International Journal of

Environmental Research
and Public Health

Article
Spirituality in Patients at the End of Life—Is It Necessary?
A Qualitative Approach to the Protagonists
E. Begoña García-Navarro 1,2,3, * , Alicia Medina-Ortega 1 and Sonia García Navarro 1,3,4
1 Nursing Department, University of Huelva, 21007 Huelva, Spain; [email protected] (A.M.-O.);
[email protected] (S.G.N.)
2 Social Studies and Social Intervention Research Center (ESEIS), Contemporary Thinking and Innovation for
Social Development Research Center (COIDESO), Faculty of Nursing, University of Huelva,
21007 Huelva, Spain
3 Coping In the End of Life Reseach Center (AFLV), INVESTIGA+, Junta de Andalucía, 41008 Sevilla, Spain
4 United Clinical Management (U.G.C. Los Rosales), Distrito Huelva-Costa-Condado-Campiña,
21007 Huelva, Spain
* Correspondence: [email protected]

Abstract: Spirituality is the most unknown aspect of palliative care despite being the need that is
most altered in the last moments of life. Objective. To identify on the one hand the spiritual needs of
patients who are at the end of life and on the other hand, the way in which nursing professionals can
work to provide effective accompaniment in this process. Method. A qualitative study was conducted
which applied different data collection techniques. This was done to describe the phenomenon
from a holistic perspective in relation to experts’ perceptions of the competencies required by health
professionals and palliative patients’ spiritual needs. Semi-structured interviews were conducted
within both populations. In order to analyze the qualitative data collected through interviews,





 discourse was analyzed according to the Taylor–Bodgan model and processed using Atlas.ti software.
Citation: García-Navarro, E.B.;
Results. Three well-differentiated lines of argument are extracted from the discourse in each of
Medina-Ortega, A.; García Navarro, the groups, on the one hand in the group of patients they define the concept of spirituality, system
S. Spirituality in Patients at the End of values and beliefs, and the Factors that influence the spirituality of patients at the end of life
of Life—Is It Necessary? A (differentiating palliative care areas/other areas) and on the other, the professionals agree with the
Qualitative Approach to the patients in the line of argument of concept of spirituality although they define more metaphysical
Protagonists. Int. J. Environ. Res. categories and the other two lines of argument that result are the spiritual attention in this process
Public Health 2022, 19, 227. https:// and the need for formation in spirituality. Conclusions. The provision of spiritual care gives meaning
doi.org/10.3390/ijerph19010227 to the actions of nursing professionals when it comes to providing end-of-life care, achieving holistic
Academic Editors: Richard Gray, care, humanizing death, and promoting a dignified end.
Sonia Udod and Paul B. Tchounwou
Keywords: spirituality; palliative care; nursing skills; end-of-life
Received: 11 November 2021
Accepted: 24 December 2021
Published: 26 December 2021

Publisher’s Note: MDPI stays neutral 1. Introduction

with regard to jurisdictional claims in
In a first approach to the word Spirituality, it is necessary to mention that it comes from
published maps and institutional affil-
the Latin spirit, which means breathing, vitality. If this concept is related to the word Alma,
iations.
in Latin anima, it means the capacity for transcendence [1]. A more contemporary definition
is described by Mytko and Knight [2] as a set of feelings that lead the individual to connect
with himself, with others, with the purpose of life or with nature in search of value and
Copyright: © 2021 by the authors.
meaning, to find peace and harmony. These authors mention the difference between the
Licensee MDPI, Basel, Switzerland. constructs of Spirituality and Religiosity, indicating that they are not exclusive of each
This article is an open access article other, that they can overlap or exist separately, as long as, carefully, they are categorized
distributed under the terms and and interpreted. Under this same conceptual line, Puchalski describes spirituality as the
conditions of the Creative Commons aspect of the human condition that refers to the way in which individuals seek and express
Attribution (CC BY) license (https:// meaning and purpose, as well as the way in which they express a state of connection
creativecommons.org/licenses/by/ with the moment, with oneself (self), with others, with nature and with the significant or
4.0/). Sacred [3].

Int. J. Environ. Res. Public Health 2022, 19, 227. https://doi.org/10.3390/ijerph19010227 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2022, 19, 227 2 of 13

The appreciation of the spiritual dimension and the inclusion of professionals trained
in palliative and spiritual care capable of listening to fears and pain providing hope and
recognition to terminally ill patients are the basis of spiritual care models. This model
of care has its foundations in the biopsychosocial–spiritual model of care [4] and the
patient-centered model of care [5].
Spirituality is the least understood aspect of end-of-life care despite, surprisingly,
being the most altered need in this process. Spirituality is a priority in the fundamental
objectives of palliative care work. Palliative care focuses on improving the patient’s quality
of life, and this cannot be favored as a whole if the spiritual dimension is not addressed [6].
In the words of Stanislav Grof: “Spiritual development is an evolutionary capacity that is innate
to all human beings”. It describes an impulse towards totality and the discovery of one’s true
potential [7]. It is as common and natural as birth, physical growth, and death, being an
integral part of our existence. It is a classic concept, in the same way as the concept of human
beings and their fear of facing death and the search for vital meaning. This means that,
at the end-of-life, this fear and anguish grows exponentially making spiritual care hugely
important for terminally ill patients [8]. For patients in palliative circumstances, spirituality
is considered as a driving force to provide an optimal response to the circumstances of
these individuals in relation to their own existence. “The practice of spirituality is also seen
as an agent for the transformation and regulation of emotions, with this representing an
effective tool for reducing levels of depression and anxiety in those who find themselves in
the final stages of life” [9].
A high percentage of hospitalized patients are faced with emotions such as anguish,
fear, depression, anger, dissatisfaction, etc., which are emotions with a high emotional and
spiritual load. Nursing must care for these emotions [6]. According to studies conducted
by Silvia Caldeira, “spiritual anguish is defined as a state of suffering which is related with a lack
of meaning in life” [10]. In order to tackle this diagnostic, spiritual care must be provided
by nursing professionals. This care should consider the way in which professionals are
and act with both patients and their families. It should, therefore, be perceived as a holistic
dimension of palliative care which preserves dignity and facilitates patients in their search
for vital meaning and the relief of suffering [8].
It should be recognized that this sphere is a competence which must come, not only
from psychology professionals belonging to the palliative care team but, also, from within
the entire multidisciplinary team [11]. Different studies show that the nursing plays an
important role at the time of facing death. Facing death appropriately poses the need to
know the best way to act when faced with situations which generate great suffering and
anxiety. This is the case as much for the individual living the end-of-life process, as for the
professionals accompanying them and conditions their approach to providing care fitted to
patient needs. An appropriate approach helps patients have a good death [10–12].
At its heart, all nursing care provision is based on spirituality as it is guided by
hope, compassion and the conviction that an individual’s life remains full of possibilities,
even though it is limited in certain aspects [12,13]. Nonetheless, some challenges are
encountered in real life. Indeed, despite spiritual care being an integral part of nursing
care, it’s provision is highly diverse and can be influenced by the individual, cultural, and
educational background of each nurse [13]. In the same way, a number of prejudices with
regards to nursing are found in the healthcare system. Nurses have been judged to have
underestimated the spiritual dimension in care and various factors have been proposed to
explain this limitation. These factors include a lack of awareness of its importance and a
lack of preparation, incorrect interpretation of the term spirituality, lack of desire to provide
spiritual care. However, different systematic reviews have served to demonstrate [8–14]
that in the nursing setting, nurses demonstrate an understanding of spiritual and religious
care that is in tune with the construct that is advocated in the present day as much in the
current Spanish setting as in Europe and the United States. Professionals have also indicated
that patients serve as a mirror of their own mortality and, when health workers are open
to listening and sharing anguish, they are able to understand the process gone through
Int. J. Environ. Res. Public Health 2022, 19, 227 3 of 13

by patients and facilitate the search for making sense of the illness itself. Nevertheless,
professionals who are not able to face up to their own problems with regards to death
will find it even more difficult to face up to the death of another person and with seek
to distance themselves from it [15]. The attitudes of nurses towards this type of care is
favorable, although a need to raise awareness of specific related care responsibilities is
detected. Training relating to some aspects of intervention needs to be completed [16].
With the development of the study we propose on the one hand to identify the spiritual
needs of patients in a situation of terminality through their discourse and on the other,
by the hand of experts in palliative care, to know what professional skills are decisive to
respond to the needs of patients at the end of life. In this way, the foundations would be
laid for future lines of research aimed at establishing proposals for improvement based
on evidence.

2. Materials and Methods

A qualitative design and phenomenological approach was followed through content
analysis as described by Taylor and Bodgan [17]. We have used this methodology since
it allows us to know the emic of the participants, that is, to understand the perception
of people, as well as feelings and thoughts, from their testimonies, full of meanings,
symbols, intentions, motives, and beliefs. Esta investigación se adhiere a las directrices del
COREQ [18].
In order to respond to the proposed objectives, we address two populations. On
the one hand, we selected palliative patients belonging to care support groups in the
municipality and on the other hand we selected expert professionals that worked in in end-
of-life processes in the same geographical setting. The sampling strategy was theoretical
sampling, a technique that was developed by Glaser and Strauss [19] and where the sample
is selected through the use of a successive strategy, progressive incorporation of informants,
and evidence of similar studies, coinciding in a total of 10 expert professionals. However, in
the group of patients, given the difficulties of accessibility to palliative patients voluntarily
reported to be informants, the snowball sampling technique was used [20], we were able to
reach 7 patients who behaved in a heterogeneous sample, and given their generosity and
need for expression we managed to saturate in each of the dimensions found.
Intentional sampling was carried out during the months from May to November
2020. The sample size was determined progressively during the course of the research
incorporating informants until the saturation of the information was reached [21]. In
other words, research activities were continued until no new data pertaining to thematic
categories could be extracted. In order to be considered for inclusion, this patient group
had to comply with the criteria of belonging to the municipality under study, being of adult
age, having been informed of their diagnosis and prognosis, having been informed about
the process to be undergone, and, finally, having signed an informed consent form. In the
case of expert professionals in end-of-life processes, once relevant individuals agreed to
participate, the only criterion was that they provided written informed consent.
In order to analyze the discourse obtained in the interviews, the model described by
Taylor–Bodgan [17] (Table 1).
The research team meets to obtain the script of the interviews and we carried out a pilot
test with a professor and a collaborating student. Subsequently, the principal investigator
conducted in-depth interviews with the aim of further exploring some of the dimensions
that had emerged in the first interviews and thus obtaining more data.
Interviews were recorded and transcribed. The research team listened to and read the
interviews in order to make an initial superficial interpretation. This provided a general
idea which supported a more in-depth analysis (identification of relevant recurring themes,
search for similarities and differences between themes in order to develop codes-dimensions
and, with these, thematic categories. The repetition of codes—dimensions—on behalf of
researchers—blind analysis—indicated that the analysis got to the essence and exposed the
meaning of the studied phenomenon).
Int. J. Environ. Res. Public Health 2022, 19, 227 4 of 13

Table 1. In-process analysis approach in qualitative research (Talor–Bogdan).

Stage Action

1. Read the data repeatedly

2. Keep track of themes, insights, interpretations and ideas
3. Look for emerging topics
Discovery 4. Build topologies
(search for topics by browsing the data in every possible way) 5. Develop concepts and theoretical propositions
6. Read the bibliographic material
7. Develop a history guide

• Develop coding categories

• Encode all data
Coding • Separate the data belonging to the various coding
(meeting and analysis of all the data that refer to themes, ideas, categories
concepts, interpretations and propositions) • See what data has been left
• Refine your analysis

1. Requested o unsolicited data

2. Observer influence on stage
3. Who was there? (differences between what people say and
Data revitalization do when are alone and when there are others in the place)
(interpret them in the context in which/where they were 4. Direct and indirect data
collected) 5. Source (distinguishing between the perspective of a single
person and that of a larger group
6. Our own assumption (critical self reflection)

The two study populations were made up of patients and expert professionals in
end-of-life processes. In order to ensure validity and reliability, the entire process of coding
and analyzing discourse was conducted independently by three members of the research
team. Discrepancies were discussed until consensus was reached.
The study was conducted according to the guidelines of the Declaration of Helsinki,
and approved by the Ethics Committee PPEIBA, government of Andalusia, Spain (protocol
code 01/2020 CEPP and date of approval 18 January 2020).

3. Results
3.1. Participant Characteristics
Seventeen informants were interviewed. This included seven patients, of both sexes
and with different illness progression states, undergoing palliative processes. This also
included ten end-of-life expert professionals, these were representative in terms of age,
gender, and years of experience in the field (Table 2).
The coding of discourse from interview transcripts produced 27 different codes. Of
these, 17 were generated in the patient group and 10 in the expert population. This basis
was developed using the data management program Atlas.ti. In consideration of the
repetition of utterances in relation to each code, six lines of argument emerged which
were equally distributed within both population groups, suggesting that the concept of
spiritually coincided in each population (Table 3).

3.2. Lines of Argument

Line of argument 1 (patient group), coincides with line of argument 4 (professional
expert group) with regards to the concept of spirituality. This agreement is not so much
seen in the content overall, which is understandable given existing differences between
both populations, but in reference to the search for the meaning of life as a cornerstone of
spirituality (Table 4).
Int. J. Environ. Res. Public Health 2022, 19, 227 5 of 13

Considering further the idea of individual projection used by the palliative patient
group to discuss spirituality relative to end-of-life processes, a code emerges which reached
saturation very quickly. This code referred to connecting with others in order to give
meaning to the processes. Selected patients also added accompaniment and communication
to this concept.

Table 2. Sociodemographic characteristics of those interviewed.

Disease Evolution
Participant Patient/Professional Age Palliative Care Experience Sex
(Years)
Participant 1 Palliative Patient 74 4 Female
Participant 2 Palliative Patient 78 2 Male
Participant 3 Palliative Patient 45 0 Male
Participant 4 Palliative Patient 64 6 Female
Participant 5 Palliative Patient 69 3 Female
Participant 6 Palliative Patient 51 4 Female
Participant 7 Palliative Patient 60 3 Female
Nursing
Participant 8 53 17 Female
Professional
Academic
Participant 9 47 17 Female
Professional
Nursing
Participant 10 60 28 Female
Professional
Nursing
Participant 11 49 24 Female
Professional
Nursing
Participant 12 56 28 Female
Professional
Nursing
Participant 13 55 24 Male
Professional
Academic
Participant 14 34 10 Female
Professional
Nursing
Participant 15 41 16 Female
Professional
Nursing
Participant 16 48 22 Female
Professional
Nursing
Participant 17 56 26 Male
Professional

“I am really well attended to by all of my family. My sister-in-law comes every other day
to see me and asks me many questions. I am grateful to my wife for all of the help and
love that she is giving me, and of course for caring for me completely. I feel really loved
by the people who are around me, they really go out of their way”.
(Patient Palliative 02)
“I tell my daughter not to suffer because of me, that she has to live he r life. My daughter
gets scared a lot because she thinks that I am going to bleed out and I have to cheer
her up”.
(Patient Palliative 04)
Int. J. Environ. Res. Public Health 2022, 19, 227 6 of 13

Table 3. Origin of study categories and subcategories according to population group.

Work Scientific Emerging

Study Population Line of Argument Categories
Experience Evidence Discourse
Meaning of life * *
Concept of spirituality Connection with others * *
Hope *
Patient’s system of values and
* *
beliefs
System of values and beliefs
System of values and linked with religion and *
beliefs metaphysical phenomenon
Spirituality in end-of-life care * *
Spirituality in society *
Palliative care
patient Worries/concerns * *
Conflict *
Coping strategies *
Social support * *
Factors that influence Sense of security * *
the spirituality of Proximity to death *
patients at the end of life
Feelings of despair *
Pain * *
Fear of suffering * *
Body image *
Family background *
Spirituality * *
Concept of spirituality
Evolution of spirituality *
Spirituality in clinical care * *
End-of-life Spiritual care Spirituality in palliative care
processes: *
units
Professional
Need for spirituality training * *
Training needs Degree training *
pertaining to spirituality
Postgraduate training *
Personal experience *
Tools to evaluate patients’
*
spiritual needs
The * symbol indicates that each category described has been generated in the different techniques shown in the
column headings: Work Experience, Scientific Evidence y Emerging Discourse.

Turning attention back to the patient group, a second line of argument is found
which was called as system of values and beliefs, and was deemed to be fundamental
for understanding the spiritual end-of-life component. As with the other arguments
generated by this population, the intensity of this component meant that it was tightly
linked with the moment being lived at the time of data collection. Further, this line of
argument defined codes that were highly relevant to end-of-life accompaniment. On
the one hand, the system of values and beliefs emerged at a general level. On the other
hand, something more metaphysical was coded. It is important to highlight that all of the
discourse transcripts were coded as highlighting this component, with saturation occurring
prematurely following discussion of faith and religion.
Int. J. Environ. Res. Public Health 2022, 19, 227 7 of 13

“I believe so, the idea that there is someone and that I turn to them at certain times. I
believe in a higher being, accompaniment exists at certain moments. Yes at times when I
need them, when it gives me stability. But I am not practicing at all”.
(Patient Palliative 02)
Another dimension, linked with one’s belief system and, at the same time, spirituality, that
was generated by informants was hope.
“I when I lead a normal and acceptable life I feel super satisfied, I have learned to enjoy
the small things. Get up and do three things in my house, it’s the most wonderful thing
in the world to me, because maybe in the future I won’t be able to. I have hope again. I am
able to cling onto anything. With really small things, share time with others. I think that
that is really positive and it helps me a lot in these moments”.
(Patient Palliative 01)
The palliative patient population also coincided with the expert professional population
with regards to the need for palliative care to include attention to spirituality. Differences
emerged in patient discourse which pertained to the approach taken in palliative units and
in other units.
“In palliative patient they do it really well, because they approach that facet, they treat
your symptoms, but also your concerns”.
(Patient palliative 03)
The last line of argument generated from patient discourse, Line of argument 3, pertains
to the factors that influence patient spirituality at the end of life. This argument is charac-
terized by a large volume of emergent dimensions, with all being born out of service user
perceptions. Saturation was reached with regards to the need to address conflict (Table 5).
With regards to the expert professional group, we previously described a line of
argument that is in sync with another given by patients; however, another two arguments
stand out for revealing idiosyncrasies of this group. Namely, these are spiritual care and
training needs for effectively providing this care.
One of the subcategories underlying this first argument is spirituality in clinical
and spiritual care. Utterances gathered together in relation to this dimension came from
discourse that focused on a need that is currently not catered for, not even in palliative care.
“I’ll sum it up in a really simple way, if when the moment comes you are not capable of
standing 25 minutes of hugs and grief with a person in your arms, you’re not qualified.
We are used to working with the pain ladder and when one approaches on an existential
level the reality of a person who is dying they must be able to open up, to tremble with the
other and above all to look with them into the abyss, I think that it isn’t done well because
I think that we live with little awareness us professionals”.
(Professional expert 08)
“Because there isn’t the custom of talking about this, and less in those moments at the
end of life. For me it was much more difficult to do it at other services where there was
a lot of need because it wasn’t expected of me, in the palliative context it is. But there
isn’t any assessment of the life project, religious dimension, celebrations, last rites; rites
are really important to the spiritual dimension. It isn’t integrated as a part of the job.
Because there is a need to respond to what is expected of the nurse”
(Professional expert 02)
Int. J. Environ. Res. Public Health 2022, 19, 227 8 of 13

Table 4. Line of argument 1 patients: Concept of spirituality vs. line argument 4 Professional expert: Concept of spirituality.

Role
“It is the need that men and women have to transcend daily life, giving it meaning. The same with passions, that can be related with the
image of some type of God or specific ideas . . . that people can demonstrate solidarity with each other is nothing more than the most
EXP02
beautiful or wonderful branches of spirituality. It is a dimension that is within all human beings, and not only in each human being, but
also in every town”
Professional expert
Line of Argument 1 “Spirituality, which does not identify with a single unique divinity, is the expression of the essence of a person from where everything is
Vs. governed and finds value. A person who does not have spirituality bears a higher burden of internal defeat. They lack the foundations
EXP07
Line of Argument 4 and nutrients that help to interpret life . . . A society without spirituality is dead, it gets manipulated by whatever ideology regardless of
where it comes from. For this, mature spirituality leads individuals and society to be critical”
“I am very satisfied with the life I have led before the illness, and with the life I lead now. I go out, I don’t hide myself away at home. I
PPAL01
don’t ask for things I can’t do. I don’t have that feeling of “I could have done that and I didn’t do it”
Palliative Patients PPAL03 “I know everything I have, I don’t stop asking because I want to know how long I have left to live and how I am going to be up until I die”
“But I want to be awake up until the end if I don’t have strong pains. Until the end I want to see my children, my grandchildren, my
PPAL07
neighbors, my daughters-in-law. I wouldn’t like to lose my mind or say silly things”
Int. J. Environ. Res. Public Health 2022, 19, 227 9 of 13

Table 5. Line of argument 3, palliative patient group. Factors that influence patient spirituality at the end of life.

Role
need to address “People are not really used to expressing anything that is not exactly physical, for this reason I try to resolve
PPAL3
conflict conflict both talking and without talking”
“I am dealing with it 100% well, don’t consider it, I move forward, I keep going. I am great, I always say that
coping strategies PPAL6
I am good, it is better to not dwell”
“My husband is my main support, because my children support me, they call me every day, but they live in
social support PPAL3
Madrid. They really do care for me a lot. But without him I wouldn’t have had the strength to go on“
“It makes me feel good being able to lead the most normal life possible. To be able to have a beer someday with
sense security PPAL7
friends, any little thing will do for me”
“I know I’m in a very advanced stage of metastasis but then... how it’s going to be, what I’m going to feel......
Line closeness to death PPAL2
I think everything will be fine and that relaxes”
Argument: Palliative Patients
Concept of Spirituality feelings of “But yesterday got me a bit despairing, and I said “now whatever has to happen”. Plus I really wanted to cry
PPAL4
despair and I said “now I can’t stand this anymore”
My legs I can hardly move them for the pain. And for this I take a lot of painkillers every day, that has
pain PPAL2 morphine, up until now they haven’t given me a single day without pain. They tell me that my pain is very
difficult because it is in the bones and the nerves”
“Ay goodness me, that I don’t have to suffer much when I am dying, that my loved ones don’t see me suffer so
fear of suffering PPAL1
that they don’t suffer, that I fall asleep one night, but the suffering . . . ”
“7 years ago now I had an operation for breast cancer, they gave me a prosthetic and it looks awful, looking at
body image PPAL7 it, it’s the difference between the two that you notice even with clothes, but it doesn’t bother me as much now
because I have other concerns”
“Four siblings have died of the same thing. And my mum, I think it is hereditary. There’s more to come . . . I
family
PPAL5 had a really bad time when they went, with my twin, we always used to go out together . . . . It is obvious that
background
my destiny is what it is, the same as my family”
Int. J. Environ. Res. Public Health 2022, 19, 227 10 of 13

Other experts, in this same category, had already pointed to training as the answer to
integrating the spiritual component into end-of-life care. The absence of this care is linked
with the scarcity of competencies in this area.
“If it isn’t taught or if no experience is given of spirituality in the teaching of medicine or
nursing, well we run the big risk of putting ourselves in front of a sick person without
criteria that help us to understand beyond what is presented in their illness. It is never
our job to judge anybody, but to be the doctor to whom the person can flow what they
really want to express from inside of them. And all of this in a climate of confidence and
serenity. Embodied spirituality is also this expression of support in daily things that make
life more dignified”.
(Professional expert 10)
Finally, the presentation of results is ended with the sixth line of argument, which was
alluded to in all of the aforementioned categories and for which a code emerged following
specialization of discourse. This code refers to the training needs of professionals to
approach the spirituality of patients who find themselves undergoing end-of-life processes.
Some utterances agreed on the need to know oneself and undergo introspection in order to
be able to attend to another.
“The patients open up the path to this search and I study. A lot of things come out of
your own free will, but, are you doing it right or not? It isn’t easy to bring serenity to
someone who is dying, that this process that they go through is a process of personal and
family growth, if you yourself don’t believe it. First you have to wake up within yourself,
then you have to train yourself to not do things wrong, because without wanting to you
can do harm”.
(Professional expert 04)
Other utterances refer to the need to conduct team training in an interdisciplinary way in
order to be able to provide holistic patient care.
“From our daily experience in hospitals at no time is a formal meeting space found where
it is possible to work on teamwork in all of the required areas. And this is a mistake
because it limits a lot the reach of care to patients and to those around them. Medical care
and nursing slip into healthcare, but the spiritual is not integrated”.
(Professional expert 07)

4. Discussion
The two populations under study in this research coincide in defining spirituality, in
describing it as a way to connect with others and give meaning to the final process they
are experiencing—in the case of palliative patients—or to give meaning to their existence
and contact with life in the case of expert professionals. Authors, like Torralba [22], define
spiritual intelligence as a form of existential or transcendent intelligence which enables
human beings to question the meaning of their existence. It allows them to step away from
reality, favors the elaboration of a life project, and permits them to transcend materiality,
interpret symbols and understand the wisdom of life.
Another of the dimensions described in the results where both groups, coincide is
the need to addressing the spiritual component in end-of-life care. Various authors [3,4,6]
agree that treatment that strives to provide integral and dignified care must attend to all
dimensions of the human being and tackle all patient and family needs. It should converge
to include “dying well”, the absence of suffering (in terms of the physical, emotional and
spiritual) and the absence of pain for both the inflicted individual and their family. The
present study, in accordance with a previous study [3], verified that these spiritual needs
are present during the final moments, even when the patient is not aware of it. This is
exemplified by the comment: “I have learned to enjoy the small things. Get up and do three
things in my house, it’s the most marvelous thing in the world for me, because maybe in the future I
won’t be able to” (Patient Palliative 01). Other previous research studies have also revealed
Int. J. Environ. Res. Public Health 2022, 19, 227 11 of 13

similar outcomes [11,12]. Torralba [22,23] named needs of a spiritual nature that were
conceived by the philosopher Simone Weils [24], in which the need to find meaning during
these moments of life and reconciliation with oneself require spiritual intelligence. These
can also be extrapolated from the discourse provided by unwell individuals in response to
the situation in which they find themselves as a means to overcome it.
Delving deeper into the narrative of interviewed patients undergoing end-of-life pro-
cesses, two main worries or concerns emerged with arise at these moments [22]. Specifically,
these were concern around what death would be like or what would take place at the
moment of death (Patient palliative 01) and fear of suffering (Patient Palliative 04). At the
same time, references to spirituality emerged in all aspects of life as a method of help and
support. This is demonstrated in the quote: “A lot of pain, but always positive, wanting to
better myself, wanting to be strong and smiling for my husband, for my son, for my parents and
my sister . . . ” (Patient Palliative 03). Similar outcomes have also been described in works
conducted in the clinical setting [3,25].
Based on the discourse resulting from the content analysis of expert professionals, the
physical and emotional vulnerability developed to end-of-life processes causes an increase
in the spiritual needs of patients and their families. These needs must be satisfied by
health professionals in the end-of-life care setting. These results coincide with previous
studies [3,4], that spiritual needs permeate the discourse of informants along with the
importance of addressing them in order to provide comprehensive and exemplary care to
patients and families involved in palliative care.
Besides, outcomes of the present study demonstrate the importance of spirituality at
these moments and the huge impact of the quality of care, in the same way as reflected
in other research [3]. It can be concluded that, based on the discourse of participating
informants, the spiritual dimension is a felt need pertaining to the population of palliative
patients in Huelva.
According to the palliative patients interviewed, nursing professionals must attend
to the spiritual needs of patients at the end of life. There are authors [26] who agree on
this idea, and conclude the need to include it in the academic world. An idea that in
turn coincides with the speeches provided by the expert professionals interviewed. For
instance, “I have the feeling that this dimension is not touched upon not even when covering other
material. The spiritual dimension is not integrated in the curriculum anywhere, therefore, nobody
has to give it” (Professional expert 02). The study confirms that spirituality is forgotten
about. Nonetheless, it is true that students present high indices of knowledge and positive
attitudes towards spirituality [8], although deficiencies are observed in knowledge and
the delivery of nursing interventions related with spirituality [11]. New generations of
students will be the future of the nursing profession. If these students are not trained to
meet this need, spirituality will once again become an empty space in “integral” care plans.
With regards to discourse provided by professionals, it was revealed that positive
attitudes exist along with a predisposition towards spiritual care. Such spiritual care
is not only for religious individuals but also includes atheists and agnostics. This is
in accordance with the concept of holistic health care proposed by the World Health
Organization, which includes the integration of spirituality in nurses’ care plans in line
with previously conducted studies [12].
According to various studies [3,11] and two of the interviewed experts (Professionals
Experts 01, 05), the act itself of working at a palliative care unit, where professionals
continuously come into contact with death, should help them develop skills to provide
spiritual care. In this sense, the compassion satisfaction shown by the care provider to the
sick person connects with that individual and, at the same time, helps the professional
manage their own feelings and compassion satisfaction [27].
The concept of spirituality defined by the panel overall agrees with current under-
standing of the construct, not only in the Spanish context but, also in Europe [7,13,22,28].
“Spirituality, which does not identify with a single unique divinity, is the expression of the
essence of a person from where everything is governed and finds value” (EXP05). Spiritual
Int. J. Environ. Res. Public Health 2022, 19, 227 12 of 13

care is understood as being basic to nursing care, as indicated by: “Each one is how they
are, this generates suffering at the time of death and if you as a professional don’t mitigate
that, death is not as dignified as it should be” (Professional expert 01); “Spirituality is the
capacity to tremble with the other person” (Professional expert 04). The importance of
training in this environment was emphasized, in both nursing degrees and postgraduate
training, and of the use of therapeutic tools and tools to detect spiritual suffering. This
was outlined in the quote: “But we realized that it wasn’t just an exploratory tool but a
therapeutic tool. Those who use it must be really aware, be in control, know how far to
go, when they have to interrupt, when is the right moment and when no, for this you have
to be trained” (Professional expert 03). Similar outcomes have been reflected in various
articles [3,4,6,24,29].

Strengths and Limitations

This study is innovative as it describes the need for spiritual accompaniment in the
final process of life from the perspective not only of the professional who performs it, but
of the protagonists themselves, the patients who are in this process. More studies and
research, both quantitative and qualitative, are needed that contemplate the spiritual need,
as well as the competences of nursing professionals for their development both in our field
of study—palliative care—and outside it. Therefore, this research should be extended to
different health professionals, doctors, nurses and psychologists, as well as to different
areas where addressing the end of life is a priority.
Social awareness, and specifically of health professionals, in the spiritual field is
fundamental, so this content should be included in the most initial stages of individual
education. “A society without spirituality is dead, breathless, without criteria, it allows itself
to be manipulated by whatever ideology it comes from. That is why a mature spirituality
makes the person and society critical, open, non-manipulable, constructive: free”.

5. Conclusions
The provision of spiritual care gives meaning to the actions performed by nursing
professionals and the end of life, achieving holistic care, humanizing death, and promoting
a dignified end. In the present work, it is true that spiritual accompaniment was seen to
be challenged by its very nature given that the experimental paradigm did not achieve
complete understanding or exploration. This being said, obtained outcomes verify that
the spiritual dimension is understood by professionals on hand to accompany as a human
universal and, with that, approaching it correctly will help other needs to be addressed.
For this reason, following elaboration of the present study, it can be concluded that better
training is required in this setting. Such training should be transversal, and be included
within the Nursing degree, as well as in postgraduate training. This would promote the
lifelong learning of nursing professionals in the city. In this way, social awareness could be
strengthened within the nursing context in a way that encourages professionals working in
the field to contemplate spiritual accompaniment as an indispensable aspect of care plans.
In the run up to the end of life, a lack of spiritual care becomes even more tangible for
patients. Through the present study it can be confirmed that not only palliative patients are
impacted by this dimension and, instead, spiritual conflict take occur at any vital stage and
generate suffering. Nursing must be on hand to meet this need and mitigate its potential
consequences through the route of integral and personalized care.

Author Contributions: Conceptualization, E.B.G.-N.; Formal analysis, A.M.-O. and E.B.G.-N. Re-
search and analysis S.G.N., A.M.-O., and E.B.G.-N. Writing and preparation of the first draft E.B.G.-N.
Drafting A.M.-O., S.G.N., and E.B.G.-N. All authors have read and agreed to the published version of
the manuscript.
Funding: This research received no external funding.
Int. J. Environ. Res. Public Health 2022, 19, 227 13 of 13

Institutional Review Board Statement: The study was conducted according to the guidelines of
the Declaration of Helsinki, and approved by Ethics Committee PPEIBA, government of Andalusia,
Spain (protocol code 01/2020 CEPP and date of approval 18 January 2020).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Conflicts of Interest: The authors declare no conflict of interest.

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