligence and laxity, they are very important and vital for religiously believed patients. To the extent that some of them are even frustrated by actions such as IV or muscle injections, which are associated with the least patient contact. And if it is inevitable that a nurse of opposite sex perform these actions, they get to wear gloves so that their skin is not touched by the health-care providers or the skin of the therapist of the opposite sex is not rubbed against their skin. A female nurse participating in the study said:

• Sometimes, some patients who are very religiously strict about compliance with religious issues tell us, "You should wear gloves when you are taking care of us." For example, a 90-year-old man told me: "Do not touch me". It meant that I'm not a man and a male nurse must come to do his work for him.

Another female nurse said:

• We try to wear glove when working for patients, but sometimes it cannot be done under emergency conditions, for example, if the unconscious patient is about to falls down from his bed, we do not follow this rule because there is no opportunity to do this.

Considering the importance of keeping hijab and respecting personal privacy as the spiritual needs of patients, other participating nurses stated:

• A female patient was admitted to our ward that needed an echo cardiogram. To reach the echo, she had to walk through a corridor that was only twenty feet long, but insisted on wearing a veil in this short path.

• When non-mahram (male doctors, facilities, guardsmen etc.) come to our ward, we draw the curtains because this is a special section for women to be admitted and patients want to be comfortable.

• A hospitalized young woman's mother-in-low complained that the male guards commute in the ward off and on, and that her bride had to wear veil each time. And she insisted so much that we had to move the guard's desk so that the guards had no control over the ward and that the patients would be comfortable.

• A few years ago, my husband was admitted to the ICU in one of the private hospitals. He is a religious person and does not listen to illegal(Non-religious) music tracks, but the officials in that ward, because of the pleasures of a wealthy patient in the ward, were broadcasting one of the unauthorized songs from the loudspeaker, which displeased me and my husband, but they did not pay attention to our protests, and my husband, every time and especially when he did prayers, put cotton in his ears so that he didn't hear the sound of the song, while the ward officials could give the guy a handset and a phone to listen to his favorite song, and on the other hand they could also respect the religious beliefs and privacy of others patients.

Fourth Theme: Being Supported

From the perspective of participants in this research, one of the spiritual needs of patients admitted to hospitals is to be protected from various aspects by health-care providers and especially nurses. According to them, the hospitalized patient needs to be considered and helped in "performing religious rituals", and the nurse can meet this need either by himself or allow the patient's companions and confidants, who in most cases are his family members, to come to help the patient. Considering this issue, one of the participants said:

• Many of our patients need help with their religious worship. We help those sick people who are alert and willing to do prayers or other worship ritual, for example, we give them Tayammum's stone or Muhr to do prayers, or even help them perform wudu. Sometimes we let the patient's companions enter the ward so that they will help their patient do wudu and prayers.

"Being at the patient's bedside" is another manifestation of support that nurses involved in this study considered it a spiritual need for the patient, one of whom considered it the essence of spiritual care, and said:

• Surely, being at the patient's bedside and saying that "God will help you" is the very spiritual support and a positive energy for the patient.

Nurses participating in the study recognized "giving hope and empathizing with the patient" as another aspect of support, and believed that patients would like to confide to nurses and would like nurses to give them hope. A hospital supervisor, who has worked in dialysis ward for many years, said:

• When I was supposed to be transferred from the dialysis ward to the superintendent's office, some of the earlier patients of the ward shed tear and came in protest to the hospital's management office in order to prevent them from transferring me. The reason for this reaction on their part was that I was talking with my patients all over the work shift. I laughed, smiled and supported them spiritually.

In confirmation of this opinion, one of the pregnant women giving birth in a hospital told the researcher interviewing her:

• I like one of the midwives of the hospital over the rest because she comes more often than his colleagues at the time of delivery, she talks more with them and comfort them. She even prays for facilitate the delivery, and this gives you strength and soothes you.

Another component of the theme of support is "guidance and giving explanation to the patient," which, according to the participants in this study, is an important and essential item of the spiritual needs of patients, to the extent that some of them confessed their own knowledge of religious and spiritual issues was insufficient and considered the establishment or full-time access to a religious advisor as one of the important tasks of medical institutions. Considering this issue, one of them stated that:

• We have come to the conclusion that there should be always a clergyman to provide religious advice to patients in the hospital because patients sometimes ask questions that we cannot answer, or are not concentrated enough to provide the correct answer.

Fifth Theme: Being Respected

Based on this theme, the participants emphasized the need for being good-natured, respectful and not questioning beliefs of the patient and considered it an aspect of the spiritual needs of the patient and believed that the nurse was obliged in any case to refrain from interfering his spiritual and religious beliefs and feelings with how to provide care for the patient, even if the patient's beliefs contradict his beliefs. One of the officials with a history of nursing wards stated, in the field of the necessity of having a good mood in his work environment, that:

• My work experience always leads me to treat patients with broad-mindedness and never allow that smile to disappear from my lips because these are really needy patients, they are painful, they have enough problems themselves, and my bitterness with them is a double cruelty.

One of the hospital's supervisors, who had a great deal of experience as a person in charge of medical and surgical wards, considering respecting different beliefs and not questioning the opinions of the patients, also said that:

• We, as the nurses of this hospital, respect the beliefs of patients and we do not care what trend of thought or beliefs they are holding. We don’t mind what religion they believe; Christian, Jewish, Zoroastrian, Muslim (Shiite or Sunni), all are our patients, and we do not allow ourselves to inquire on their beliefs, and we respect all of them, and we try to make professional duties. We do our best for them and do not judge their ideas.

Sixth Theme: paying attention to rites of the Ihtidar and death

The last theme obtained from this study is " paying attention to rites of the Ihtidar (when the person is about to die) and death" of patients, which, according to the opinion's participants, consists of two general categories of "readings" and "practical actions", So that they considered one of the major needs of dying Muslim patients is Talqīn , reading certain parts of the Qur'an such as Sura Yasin, some supplications that would facilitate death for them to die and saying Salawat on the bedside of the patients. Moreover, doing things like laying the patient's leg in the direction of Qibla as far as possible, giving Zamzam water to the patient and rubbing the soil of Karbala to his forehead and allowing companions to attend the patient's bedside at the last moments of their life and respecting the corpse made the patient and his family relaxed and helped his family better accept the loss of the patient. Considering this issue, one of the specialist nurses said that:

• Sometimes we ourselves read Sura Yasin on the bedside of the patient who is about to die. We say Talqīn and Salawat while performing resuscitation process. Sometimes the patients' companions bring Zamzam water or the soil of Karbala and ask us to put them on the patient's forehead and we do these things. Sometimes we allow the companions to enter and do these things for their dying patients.

And about the necessity of respecting the dignity of the muḥtaḍar and of a corpse, another participant asserted that:

• We must preserve the conditions of muḥtaḍar and remain respectful to them. We are even obliged to respect the corpse in the morgue and keep their dignity.

Discussion:

Nurses participating in this study referred to issues such as expressing opinions, paying attention to ritual of worship, respect for religious prohibitions, the need for support and being respected as manifestations of the spiritual needs of hospitalized patients, which have been recognized in other studies both inside and outside of Iran as a spiritual need for patients^18,20-22. Moreover, what is clearly evident in this study is the lack of disparity between participating nurses in spirituality and religion, so that they do not distinguish between the two concepts and considered both as synonyms. And their perception of spiritual issues was the implementation of religious practices and religious rituals and worship. This finding was also found in other studies on spirituality and spiritual care in Iran^18,21. In confirmation of this issue, Rasoul (2000) also asserted that: there is no spirituality without thoughts and religious practices ²³.

Another important that is derived from this research is that despite the urgent need of the Iranian community to receive spiritual care in health centers^21,24, this need has not been highlighted and met seriously and fundamentally by authorities, practitioners and even the personnel of these centers, including nurses, so they do not recognize the provision of spiritual care as a task, alongside their other tasks, and do not have a serious determination to provide formal and systematic care. Their limited and scattered responses to this need are also due to their own personal interests and beliefs, and they accomplish them despite their busy time and lack of time^24,25. Organizationally, the spiritual needs of patients and their companions are met in the hospital by doing such things as informing patients of the time of call to prayer, providing special tools for worship (Muhr and marble stone special for Tayammum, pitcher and washtub for ablutions of patients with motor limitation, a number of religious books [Quran, supplications (Mafatih al-jinan), and religious ordinances (Tawdih al-masa'il)], separating some sections or rooms for admission of male and female patients from one another, identifying the direction of the Qibla in the rooms of the sections using the arrows installed on the wall or ceiling of the room, making the public prayer room.

Another important finding of this research is the nurses' attention to the issues related to Ihtidar (when the person is about to die) of patients as one of the spiritual needs, that less attention was directed to them in other researches carried out in line with this research in Iran. Since among all Muslims, and based on the Qur'an teachings, death is not the end of human life, but the starting point of eternal life and his afterlife²⁶, and on the other hand the believer is of high dignity and personality, whether dead or alive. Therefore, the Muslim participants in this research considered the respect to the dying man, their corpse and their relatives as one of the spiritual needs of the Muslim patients and considered themselves obligated to do so. As they respect them during the life of humans, they should respect their patients and relatives while they are dying and after the death of the patient, and carry out the acts and rituals prescribed by the religious authorities for the dying patient; For example, they should lay the dying patient on his back as far as possible and stretch his legs towards the Qibla (the house of Ka'bah, located in the city of Mecca), keep incessantly silent as far as possible at the bedside, inculcate special incantations and read certain surahs of the Qur'an (Surah Yasin, Al-Saffat, Al-Ahzab, Al-Kursi Verse, The fifty forth verse of Surah al-A'raf and the last three verses of Surah al-Baqarā, and as far as the Qur'an is possible), Al-'Adila supplication and other special supplication for the dying moment at the bedside²⁷. And after the death of the patient, ask God for forgiveness for him, and give the survivors condolences.

Conclusion:

The results of this study can serve as a guide for policymakers, educational institutions, hospitals and health centers to design and incorporate spiritual education and spiritual care, alongside other routine programs in Iran, and for non-Muslim nurses outside Iran to help Muslim patients, especially the Shi'a Muslims, to care them, and help them understand their spiritual needs properly.

Acknowledgments

Acknowledgments: Our thanks go for Research Deputy in Jahrom University of Medical Sciences, whose financial support made this research feasible, and also for all colleagues, participants and authorities of Motahari and Peymaniya Jahrom hospitals.

References

1. Timmins F, Caldeira S. Understanding spirituality and spiritual care in nursing. Nurs Stand. 2017;31(22):50-7.

2. Bradshaw A. Teaching spiritual care to nurses: an alternative approach. International Journal of Palliative Nursing. 1997;3(1):51-7.

3. McSherry W. A descriptive survey of nurses’ perceptions of spirituality and spiritual care. Unpublished Master of Philosophy Thesis, The University of Hull, Hull. 1997.

4. Young EW. Spiritual health—an essential element in optimum health. Journal of American College Health. 1984;32(6):273-6.

5. Fisher JW, Francis LJ, Johnson P. Assessing spiritual health via four domains of spiritual wellbeing: The SH4DI. Pastoral psychology. 2000;49(2):133-45.

6. Baldacchino DR. Nursing competencies for spiritual care. Journal of clinical nursing. 2006;15(7):885-96.

7. Lavasani M, Keyvanzade M, Arjmand N. Spirituality, job stress, organizational commitment, and job satisfaction among nurses in Tehran. J Contemporary Psychology. 2008;3(2):61-73.

8. Pugh EJ, Smith S, Salter P. Offering spiritual support to dying patients and their families through a chaplaincy service. Nursing times. 2010;106(28):18-20.

9. Tirgari B, Iranmanesh S, Cheraghi MA, Arefi A. Meaning of spiritual care: Iranian nurses' experiences. Holistic nursing practice. 2013;27(4):199-206.

10. Fatemi MM, Nazari R, Safavi M, Naini MK, Savadpour MT. The Relationships between nurses’ spirituality and PATIENTS'SATISFACTION in the Hospitals of Ardabil University of Medical Science. Medical Ethics Journal. 2016;5(17):141-59.

11. Van Leeuwen R, Tiesinga LJ, Post D, Jochemsen H. Spiritual care: implications for nurses’ professional responsibility. Journal of clinical nursing. 2006;15(7):875-84.

12. Yousefi H, Abedi HA. Spiritual care in hospitalized patients. Iranian journal of nursing and midwifery research. 2011;16(1):125.

13. Chan MF. Factors affecting nursing staff in practising spiritual care. Journal of Clinical Nursing. 2010;19(15‐16):2128-36.

14. Vance DL. Nurses' attitudes towards spirituality and patient care. Medsurg Nursing. 2001;10(5):264.

15. Taylor EJ, Highfield M, Amenta M. Attitudes and beliefs regarding spiritual care. A survey of cancer nurses. Cancer Nursing. 1994;17(6):479-87.

16. Zand S, Rafie M. Assessing religious care needs of patients in hospital. Teb va Tazkye. 2010;19(4):21-34.

17. Habibi A, Savadpour MT. Spiritual Well-being in Cancer Patients under Chemotherapy. Journal of Health and Care. 2011;13(3):0-.

18. Karimollahi M, Abedi HA, Yousefy A. Spiritual needs as experienced by Muslim patients in Iran: A qualitative study. Annals of General Psychiatry. 2008;7(S1):S147.

19. Rahnama M, Fallahi Khoshknab M, Seyed Bagher Maddah S, Ahmadi F,. Cancer patients’ perception of spiritual care. Journal of medical ethics and history of medicine 2012;24(5):64-80.

20. Taylor EJ, Mamier I. Spiritual care nursing: what cancer patients and family caregivers want. Journal of advanced nursing. 2005;49(3):260-7.

21. Momennasab M, Moattari M, Abbaszade A, Shamshiri B. Spiritual experience of heart attack patients: A qualitative study. Journal of Qualitative Research in Health Sciences. 2013;1(4):284-97.

22. Mauk KL, Schmidt NA. Spiritual care in nursing practice: Lippincott Williams & Wilkins; 2004.

23. Rassool GH. The crescent and Islam: healing, nursing and the spiritual dimension. Some considerations towards an understanding of the Islamic perspectives on caring. Journal of advanced nursing. 2000;32(6):1476-84.

24. Abbas Zadeh A, Borhani F, Abbasi M. Spiritual health, a model for use in nursing. 2015. 2015;9(30):20.

25. ZARE A, JAHANDIDEH S. THE IMPACT OF SPECIAL WARDS NURSING SPIRITUAL WELL-BEING UPON PATIENTS’ SPIRITUAL CARE. IRANIAN JOURNAL OF NURSING RESEARCH 9(3):30-8.

26. wikishia. Barzakh [cited 2018 March 2]. Available from: http://en.wikishia.net/view/Barzakh.

27. Wikishia. Ihtidar [cited 2018 January 30]. Available from: http://en.wikishia.net/view/Ihtidar.