ANSWER
Nurses strive to provide all patients with holistic care, including spiritual care. However, nurses in crowded critical care units are frequently pushed to prioritize physical care over emotional and spiritual care. This study aimed to investigate how Palestinian nurses working in intensive care units (ICUs) perceive spirituality and the provision of spiritual care at the end of life. The author presents background studies to encourage a greater emphasis on spiritual care and describes the qualitative method used to study 13 ICU Gaza Strip nurses’ understanding of spiritual care in this article. The following themes emerged from the findings: the meaning of spirituality and spiritual care, identifying spiritual needs, and taking action to meet spiritual needs. The author discusses the difficulty nurses had in differentiating spiritual and religious needs, points out study limitations, and concludes by recommending that spiritual care be provided to all patients.
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Spirituality, spiritual care, spiritual needs, end-of-life care, spiritual understanding, ICU nurses, Palestine, Gaza Strip, religion, spirituality

Respecting, caring, loving, being fully present, and supporting one’s search for meaning are all aspects of spiritual care deeply embedded in nursing. Prolonging life may not be the ultimate goal of end-of-life care. Rather than providing a cure, goals may shift to caring, comforting, and alleviating pain (Institute of Medicine [IOM], 2015; Truog et al., 2008). As patients’ spiritual and religious concerns may be awakened or intensified near the end of life, this shift in goals results in an increased emphasis on other parameters of health, such as religion and spirituality (National Consensus Project for Quality Palliative Care, 2013; Lo et al., 2002). Spiritual care is now an integral part of holistic care in many countries, with increased emphasis on spirituality throughout the healthcare arena. A holistic approach to healthcare meets patients’ physical, social, emotional, and spiritual needs (Murphy & Walker, 2013). According to Taylor (2002), the process of providing spiritual care is an approach used to integrate all aspects of human beings. Respecting, caring, loving, being fully present, and supporting one’s search for meaning are all aspects of spiritual care, which is deeply embedded in nursing (Taylor, 2008).

In this article, I will present background studies that advocate for a greater emphasis on spiritual care and describe the qualitative method I used to investigate the understanding of spiritual care among 13 Intensive Care Unit (ICU) nurses in the Gaza Strip. The following themes emerged from my findings: the meaning of spirituality and spiritual care, identifying spiritual needs, and taking action to meet spiritual needs. I will also discuss the difficulty nurses had in differentiating spiritual and religious needs, share the types of spiritual care provided by these nurses, discuss the study’s limitations, and conclude by recommending that spiritual care be provided to all patients.

Background
There is mounting evidence that spiritual care positively impacts patients coping with illness, improves the quality of life, and prevents illness… There is growing evidence that spiritual care improves patient coping with illness, increases the quality of life, and prevents illness (Molzahn, 2007; Nelson, Rosenfeld, Breitbart, & Galietta, 2002; Tarakeshwar et al., 2006); it also reduces depression and improves general health status and recovery (Bekelman et al., 2009). A few studies, however, have found that some patients experienced negative religious coping, in which they saw illness as a punishment from God. This negative religious coping has been linked to distress and harms the quality of life (Hills, Paice, Cameron, & Shott, 2005; Sherman, Simonton, Latif, Spohn, Tricot, 2005).

Patients may wish to discuss complex spiritual questions and needs with nurses during life-threatening situations. As a result, nurses who have direct contact with these vulnerable patients must be knowledgeable and prepared to answer questions from patients and families to meet their spiritual needs and address their concerns (Dhamani, Paul, & Olson, 2011). ICU nurses must be adaptable and capable of providing appropriate end-of-life care, which includes spiritual care (Beckstrand, Callister, & Kirchhoff, 2006).

Patients may wish to discuss complex spiritual questions and needs with nurses during life-threatening situations. Despite being well-trained and knowledgeable in providing physical and curative care, many ICU nurses believe they must prepare for appropriate end-of-life care (Ciccarello, 2003; Shannon, 2001). Because the Palestinian healthcare system lacks spiritual health policies, providing spiritual care still needs to be fully understood. This study aimed to discover how Palestinian ICU nurses perceive spirituality and the provision of spiritual care at the end of life.

Method
The interpretive-descriptive approach was used in this qualitative study to answer specific questions about practical aspects of nursing or any specific phenomenon (Thorne, 2008; Thorne, Kirkham, & O’Flynn-Magee, 2004). Participants in this study included registered nurses recruited face-to-face in the ICUs of two major hospitals in Gaza, Palestine, by the researcher. The first hospital had 740 beds, 12 of which were intensive care units (ICUs) and 24 ICU nurses. The second hospital had 240 beds, including 12 intensive care units and 18 ICU nurses. The Gaza Strip has five intensive care units (ICUs) with 39 beds and 89 ICU nurses.

The nurses had to have at least one year of experience in intensive care nursing and be directly involved in clinical practice, caring for patients at the end of their lives during their ICU careers. In addition, recruited nurses must demonstrate a willingness to articulate and share their thoughts and experiences with spirituality and spiritual care.

Nineteen nurses across the two units met the criteria. Thirteen nurses agreed to participate in the study (five females and eight males). The ages of the participants ranged from 26 to 47 years, with a mean of 34.3 years. Working experience ranged from 3 to 22 years, while ICU nurse experience ranged from 2.5 to 20 years. Three participants held master’s degrees, while the rest held baccalaureate degrees in nursing. All nurses provided end-of-life care and were eager to express and share their experiences with spiritual care at the end of life. All nurses were Muslims, which corresponded to their society’s religion (the great majority of people living in the Gaza Strip are Muslims).

The Gaza Ministry of Health provided ethical approval prior to data collection. The study’s protocol was explained to all study participants. Each participant provided informed written consent. Data were gathered through in-depth, face-to-face, semi-structured interviews that followed a pre-planned guide. Participants’ responses to open-ended questions about their experiences with spiritual care and spirituality were elicited. Among the questions asked during the interview were:

Please tell me about your knowledge of spirituality and spiritual care and how you define each.
How do you identify your patients’ spiritual needs?
What steps do you take to meet your patient’s spiritual needs?
The researcher interviewed each participant in private. After obtaining permission from each participant, I audiotaped the interviews. The duration of the interviews ranged from 35 to 50 minutes. Before the interview, each nurse filled out an information form with demographic information such as gender, age, level of education, and experience.

Data collection and analysis took place at the same time. I listened to the audiotaped interviews several times and transcribed them verbatim. Interview transcripts were read several times to gain a better understanding of the study phenomenon on multiple levels (Creswell, 2003). The researcher coded data and organized the participants’ sentences and paragraphs with similar properties into different categories while reading the transcripts.

To ensure rigour and avoid bias in qualitative studies, at least two experts should read each interview, each identifying themes based on the data (Cohen & Crabtree, 2008; Polit & Beck, 2004). Experts then debate the findings until they reach an agreement on the themes. I asked two qualitative research nurses to listen to the interviews and extract the main themes of the study. Following that, we met to discuss the extracted themes until we agreed on the study’s main themes. We extracted three main themes from this data thanks to the coding process: the meaning of spirituality, spiritual care, identifying spiritual needs, and taking action to meet spiritual needs.

Findings
The Figure depicts the three themes identified during our analysis. This section will go over each theme one by one. To protect the participants’ confidentiality, I identified participant quotes using pseudonyms. Using pseudonyms is common in qualitative research because it presents rich, detailed data while maintaining respondent anonymity and confidentiality (Kaiser, 2009).

Figure: Themes for Research

Perception and Practice of Spiritual Care at the End of Life by Palestinian ICU Nurses

Spiritual Meaning, Spiritual Care

For most participants, the concepts of spirituality and spiritual care were not distinguished; both were difficult to define. For most participants, the concepts of spirituality and spiritual care were not distinguished; both were difficult to define. Hassan, one of the participants, stated, “I’m not sure what was meant by spiritual care. Consider the religious needs of the patients, in my opinion.”

Although those who attempted to define the two concepts did not reach a consensus, most of them defined spirituality and spiritual care in terms of religion and religious healing practices. Most participants defined spiritual care as incorporating religious practices or beliefs into their daily delivery of holistic nursing care. “Spirituality is religion,” Samia says, and “spiritual care involves using religious practices to help our patients get better.”

Similarly, Hani acknowledged that he could not precisely define spirituality, noting:

Spirituality, to me, is believing in Allah (God). Spiritual care includes religiosity, belief in Allah, and religious practices in our care. We must link the issue of illness and wellness to our fate… Allah is the source of everything. Regardless of their condition, we must constantly remind our patients to thank Allah for everything.

Hani’s words demonstrate the close relationship between spiritual care and religion. Others attempted to define spiritual care as well. In his own words, Ahmmed attempted to define spiritual care as follows:

During illness, each of us is frail and vulnerable. Treatment entails more than just taking drugs… The true cure is in the hands of Allah. As a result, we encourage our patients and their families to worship and pray to Allah to get closer to Him. We encourage them to recite the Quran more frequently and to maintain their faith and trust in Allah, as this (the state of illness) is their fate and accepting it is part of our religion. This, I believe, is spiritual care, and it benefits our patients and improves their health.

Hala attempted to define spirituality. She described spirituality in this way after admitting that it was not easy:

Our religion adequately addresses spirituality in all of its facets. Our society is predominantly religious, and religiosity rises during illness… While caring for such patients, we increase the use of Holy Quran verses and religious terms. We try to remind our patients about Al-Shahadateen (confessing that there is no God but Allah and that Mohammed is his Messenger). We believe and have observed that this helps to relax and comfort our patients.

Most participants defined spiritual care as incorporating religious practices or beliefs into their daily delivery of holistic nursing care. Hala described some religious practices she employs to meet the spiritual needs of her patients.

Other participants described spiritual care as an additional intervention and physical care. In fact, some people confused spiritual care with emotional or psychological care, believing that they were interchangeable. Samira, for example, defined it as “care that touches the soul or inner part of our clients,” as well as “care that gives people worth and gives them hope and positivity about themselves.”

Identifying Spiritual Requirements

Communication with patients and family members, patients’ health status and diagnosis, close observation of the environment, and direct expression of feelings were identified as methods of recognizing patients’ spiritual needs. Each of these is discussed in greater detail below.

Communication with patients and their families. Participants stated that they could tell which patients require spiritual care during their interactions. “It is good to know about your patients’ religiosity before beginning to provide spiritual care,” Samira said. Hothifa added that some patients or their families provide hints about the patient’s religious importance:

When a family member tells you that the patient used to pray five times a day in the mosque and read an entire chapter of the Holy Quran daily, you know that this patient is religious and will need spiritual fulfilment.

Hothifa’s words show how nurses can assess spiritual needs by speaking with patients and family members.

Patient’s health status and diagnosis. Other nurses stated that, based on their experience, patients’ diagnoses and health status reflect the need for spiritual care. Sawsan stated, “We can tell which patients require spiritual care based on our experience. Patients with terminal illnesses, such as terminal cancer, and those nearing the end of their lives, require more spiritual care than others.” Nazmi revealed:

Patients who have been hospitalized for an extended period or are terminally ill or dying are good indicators of the need for spiritual care… When there is no hope and death is near, spiritual care is even more important. At this time, I believe this patient requires me to sit and talk with him or her. Perhaps this is all he/she wants me to do at times.

Nazmi recognizes the importance of spiritual care at the end of life in this quote.

Scrutiny of the surroundings. Many participants believed that paying close attention to their patients’ words, and expressions made them more aware of their spiritual needs. Sami stated:

One of my patients who could not speak at the time was moving his right fourth finger. I knew he was attempting to say Al-tasahod (part of Muslim prayers). I immediately turned his bed to face Mecca (a city in Saudi Arabia where Muslims turn their faces during prayers) and began to say Al-tashahod. I could tell by his expression that he was pleased with what I had done, and I could see him trying to repeat Al-tashahod after me. This made me happy as well.

This quote by Sami emphasizes the importance of nurses closely observing patients’ behaviour in order to meet their needs. Nahla described her experience as follows:

During one of my late-night shifts… One of my patients was crying, and I noticed. I held her hand and tried to figure out why she was crying, but she just kept crying. I could tell she was scared of something. I sat next to her and held her hands for a few minutes. I read several verses from the Holy Quran until she stopped.

Nahla’s words demonstrate how a nurse can interpret her patients’ behaviour and take appropriate actions to meet her needs.

Feelings are expressed directly. Some participants mentioned that some patients or family members express their need for spiritual care. As Sami stated, “Some patients expressly request that we pray for them. When they believe there is no hope of healing, they ask us to pray for them to die peacefully and without pain and suffering.” Similarly, Hassan stated:

You can tell when your patients require spiritual care… Some of them request that we pray for them, while others request that we recite the Quran or play a cassette player with the Quran next to them. Some patients cannot communicate points to the Quran, and you recognize what he or she requires.

As a result, patients may express their spiritual needs to their nurses verbally or nonverbally in some cases.

Taking Steps to Address Spiritual Needs

Nurses… will shift the goal of curing to the goal of comforting if they believe the treatment is futile and will not improve the patient’s condition. Nurses who participated in this study stated that when they believe the treatment is futile and will not improve the patient’s condition, they will shift their focus from curing to comforting. They will do everything possible to provide measures that will aid in the comfort of their patients. They also become more sensitive to the patients’ and their family members’ psychological and spiritual needs. Hala described how this could happen:

When the unit is not busy, we spend more time with them, just listening or holding their hands. We let family members stay for extended periods. I believe that the hospital should provide TVs for religiously conscious patients so they can watch religious programs and listen to the Quran.

Nurses also stated that at the end of life, they would allow family members to visit more frequently and spend more time with the patient. Hani stated:

When the ICU is not overcrowded, we allow family members to visit more frequently and for longer periods. Sometimes, when it is extremely quiet in the ICU, particularly during the night shift, we allow one family member to remain beside the patient. I believe this is critical for both the patient and the family. The patient will have the impression that someone was there for him/her when he/she needed them, to hold his/her hand and let him/her know that he/she is not alone. They would feel they had done something worthwhile for their loved ones.

Both quotes show how nurses’ goals shift from curing to caring and how they meet patients’ spiritual needs at the end of life.

Participants stated that family members would be allowed to bring a cassette player or MP3 player to recite the Quran to the patient. Hothaifa mentioned:

We allowed the family to bring in a cassette player or similar device and play Quran next to the patient. We allow family members to stay with the patient for extended periods, and some recite verses from the Holy Quran to him. We do this, especially when we believe the patient’s condition is deteriorating. When I have time, I will recite some verses from the Holy Quran and allow the patient to hear my voice, even if he or she is unconscious.

Hothaifa emphasized the role of religion in meeting their patients’ spiritual needs. Nurses may sometimes provide more care to the patient because they feel more responsible for this patient and make extra efforts to comfort him/her. Zaki described how this could be accomplished:

In terms of end-of-life care, we treat all patients on the same level, particularly in terms of hygiene. It is our responsibility to keep him/her clean at all times. This is our responsibility and a part of our religion. We make no distinction between patients nearing the end of their lives and other patients. Even if our clients are unconscious, we speak to them while providing physical care. We know they can hear us. We constantly remind them to remember Allah. We tell them Allah loves them, cares about them, and looks out for their best interests.

Nurses recognized that, despite the hectic nature of the ICU, they could still provide spiritual care to their patients while also providing physical care.

Some nurses reminded their patients and assisted them in preparing for their prayers by washing their body parts. According to Hothaifa:

We remind our patients about prayer, one of Islam’s five pillars. When an Imam (clergyman) visited the unit, he told us that we needed to remind the patients to pray because every Muslim is required to pray unless he or she is unconscious. When we do this, we feel good about ourselves and like we have done something useful for our clients.

This quote exemplifies the intertwining of religion and spiritual care once more. To emphasize the importance of prayers in spirituality, Sa’id added the following remarks:

Patients’ faith and spirituality are strengthened through prayer. It promotes inner peace and harmony between the soul and the body. It calms and reassures the patient, keeping him or her at ease. It makes patients feel better.

This quote reflects nurses’ beliefs about spiritual care and how it can help patients.

They not only assist their patients in praying, but they also pray for them most of the time. Zaki remarked, “At this time, our role shifts to provide more spiritual care. During my own prayers, I usually pray for my patients.”

Discussion
This study’s findings were consistent with the literature. Many participants in comparable studies needed help defining spirituality and spiritual care. Similar to the findings of this study, McSherry and Jamieson (2011) discovered some uncertainty about spirituality and spiritual care among participant nurses in their study. Indeed, many authors, scholars, and experts in the field found it difficult to define spirituality. Several stated that defining these terms was difficult (Lemmer, 2005); they described it as attempting to define something mystical and intangible (Sawatzky & Pesut, 2005).

Some authors have described spirituality as an elusive and difficult-to-define concept (Narayanasamy et al., 2004). According to McSherry and Jamieson, Spirituality is “an umbrella term because, underneath the word, there is a wide range of individual meanings, associations, and interpretations that individuals may use to define and articulate understanding” (2011, p. 1761). The numerous definitions of spirituality in the literature reflect the difficulty in defining this term. Rufener commented on the abundance of definitions in the literature, saying that “…the varying content of these definitions can be a source of confusion to nurses as they address components of spirituality assessment, intervention, and evaluation.” ” (2011, p.5).

Confusion was evident in the attempts of nurses who took part in this study to combine spirituality and religion. They neglected to include several other components of spirituality and spiritual care in their definitions, such as respect, caring, loving, being fully present and supporting one’s search for meaning (Taylor, 2008). This is not surprising given that the vast majority of people in Gaza are Muslims, and part of Islamic doctrine is to believe in Allah and fate. Our participants’ responses are consistent with many studies and definitions in that they perceived spirituality as synonymous with religion, frequently using these terms interchangeably (McBrien, 2010; Swinton, 2001). Participants in other studies perceived religious practices and beliefs as the core principles of spirituality and spiritual care (Davis, 2006; Dhamani et al., 2011; McSherry & Jamieson, 2011).

…identifying patients’ spiritual needs at the end of life frequently relied on nurses’ observations and patients’ or their families’ implicit or explicit communications.

According to the data analysis and examples shared by participants, identifying patients’ spiritual needs at the end of life often relied on nurses’ observations and patients’ or their families’ implicit or explicit communications. Our participants reported that talking to patients and their families, listening to them, and observing their surroundings aided them in identifying patients’ spiritual needs. These study participants’ strategies were similar to those reported in the literature (Anderson, 2006; Dhamani et al., 2006).

Spiritual interventions identified and offered by participants in this study were primarily based on religious practices, with a few non-religious interventions thrown in for good measure. Examples of religious-based interventions include praying for the patients, preparing and assisting conscious patients in performing their daily prayer, allowing a family member to recite Quran besides the patient, and allowing visitors to bring in a cassette player or MP3 player into the unit so the patient could listen to the Holy Quran. Allowing more visits, allowing family members to stay longer, and sometimes allowing a family member to stay beside the patient overnight are examples of non-religious interventions. These findings are generally consistent with the literature on spiritual care practices that include religious components (Anderson, 2006; Dhamani et al., 2011; Mahlungulu & Uys, 2004; McSherry, 2007).

According to the literature, praying in health-related situations can promote health and a sense of hope during critical times and crises (Doucet & Rovers, 2010). Salman and Zoucha (2010) say praying brings people closer to God (Allah, for Muslims). Such closeness to Allah during difficult times can reduce the likelihood of developing anxiety, depression, and helplessness. In addition to praying, nurses said they assisted or participated in reciting the Holy Quran to their patients. The literature supports such interventions. Several authors described Holy Scripture reading as a source of spiritual comfort and reassurance for patients (Grundmann & Truemper, 2004; Salman & Zoucha, 2010; Schmidt & Mauk, 2004).

Participants mentioned other interventions such as listening, holding patients’ hands, praying for them, and expressing respect to patients and their families. Such interventions demonstrate nurses’ love and respect for their patients. They can help to foster a sense of connectedness among nurses, patients, and family members, positively contributing to patients’ and family members’ sense of comfort (Galek, Flannelly, Vane, & Galek, 2005). Some authors (Puchalski, 2001) have advised nurses to be compassionate and available to patients, as well as to listen to them. She went on to say that compassion and listening skills are required in order to provide spiritual care.

Limitations
There are a few limitations to this study that should be mentioned. For starters, the study only included Muslim nurses and patients. As a result, the results cannot be assumed to apply to other populations. It would be interesting to study people of other religions to see if nurses of other faiths identify the same themes. The religious belief system itself may influence other participants’ thinking. Second, because the meanings of the terms spirituality and spiritual care are ambiguous, assessing these concepts took time and effort. The assessment of these terms was based on face-to-face interviews with participants; thus, participants’ lack of anonymity when sharing their thoughts and experiences may have influenced their responses. Furthermore, data collection took a relatively long time because interviews could only sometimes be conducted on time. Interviews were cancelled and rescheduled several times because participants were extremely busy providing critical care to their ICU patients and could not leave their bedside in this busy environment.

Conclusion
Nurses used communication and observation to identify patients’ spiritual needs and provide appropriate care.
This study shed light on how Palestinian ICU nurses understand and practice end-of-life spiritual care. It was not easy to define the terms spirituality and spiritual care. As in previous studies, most participants defined them in terms of religion. Most participants were involved in spiritual care for their patients and family members. The majority of spiritual care provided was based on religious beliefs and practices, demonstrating the importance of religion in healthcare provision. Nurses used communication as well as observation to identify patients’ spiritual needs and provide appropriate spiritual care.

This research is an initial step toward better understanding how Palestinian ICU nurses describe spirituality and spiritual care interventions. More research is needed to explain the spiritual needs of patients with various diagnoses, identify spiritual needs for different groups of patients, investigate how often spiritual care is provided in healthcare settings, identify barriers to providing spiritual care, and learn how healthcare providers can overcome barriers to providing appropriate spiritual care to their patients. The findings of this study and future studies will help guide new interventions and health policies that can improve nursing practice in Palestine and around the world.
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The use of spirituality in nursing practice is not new. However, it is more studied and utilized in a more structured format in nursing. Identify and discuss tools used to evaluate spirituality. Please include 400 words in your initial post with two scholarly articles