Spiritual Distress in Cancer Patients: A Synthesis of Qualitative Studies

religions Review Spiritual Distress in Cancer Patients: A Synthesis of Qualitative Studies Helga Martins 1 1 2 * and Sílvia Caldeira 2, * Institute of Health Sciences, Universidade Católica Portuguesa, 1649-023 Lisbon, Portugal; Researcher at the Centre for Interdisciplinary Research in Health, Institute of Health Sciences, Universidade Católica Portuguesa, Palma de Cima, 1649-023 Lisbon, Portugal Correspondence: Received: 21 August 2018; Accepted: 18 September 2018; Published: 20 September 2018



 Abstract: Cancer affects individuals in all human dimensions. Cancer patients are more susceptible to spiritual distress. Several studies have addressed spiritual distress using quantitative designs; however, a qualitative approach to the experience of spiritual distress could provide a deeper understanding of the phenomenon. This study aims to synthesis the experience of spiritual distress as lived by cancer patients in qualitative primary studies. This is a literature review based on electronic databases search. A total of 4075 citations was identified and 23 studies were included. The most frequent qualitative research method was phenomenology (n = 15), and interviews were the main data collection method (n = 20). Two major themes have been identified related to the experience of spiritual distress: suffering and coping. Spiritual distress is an intimate, deep and suffering experience in life, which requires coping strategies and involves spiritual values and beliefs. Healthcare providers should be aware of this experience and recognize spiritual distress in cancer patients, as it is critical in providing holistic nursing care. Keywords: cancer patients; nursing; qualitative studies; spiritual distress 1. Introduction Cancer leaves an alarming and devastating effect at the global level and is considered a leading public health problem (Siegel et al. 2018). Cancer is one of the world’s leading causes of morbidity and mortality, with 14 million new cases and eight million cancer-related deaths have been diagnosed in 2012 (WHO 2014). In the USA, 4700 new cases of cancer are diagnosed each day (Siegel et al. 2018), 87% of all cancers are diagnosed in patients having 50 years of age or older, and the mortality rate is 1670 deaths per day, resulting in the second leading cause of death (American Cancer Society 2018). The burden of having cancer is a worldwide reality, but main cancers can be avoided, and the focal key word to fight cancer is prevention through tobacco control, vaccination, early detection, and promotion of healthy lifestyles (Torre et al. 2016). Cancer has a nefarious effect on patients’ life and can decrease hope and dreams (Villagomeza 2005). The diagnosis of cancer originates the most alarming response, as compared to other diagnosis (Sawyer 2000). The diagnosis and progression of cancer disturbs patients’ lives (Gurevich et al. 2002) who start frightening an imminent death and the suffering associated with the treatments (Caldeira et al. 2014). Cancer affects individuals in all human dimensions: physical, psychological, social and spiritual (WHO 2014; Caldeira et al. 2016). These patients seem more susceptible to spiritual distress when they are diagnosed, during progression of the disease and at the end-of-life (Skalla and Ferrell 2015). Spiritual distress is also found in the literature as “existential suffering” (Bates 2016), “spiritual Religions 2018, 9, 285; doi:10.3390/rel9100285 www.mdpi.com/journal/religions Religions 2018, 9, 285 2 of 17 anguish” (Chaves et al. 2010), “spiritual pain” (Delgado-Guay et al. 2013), and “spiritual struggle” (Exline et al. 2013; Wilt et al. 2016). Several studies have been conducted that support the existence of spiritual distress in cancer patients. In particular, Hui et al. (2011) conducted a study in patients with advanced cancer admitted to an acute palliative care unit and found an occurrence rate of 44.0% of spiritual distress. Gielen et al. (2017) found 17.4% of cancer patients in palliative care in India experience spiritual distress. Recently in Portugal, Caldeira et al. (2017) found 40.8% of cancer patients undergoing chemotherapy have spiritual distress. Notwithstanding the subjective nature of spiritual distress, it can be assessed using various measures, tools and scales which have been developed, validated and translated in different countries and samples, such as, the Spiritual Distress Scale (Ku et al. 2010), Spiritual Distress Assessment Tool (Monod et al. 2012) and the Distress Thermometer (O’Donnell et al. 2013). Spiritual distress is an important issue in patient’s response towards a health problem and is the title of a nursing diagnosis listed in the taxonomy II of NANDA International, Inc. (NANDA-I) since 1978. This nursing diagnosis is included in the domain 10—Principles of life—and in the class 3—Congruence between values/beliefs/acts (Herdman and Kamitsuru 2018). The most recent nursing diagnosis validation study has proposed a new definition of spiritual distress as follows: “a state of suffering associated with the meaning of his/her life, related to a connection to self, others, world, or a Superior” (Caldeira et al. 2013, p. 6). The assessment of spiritual distress is critical for getting an accurate diagnosis (Simão et al. 2015). The screening of patients’ spiritual needs is considered an individual experience and ongoing process, which makes the assessment a complex process (Timmins and Caldeira 2017). Nevertheless, it is important to identify patients’ spiritual needs, to promote and to provide holistic nursing care (Guerrero et al. 2011). Likewise, different nursing interventions have been described as adequate in supporting patients in overcoming spiritual distress, such as music therapy, guided imaging, therapeutic touch, progressive muscle relaxation, distant intercessory prayer, reminiscence therapy, affective support group and meditation (Guilherme and de Carvalho 2011). Irrespective of all the scientific evidence on spiritual distress, a gap in implementing spiritual care in nursing practice remains. Several barriers to the provision of spiritual care have been described, such as, lack of training and time (Balboni et al. 2014), ignoring the spiritual aspect of care (Nascimento et al. 2010; Tiew et al. 2013), or misunderstanding the meaning of spirituality and the role in providing spiritual care (Rushton 2014). Spirituality and spiritual distress are individual experiences, and both require an individual approach. But, a deeper understanding of spiritual distress, based on the experience of having or living with spiritual distress, could be helpful in promoting an evidence-based practice and in supporting nurses in better diagnosing and intervening. The aim of this review is to synthesis original qualitative research regarding spiritual distress of cancer patients, as qualitative research provides the information about participants’ feelings (Sutt (...truncated)