What is already known about this topic?

Spiritual care is one of the essential components of oncology care to improve a patient’s quality of life.

Clinicians like nurses and doctors are key players in the provision of spiritual care for cancer patients. Their reflections on spirituality help them to address the challenges of spirituality and religion, which assist them in providing spiritual care to oncologic patients.

Spirituality, according to cancer patients, helps them find hope, gratitude, and positivity in their cancer experience

What this paper adds?

Understanding the influence of spirituality among clinicians that can affect the response to oncology care which are essential to provide effective care.

Clinicians who are well familiar with their own spirituality will be better at recognizing, understanding and attending their patient’s spiritual needs and concerns.

More and more people are receiving education and training on how to communicate with cancer patients about their spiritual needs as well as how to identify and meet them.

Spirituality is one of the sensitive and challenging areas to deal with when it comes to providing care. Spiritual care is part of the health care provider’s job, reflected in the professional code of ethics, policy, and education guidelines [ 1]. It is one of eight qualitative palliative care areas, as it is essential in oncology care to contribute to a patient’s quality of life [ 2]. In the healthcare community, there are opinions on whether spiritual care should be part of the treatment process, how it should be provided, and who should provide it. Spirituality is coined as a characteristic of humanity, which includes a person seeking and expressing one’s purpose and relating its connection to himself, others, the moment, nature, and the sacred or significant [ 3]. In the last two decades, developments in health care showed an increasing awareness of the importance of shifting skepticism toward spiritual care and its role in delivering holistic care [ 4]. The role and significance of spirituality and religion have been widely accepted. About 85% - 93% of doctors agree that they should be acquainted with and contemplate the patient’s spiritual beliefs and should be sensitive to these issues and that healthcare institutions must ensure that these spiritual practices and beliefs are evaluated and accommodated [ 5].

Patients’ spiritual and religious beliefs impact their decision-making toward oncologic care. Spiritual well-being impacts the quality of life of cancer patients, how aggressive they are in their treatment, and how to be more prepared for end-of-life issues [ 6]. In patients diagnosed with cancer, it is a daunting prospect of emotional and physical challenges for both patients and nurses, which is why the nurses’ perception of the potential or actual loss impacts their clinical practice and quality of care [ 7]. Multiple studies have shown that spirituality plays a role in the overall well-being of a patient with cancer, demonstrating notable improvements in stress reduction, choice of therapy and response, empathy, compassion, and quality of life [ 8]. However, challenges remain for those interested in conveying oncology's spiritual aspects. Perhaps the simplest way is first to define spirituality in the context of the healthcare providers so that it would bridge the gap on how these clinicians can provide a more holistic care approach, including spiritual care. Clinicians like oncology neurocritical are key players in assuring that the spiritual needs of patients are being addressed and provided as they believe it gives considerable significance towards their self-actualization [ 9].

There is a distinctness between healthcare providers’ beliefs regarding the role of religion and spirituality in oncology care; 61.8% of nurses, and 60.3% of allied health providers were more likely to believe that God intervenes in patient health versus the physicians, which are only 41.7% [ 10]. This data implies that clinicians should view spirituality as beneficial for the patients' mental health, and that under is standing these differences in beliefs and perceptions will determine how to best incorporate spirituality in providing oncologic care to our patients.

The clinicians’ perception of spirituality is one of the essential aspects to assess, as these would be beneficial in providing oncologic care to the patients. Multiple studies have been conducted on patients’ views towards spirituality and less on the views of the health care providers, mainly qualitative studies [ 11]. Thus, a need to further study and explore this subject matter. This review focuses on clinicians' spiritual perceptions of oncology care context using a qualitative synthesis approach. This qualitative synthesis aims to discuss the perceptions of the clinicians towards spirituality in the provision of oncology care. Specifically: a). To describe the clinician’s clinical encounter and experiences in providing spiritual care to their cancer patients. B). To characterize the clinician’s perceptions of the role of spirituality; c). To discuss the potential effects of spiritual care on patient-provider relationship in the provision of oncologic care; and d. To identify the implications of spiritual care in the practice of oncology care

This is an extensive review of the available qualitative research of well-established data on the topic of the perception of clinicians on spirituality towards oncology care. This qualitative synthesis involves the collection of data from the different perceptions of clinicians that will be summarized and aggregated using themes [ 12]. The themes emerging from the impact of spirituality in the provision of oncologic care will be interpreted to develop new conceptual understandings to generate maximum explanatory value. This qualitative synthesis will utilize a thematic synthesis approach. It is a combination of approaches from grounded theory and meta-ethnography that was developed to conduct reviews for the inscription of appropriateness, acceptability, and effectiveness of the intervention without compromising the critical principles developed for the systematic review [ 13]. Thus, this qualitative synthesis involves pointing out themes, summarization, and interpretation of data.

The search was carried out in August 2022 and included all results up to that date utilizing online resources such as SCOPUS, CINAHL, Google Scholar, Science Direct, PubMed, SAGE, Taylor and Francis, Springer, and Wiley. Keywords used in the search were: spirituality OR spiritual care OR spiritual support AND clinicians OR doctors OR nurses OR oncologists OR oncology nurses OR healthcare workers OR physician AND perception OR perspectives OR opinions OR experiences. The use of PRISMA diagram was shown onFigure 1.

In this qualitative synthesis review, the researchers gathered, organized, summarized, and aggregated all relevant information regarding clinicians’ perceptions of spirituality that affects their care delivery in cancer patients. The articles should be a qualitative or mixed-method study. Published English articles that are peer-reviewed were included in this thematic synthesis. Opinions, protocols, one-page reviews, and letters to editors were eliminated, and studies that did not include cancer patients. Inclusion criteria also include clinicians as the centered primary respondents of the study, whether doctors, nurses, or other allied healthcare professionals that have provided direct care to cancer patients. The last inclusion criterion should be the clinicians’ perception of spirituality. Exclusion include the patient or caregiver’s perception of spirituality. No limitations on year and timeline were established.

The researchers manually and independently analyze each article using a matrixTable table by consensus with consideration of purpose, methods, and findings. All peer-reviewed articles must be in academic or refereed journals suitable in the inclusion criteria that were appended as presented onTable S1 (Supplementary Material). A consensus was made in case of disagreements. An expert colleague was also invited for external peer-review.

To a greater extent, each article should discuss the clinician’s perception of spirituality in providing oncology care. Critically appraising the articles using Critical Appraisal Skills Programme [CASP] (2018) [ 14] on qualitative studies were employed to appraise the strengths and weaknesses of the articles included in this study to ensure the reliability of the research methodologies and to draw conclusions from it since multiple studies to be synthesized are subject to a number of variables that may introduce bias [ 15]. The checklist is a 10 item questionnaire that determines if the aims of the research is clear, if method is appropriate and was able to address the purpose, if the recruitment strategy was appropriate, if the data collected addressed the research issue, if the relationship between researcher and participants have been considered and is ethical issues have taken into consideration, if there is sufficient rigor and the findings are clear, and if the research is valuable.

As presented onTable 1, eleven studies have been analyzed that are included in this qualitative synthesis. These eleven studies were conducted in different countries like the United States, Australia, China, Germany and Iran from years 2012 to 2021. Among these eleven qualitative studies, eight are descriptive designs, one study is grounded theory, one study is phenomenology, and one is with mixed method designs. The study participants were clinicians that were purposely selected and working in a hospital or cancer care treatment facility. Five of the studies have nurses as exclusive respondents, two studies have doctors as exclusive respondents, and four studies have mixed clinicians as respondents. The sample size of the participants ranges from 15 to 35 clinicians, where data is collected through in-depth or semi-structured interviews and narrative surveys. All the studies aimed to explore clinicians’ perspective and experiences in taking care of cancer patients, with discussions on palliative care that highlighted the role of religion and spirituality, and the effects of spiritual care.

From the diverse 11 qualitative studies, the discussion provided perspectives from the perceptions of oncology clinicians on providing spiritual care to cancer patients. The following themes and subthemes are created from the synthesis of the 11 studies that can guide future interventions to prepare clinicians to support the spiritual well-being of the patients and their family from a clinician's point of view of spirituality.

Five studies reported that clinicians expressed strong desires to give quality care to their patients. [ 17,21,22,25,26] emphasized the importance of keeping patients' hopes alive in a death-denying cultural context for cancer patients. The maintenance of hope is important in the care of palliative patients because it increases positive attitudes and reduces suffering, because lack of hope results in dying patient’s fear and ignorance of death.

Three studies reported that in directing the spiritual needs of the patient, thereby promoting spiritual wellness and maintaining hope. Interprofessional team support is needed like doctor, nurse, social worker and chaplain [ 16,17,18]. The inclusion of spiritual care in quality palliative care of oncology practice is a team approach . This facilitated a more holistic approach in providing spiritual care to the patient. Two of the participants mentioned.

“Ok, so we’ve addressed your understanding of your symptoms, now what helps you get through your day?....Some people say faith is important.” [ 16]

“Chaplains are unofficially part of the group, but when we see patients and families, [the chaplain] really knows what questions to pinpoint to ask.” [ 18]

Three studies reported that clinician provided spiritual support interventions offer hope and spiritual wellness [ 16,17,18,19]. The interventions identified by the clinicians other than offering prayer, are being with there and listening to patients, meditation, distraction of thoughts and music as expressed by the participants:

“I encourage them to meditate or listen to music the like, just to get their heads out of the disease.” [ 18]

“I should provide some specific help to relieve their fear about death, and talk death with them; just like the Western countries’ nurses do for their patients…talk about death openly, and say goodbye with them.” [ 17]

Four studies reported that clinicians expressed sensitivity to cancer patients. [ 2,4,6,11] Clinicians recognized the importance and value of appropriately timed conversations about spirituality with the patients. Also, with the interprofessional approach it said that it is a key assessment to know when it is needed to refer patients to chaplains and other people skilled in providing spiritual care. As identified, sensitivity to the patient’s religious background is essential and the clinicians are bound to meet the patient’s religious and spiritual needs.

Three studies reported the importance of proper timing in conversing about spirituality. [ 21,23,26]. It is important that clinicians wait for an indication that a patient is ready to talk about spiritual issues. As remarked, a patient must be physically comfortable and willing to talk and not rushed as elucidated by the participant:

“Unfortunately, spirituality is never asked about, so many times, I asked her [the patient] if she needed any psychological support.” [ 19]

In two studies, clinicians acknowledge the difficulty to talk about spirituality with their patients but they also recognize the essence of asking them about religion, faith and issues on spirituality throughout the care process [ 19,21]. That it is important to listen and understand their patients' concerns and let them feel and know that their feelings about their disease are valid and respected as stated by the participants:

“He knew he was dying and was terribly concerned about his family. We were able to discuss his concerns. After his death I was able to share this conversation with his parents [and they] were so grateful.” [ 19]

“Nurses’ characteristics” such as their abilities, spiritual issues, and mood can affect their empathy with the patient.” [ 21]

Two of the studies reviewed emphasized the importance of providing patients with culturally respectful spiritual care [ 16,18]. Clinicians have learned to respect their patients’ beliefs or religions even if it is against their own beliefs or something they are not comfortable with. They tried to be neutral and professional and focused to provide the needs of their patients knowing that part of their needs is spiritual care.

In two studies, clinicians talked about how they provided culturally respectful spiritual care by being sensitive to their culture and beliefs [ 16,18]. They provided spiritual care based on what they think their patient needs even if they are not comfortable about it, as stated:

“I have standard, neutral prayer phrases that I’ve used before that work really well with me and with families, even if it’s something that’s a religion outside of what I’m comfortable with. I make very neutral prayer statements.” [ 16]

Five of the studies reviewed emphasized the need for education in providing spiritual care of clinicians giving care to cancer patients [ 16,18,19,20,23]. Clinicians felt a lack of spiritual competency but with practice and education, they learned how to discuss spirituality and religion with their patients in a way that had a tremendous effect on their own lives which then led to their personal development. Clinicians view discussions on religion and spirituality as challenging by having difficulty in finding the right terms and that they fear that they may not be able to provide their patients’ needs.

In four studies [ 16,17,19,25], it was emphasized that lack of spiritual competence hinders clinicians in giving spiritual care to their patients thus they call for a need for education in providing spiritual support to their patients and caregivers:

“We need proper training to address it” [ 18]

Nurses throughout their care for their patients have developed ways of addressing spiritual issues that somehow contributed to their lives and resulted in their personal growth:

“Part of the struggle in my job is the locating and figuring out who to contact for help with those spiritual needs. The effort to meet those are there but finding how to meet them is the struggle.” [ 19]

The included studies explored different perceptions of clinicians regarding giving spiritual care to patients with cancer. The aim of the studies explored clinicians’ experiences in caring for cancer patients, their perspectives on challenges in meeting the spiritual needs of patients, describing how they respond to patients’ spiritual needs, and how they view the effects of providing spiritual care to their patients.

A holistic approach where the quality of life rather than quantity of life is emphasized, giving importance to quality time for cancer patients during palliative care [ 25]. Giving the correct role to the clinician such as a doctor, nurse and clinical manager has given an effect on the patient in palliative care. As oncologists, they play a big role in taking care of cancer patients, and discussing the possible effects of incorrect care for people with cancer. Unlike [ 25,26], they explained that clinicians become more focused not only on the patient but the involvement of their families. Clinicians in cancer institutes become more involved compared to ICU nurses in general hospitals, due to the differences in the setup, but the interventions for spiritual care are the same [ 26]. The importance of spirituality of a person in critical condition is highlighted. Importance was given to the spiritual perspective and understanding of the patient and family involving the placement of a chaplain in the community, this is a step in future studies to involve the clinicians in spiritual matters. Meanwhile, ethically and legally it gives consideration during palliative care treatment [ 24]. This view leads them to preserve human dignity, professional truthfulness and altruism.

On the other hand, the two research studies conducted regarding how spirituality is helping lung cancer patients [ 16,18]. In addition to this, studies have shown two types of settings, a Community-based setting and the second is outpatient setting. Specified that spiritual matters are not really the role of a clinician or oncologist, so it listed recommendations to support and prepare the clinician in this matter [ 18]. It discussed the Interprofessional team approach and, team support that can address the problem of spirituality specialists such as chaplains or social workers. An assessment of spiritual needs using a spiritual history and spiritual screening tools. The provision of culturally respectful spiritual care, where one of the important roles played by a clinician in meeting spiritual needs centered on a mutual understanding of cultural norms and respect for patients and families. And lastly, the importance of a supportive environment was also stressed as a clinician’s priority in terms of spirituality.

The importance of directly addressing the symptoms that the patient complains, in that they can establish rapport and build a trusting relationship with the clinicians [ 16]. A common strategy to make the patient feel more comfortable with the clinicians is by establishing this strategy that is reassuring for the patient, especially on the emotional and spiritual problems they are experiencing. From there the clinician can perform and view what method is appropriate to use to address the spiritual problems, not only of the patient, but also of his family. It was shown that the clinician’s role in different kinds of settings, whether community-based or outpatient basis, the interventions of care for cancer patients becomes effective when it comes to spiritual matters as long as it is properly addressed [ 16,18].

Characteristics of cancer nurses were identified as critical nursing competencies, including acceptable behavior and a positive attitude, spending time with patients, listening to them, and demonstrating empathy [ 21]. The influence of nurses' religious beliefs affects their work motivation, patient-centered attitudes, and level of compassion. The topic of spiritual competency for cancer nurses was brought up regarding the spiritual and religious convictions of oncology nurses as one of their characters. Additionally, nurses who are upbeat and optimistic about the future approach difficulties with a realistic mindset. They interact with the patient in a civil and moral manner and are able to establish good rapport with them.

Clinicians in a cancer center expressed a tremendous desire to provide excellent care to cancer patients, and underlined the significance of maintaining patients' hopes in the setting of a culture that denies death [ 17]. They also mentioned the need for flexible and focused education and training. Meanwhile, ethical concepts have an important role in palliative care on cancer patients [ 24].

Every clinician has their own perspective in view of spirituality, which is affected by their own personal religious background and beliefs, but the experiences they gained in caring for cancer patients made their knowledge broad, and their care more culturally and religiously respectful in line with their patients. Learning is a continuous process, and the affirmation of these learnings that are put into practice is sensitive with respect to cancer patients, from the time we provide comfort at the onset of diagnosis up to providing quality end-of-life care.

Patients who hear a cancer diagnosis are faced with a serious and frequently terminal illness. A patient's perception of the world is threatened by terminal disease as they must face their own limitations and mortality, which could lead to an existential crisis [ 23,22]. Every aspect of who we are is influenced, and suffers from various emotional, psychological, and needs for spiritual existence. Most of the doctors who were addressing patients stressed the importance of spirituality. Patients' spiritual convictions gave them a positive outlook and made them expect better results, thus due to their illness, patients turned to faith, religion, or spirituality. Some patients claimed that God's strength and care for them was the source of their positive outcomes [ 22]. Granted its crucial significance for cancer patients, as well as the fact that this occasionally is their primary inquiry to IM (Integrative Medicine). The pursuit of purpose and meaning was also considered to be a part of spirituality. Patients' queries about life and death, the interconnectedness of everything, and searching for and finding hope and inner serenity, especially as one is dying [ 22].

Moreover, understanding nurses' experiences of caring for terminal cancer patients may have various meanings and values to nurses according to cultural contexts in China and other countries [ 20]. Nurses emphasized the importance of oncology nurses' sensitivity to the religious backgrounds of dying patients and the positive impact that spirituality plays in helping dying patients cope with their impending demise.

The effects of spiritual care on the patient-provider relationship provide meaning for both parties. The physical presence of the clinicians in delivering care to cancer patients emphasized their willingness and sincerity to care. Thus it also includes encouragement of patient care among other members of the health care team but also provides encouragement to the patient to hope, and for the family members to participate in the provision of care, thereby strengthening the inner energy of the patient to live and fight cancer [ 16,17,25].

As such, clinicians who have provided holistic care in a patient’s course of illness have proven that the patient-provider relationship is an investment that must be established from the start. Providing spiritual care strengthens the patient’s hope and views and positively accepts death, but also makes the clinician more resilient and sensitive to the profession he is performing.

Clinicians such as oncology nurses should address the different approaches to cancer, patient physical, emotional, and especially medical problems. The existence of other religions and beliefs in our creator served as a great test, especially in responding to a person's spirituality. The finding of this study helped the importance of a clinician to be able to give hope to the cancer patient. It emphasized the importance of understanding religion, faith, and approaching spiritual issues. The essential method that the clinician needs to respond to religious aspects was also discussed, as well as the importance of our role as nurses and doctors in giving positivity to people with cancer. We know that spirituality is often only mentioned in patients who are close to death or in what we call palliative care. Still, this study showed the role played by a clinician and the effects of spirituality on diseases like cancer.

This study translates the perspectives of clinicians that provide care to cancer patients, the role of spirituality, and the challenges of integrating spiritual care into clinical practice. Self-awareness, team support, and culturally sensitive care are vital in spiritual care. This qualitative synthesis exhibits the need to improve clinicians’ capacity by providing practical tools. In nursing practice and education, formal training in handling cancer patients dealing with end-of-life care can be strengthened from the curriculum to actual performance of skills in the clinical setting and a supportive environment to better address the patient and the family’s spiritual concerns.

The limitation of this study in choosing a target population is less anticipated, oncology Nurses are specialized nurses, and the availability of participants is not that many participate in this study; different hospitals have different protocols that are implemented as well as the aspect of spiritual perception, so the use of focus group discussions or video recorded interviews became the access for thematic analysis. With the chosen studies included in this synthesis, one limitation is that the respondents came from different countries, with different cultures and beliefs, especially on interventions that addressed the spiritual needs of the patients. The clinicians' religious affiliation and personal viewpoints affect perceptions of spirituality and how they provide spiritual care. Only a few of those who conducted a qualitative study could obtain the data for this study. Hence shortcomings are unavoidable in analyzing the data.

In this study, the clinician’s perspective was obtained to understand better how their view on spirituality affects their care for oncology patients. Training in spiritual care is recommended to deepen the knowledge and understanding of clinicians to different people with different cultures, religions, and beliefs suffering from cancer. Further research may be needed, with respondents focusing on oncology nurses, to gain a better perspective on how nurses view spirituality in caring for cancer patients, which may provide a structure or standard practice in l care for terminally ill patients like cancer patients.

This qualitative synthesis recommends an inclusion in the medical/nursing curriculum of a more comprehensive discussion of spiritual care as part of the caring aspect of the patient with cancer. In addition to this, clinical exposures with opportunities to take care of cancer patients must also be included, as this will broaden the knowledge and skills of the prospective clinician and will develop the right attitude on handling such sensitive chronic diseases like cancer.

In the clinical setting, a spiritual assessment and interventions checklist can be developed to assess and address the spiritual needs of the patients adequately. This will provide a better perspective on the part of the clinician toward spiritual care. Furthermore, a spiritual care team can be developed to provide and evaluate the effects of spiritual care provided, allowing necessary adjustments to address spiritual needs and making essential modifications towards policy making in the provision of spiritual care.

This synthesis presented the perceptions of clinicians towards spirituality in providing oncologic care. Spiritual care in oncologic patients remains a delicate issue. Still, clinicians’ personal spiritual and mental readiness are elements to understand better and address not only the physical needs but also the existential concerns of cancer patients.

Communication with cancer patients regarding oncology-related subjects requires highly skilled personnel to take on matters like these, especially one’s spirituality. Spirituality impacts patients' decisions, is linked to a better quality of life, and affects how clinicians in oncology-related settings cope with difficult everyday situations. From the narratives of the clinicians, it has been proven that spirituality and religion are essential aspects of care clinicians provide to cancer patients. Such spiritual care interventions provide comfort, strengthen the quality of life, promotion of family function, and preparedness for impending death. The clinician’s empathy for a cancer patient’s condition while providing culturally respectful care, ensures the patient's well-being and provides hope for the patient and the family.

Despite the numerous difficulties that come with working in a field as complicated as oncology, clinicians must adopt a patient-centered strategy guided by empathy to provide patients with holistic care. This qualitative synthesis sheds light on the need to improve the training and education of clinicians, to improve spiritual history and screening tools where clinicians will evaluate spirituality beyond the patient’s religious inclination, but also provide targeted education about the role of religion and spirituality in helping cancer patients to cope. Such strategies guarantee patient-centered care, act as a vital source of inspiration for patients to actively engage in their care, and offer advice for controlling cancer-related emotions.

Supplementary Materials:

Each item will be scored, if the criterion is fully met, it is scored as +1, if the criterion is partially met, it is scored as 0.5, if the it is not met, it is scored as -1, and if the criterion is not applicable, it is scored zero. The scores of each study are totalled and the percentage is computed. The studies that scored 85% and above were included in this qualitative synthesis. Among the 11 studies, seven researches scored 95%, two researches scored 90%, and two researches scored 85%.

Author Contributions: MA: Conceptualization, Methodology, Formal analysis, Investigation, Data curation, Writing – original draft, Project administration. JA: Conceptualization, Methodology, Formal analysis, Investigation, Data curation, Writing – original draft, Project administration. MIDR: Conceptualization, Methodology, Formal analysis, Investigation, Data curation, Writing – original draft, Project administration. AS: Conceptualization, Methodology, Formal analysis, Investigation, Data curation, Writing – original draft, Project administration. RAN: Formal analysis, Investigation, Supervision, Validation, Visualization, Writing – review & editing

Funding: This research received no external funding

Data Availability Statement: All reference were properly cited

Acknowledgments: This study acknowledged the moral support of St. Paul University Philippines – Graduate School

Conflicts of Interest: The authors declare no conflict of interest