A Concept Analysis of Spiritual Care Based on Islamic Sources

The cultural and religious resources of every community influence the definition of spiritual care. This paper discusses a concept analysis of spiritual care in an Islamic context. The Quran, narrations (Shie’h) and commentarial books were searched, for information data. The data was used to provide a comprehensive definition of the concept of spiritual care from Islamic literature. We identified the attributes, antecedents and consequences of spiritual care according to Roger’s concept analysis approach. The review of the Islamic text showed that spiritual care is a series of spiritual skills or competencies that help patients to achieve excellent life. It is grouped into categories and has numerous positive effects on patients and caregivers. This study will be useful to Muslim clinicians and nurse educators as they strive to understand and incorporate spiritual care within their practice for Muslim patients.


Introduction
Health is a holistic concept, which encompasses physical, social, and spiritual dimensions [1].Spiritual care considers the spiritual dimension of health.It has significant advantages such as better quality of life [2], and reduced depression and despair [3].The survey of literature shows that the descriptions of spiritual care in the nursing context are characterized by diversity, ranging from the general concept of a caring presence to religious oriented interventions [4].It is defined as an effort to touch the spirit of another human being [5].At one time, it was simply defined as a set of highly fluid interpersonal processes involving mutual recognition of human values and experiences [6].Spiritual care has also been described as an interactive and intentional process between a nurse and a patient with the aim of enhancing patients' spiritual well-being [7].It shows that various factors affect the definition of spiritual care.
Two of the major factors that precipitated the different definitions for spiritual care are the cultural and religious situation of any society.The spiritual care in a particular setting may have unique culture-specific aspects sowing to the specific religions and spiritual approaches found there.For example, in Taiwan, where the culture is heavily influenced by Taoism and Confucianism; a key spiritual need highlighted in this culture, is facing death peacefully [8].Therefore, to administer spiritual care in every community, it is essential to understand the cultural and religious condition found there.
Iran is an Islamic country with 99.4 percent of the population identified as Muslims.The Islamic values and beliefs are intricately linked to cultural norms, and this shapes the patients' perception of health and illness.Islam appeared as a religion in the seventh century when the Prophet Muhammad, peace be upon him, started receiving revelations from (God).Shi'ah and Sunni are two branches of Islam.Shi'ah, which literally means follower refers to those who consider the succession to the prophet hood (may God's peace and benediction be upon him) the special right of the family of the Prophet and who in the field of the Islamic sciences and culture follow the school of the household of the Prophet [9].Quran and narrations, (sayings, deeds, or agreements of the holy prophet Mohammad (P.B.U.H) and his successions (Household of the Prophet) are sources of Islamic teachings (Shia'h).
According to Islamic teachings, spirituality is one of the dimensions of health.The survey of the Quran shows that there is much guidance on health to the extent that God introduced His book as the book of health in a few verses of the Quran ([10], 5:16).One of the pieces of Quranic guidance on health is spiritual care teaching [11].The attention to spiritual care of patients is a characteristic of believers and turning away from it results in destruction and suffering in hell ( [10], 66:6, 2:195).Therefore, there is much guidance on health in Hadith (narration); one of the Islamic thinkers puts it this way: the infallible Imams (narrations) are the only way to achieve health [12].
Spiritual care according to Islamic view and tenets is one of the rights of Muslim patients [13].Delivering high-quality care to Muslim patients signifies having a deep knowledge of the Islamic faith and beliefs.It is important therefore to analyze the concept of spirituality in Islamic culture to understand the influences these have on the concept of spiritual care for Muslim patients.Moreover, a survey of Islamic text indicated that Islamic scholars have not yet published any comprehensive information on the spiritual care concept directly from Islamic literature.Therefore, the aim of this paper is to examine Islamic didacticism in Quran and narrations (Shie'h) to provide a clear and comprehensive definition of the spiritual care concept.

Spirituality in Islam
In the humanistic approach, spirituality is described as a way of being and experience that comes about through awareness of transcendental dimension and is characterized by certain identifiable values in relation to self, others, nature, life, and whatever one considers to be the ultimate [14].
It is also described as the individual's notion of peace, purpose, and interconnectedness, containing beliefs about the meaning of life [15].Spirituality is related to the aspect of humanity that refers to the manner in which individuals look for and express the meaning of life, and the way they experience their connectedness to the moment, self, others, nature, and to the significant or sacred [16].It may include religion and other worldviews but encompasses far more general ways of expressing these experiences, including through the arts, relationships with nature and others [17].
According to Islamic literature, spirituality means the use of intellect, tendencies and abilities to experience awareness of the origin of the universe, worshiping God, seeking the satisfaction of God, humility, submission and trust, which is demonstrated by man in all of his actions [18].It is also defined as a purposeful and meaningful situation of human life, which stems from belief in the infinite power, the perfections of God and belief in life after death.Spiritual health leads to happiness, hope, satisfaction, confidence, comfort and salvation in this world and the world hereafter [19].
The concept of spirituality can be found in the Quran explicitly elucidated using terms such as pure and good life (Hayate-tayyebeh) and pure heart (Ghalbe-Salim) [20].According to Quaranic creeds, a human being experiences a special life in his spirituality.As God says in the Quran: " whoever leads a righteous life whether male or female, apart from the fact that he or she is a true believer, to them He will surely bestow a pure and good life in this world; and He will reward them in commensurate proportion of the best of their service" ([10], 16:97).Hayete-tayyebeh is defined as some form of human life that is not separated from the common life.It means that while pure life is life other than the worldly life, it is however associated with worldly life.Human beings enjoy the pure life; it is devoid of impurities [21].Joy and satisfaction is dominant in this life.Ghalbe Salim (pure heart) in the Quran is another term that expresses Islamic spirituality.God said: "and most surely Ibrahim followed his way, (remember when) he came to his lord with a pure heart" [10], 37:83-84).In Quaranic creed, heart or (Ghalb) is the source of moral virtues and moral vices.Pure heart is a kind of state of the soul in which we can find good characteristics such as, thinking, fear of the Lord, faith, virtue, trust, affection for others and peace [22].
According to Islamic literature, spirituality in Islamic theology is based on knowledge and faith in God [23].Allah is depicted as having key attributes of an attachment figure: namely, one who is close, responsive, and compassionate; and one who provides security and protection in times of danger [24].The ultimate goal of human deportment, and the real perfection of human being is to be closer to God.Therefore, faith in God is a prerequisite for the realization of Islamic spirituality.As God in his Holy book states: "believers respond to Allah and the messenger when he calls you to that which revives you.Know that Allah is between the person and his heart and that to Him you shall all be gathered" ( [10], 8:25).Although the first condition of realization of spirituality in the Holy Quran is faith in God, but it is not a sufficient condition.Nevertheless, human beings, in addition to faith in God, should do good deeds.Allah will surely bestow a pure and good life in this world only on believers who do good deeds [21].In such a structure, spirituality and religion stand in the same line and are interpreted similarly.

Methodology
In this study, a method of concept analysis was adopted to enhance the existing foundation on spiritual care.The specific approach to the analysis was the 'evolutionary view' advocated by Rodgers.The processes involved in analyzing the evolutionary concept as advocated by Rodgers consist of: (1) identifying the concept of interest and surrogate terms; (2) identifying and selecting an appropriate realm for data collection; (3) collecting relevant data for identifying the attributes of the concept, antecedents and consequences of the concept; and (4) analysis of data based on the above-mentioned characteristics of the concepts [25].After selecting an appropriate criterion for data collection, the attributes, antecedents and consequences of the concept were identified according to Rodgers' method.The data were collected by documentary methods.The literature research was not limited by start date, and it included recently published texts in November 2015.National databases such as Magiran, Hawzeh.net,Noormag, Jaame-al-Hadith, Jaame-O-ttafasir, Ahlebit library were utilized in the search for data.Keywords for the search included spirituality, nursing, health and Islam; to find relevant traditions (narrations) and verses of the Quran or commentarial books related to spiritual care.Next, all verses of the Quran and its narrations' headings and abstracts of the articles, titles and contents of books were reviewed by the lead author.In collaboration with the co-author panel, selected studies were checked to verify those accepted into the study.In this way, those that did not involve relevant narrations and verses or references to Islamic spirituality and spiritual care concerning Muslim patients were excluded.The review of each verse and narration (Hadith), commentarial books and related article was considered in identifying the Semantic units and initial coding.After review of primary codes (a), the attributes of spiritual care will be explored (b).Antecedents and consequences of spiritual care will be identified.

Attributes of Spiritual Care
The first step of the concept analysis was to determine the characteristics of the concept that leads to an actual definition.The survey of Islamic literature indicated that spiritual care was identified by a few attributes presented in the text below:

Providing Prayer Conditions
According to Islamic teachings, one of the ways of the realization of Islamic spirituality is to observe the religious rituals.Muslim patients believe that prayers, remembrance of God, repentance and giving alms would increase tolerance and patience of the patient [26].Therefore, following religious rituals at the time of sickness is more important than any other time for the patient.When a problem befalls the servant, he calls for the help of God and returns to God.As God in the Quran states: "And when distress afflicts a man he calls upon his Lord, turning to Him frequently; then when He makes him possess a favor from Him, he forgets that for which he called upon him . . ." ([10], 39:8).At this time, carrying out religious rituals such as keeping up with prayer is a compatible popular mechanism, which increases the feeling of competence and hope [27].Therefore, it is important at the hospital ward that the praying and repentance requirements for the patient and his family should be prepared.

To Guide Patients in Finding the Meaning of Illness
Humans run away from pain; on the other hand, the human life is built along with pain.As God states: "we created the human in fatigue" ( [10], 90:4).Human beings in times of illness face spiritual challenges.According to religious teachings, increase in spirituality originates from religious understanding, which can relieve the person from a feeling of emptiness, and increase the patient's ability to face the problems caused by the sickness.The nurse should be attentive to religious teachings to guide patients in finding the meaning of illness.
The most important of which are the following: accompaniment of other human beings with suffering patients ([10], 4:90), consideration of God's prudence ( [10], 2:216) as a test of God ([10], 2:155), a search for awakening and return ( [10], 32:21) and as a tool for gaining a higher moral level and a path for approaching God [28].An important duty of a spiritual caregiver is to enlighten the patient on the meaning of illness via the Quran and its traditions.

Giving Hope to the Patients
During illness, patients may be confronted by hopelessness.Nevertheless, in Islamic creed, God is regarded as the best companion and hope in times of adversity, misfortune and fear [29]-for God sees us and looks after us and does not allow the activities of the servants to be in futility; and he is kind and generous towards them ([10], 14:49).Hopelessness can lead to mental break down.According to the Quran, desperation for the mercy of God is considered paganism and a deadly sin ([10], 12:87).It is quoted by the holy Prophet Muhammad, peace be upon him, that "whenever you are ill, He heartens you to health and long life.However, this heartening does not affect the will of God (Allah); it delights the patient and bring him calmness and relief" [30].Therefore, the responsibility of the nurses is to give hope to patients in the remaining time concerning the divine mercy.

Care of Relationships
Love and kindness toward others are features of Islamic spirituality [31].Human beings need love and friendship.Therefore, the holy Quran invites humans to observe chastity of words in any discourse ( [10], 2:263).This need is even more essential among people that are ill.Spiritual caregivers use empathetic words to achieve effective contact with patients.A nurse in addition to nice discourse relations with the patient needs to have a sympathetic relation with the patient.Understanding the patient's spiritual and physical problems and emotional needs is the first step to establishing a sympathetic relation with the patient.As it is narrated by commentators of the Quran that prophet Josef attended to the nursing needs of the prisoners by consoling and admonishing them to be good tempered and honest [32,33], so it was demonstrated by Prophet Muhammad (P.B.U.H) in His tradition of taking care of Imam Ali: "He would stay awake until morning, after saying his prayers, he would come to me and ask about my condition and get information about my condition by looking at me; this He did until morning" [30].

Care of Patients in End of Life Experience
Because the nurses are aware of impending death, they should attend to the needs of the refractory patients.One of the factors that causes concern among patients is the fear of death.It is opposite to preparing the patients for a rational confrontation with death and getting ready for the next world trip.In this respect, the patient should be reminded that everyone would taste death as emphasized by the Quran: "every soul shall taste death, and to us, we shall be returned" ( [10], 29:57).Death is the continuation of life in a new format.Death for a pious person leads to the refining of sins [34].Besides that, the caregivers need to observe the religious rituals of the patients at the time of death.Accompanying one of the family members to read some Sur as of the Quran, saying a declaration of faith, (shahadatine), placing the dying towards the direction of Mecca and closing the eyes of the patient are among the respectful behaviors in spiritual care of the Muslim patients [35].

Gender Considerations in Care
One of the items of spiritual care in Islamic teachings is to observe gender considerations in the hospital environment.The Quran's teaching affirms consideration of virtues in looking upon others as well as virtues in clothing in front of alien.As God said in His book: "Saying [O, Messenger!]: to the believing men, do not stare at the women's eyes and that they should have control over their carnal desires; and this is more appropriate and purer for them.Allah has absolute knowledge of what people do; He said to the believing women that they should not stare at the men's eyes, and they should subdue their carnal desires; and they should not display their ornaments except what is customary to be uncovered [such as bracelets and rings] and that they should allow their head coverings and scarves to covert heir bosoms [if they do not wear veils . . ." ( [10], 24:30-31).
Nurses must pay more attention to the canonical commandment about looking, touching and avoiding any situation that could lead to something that contravenes religious morality.Therefore, according to people's beliefs they should avoid uncovering hijab or taking off a patient's clothes in such a way that a patient's body is exposed to aliens.Patient handling and transfer should be done with complete cover.This is a major issue in Islamic teaching especially during the handling of patients before and after operation procedures and during times of unconsciousness when a patient may not able to cover him or herself.Therefore, the separation of men from women is emphasized as part of the spiritual care at the hospital [36].

Nutritional Care
One of the approaches to spiritual care is nutritional care.According to the Quran, human beings should attend to his food needs.In this way, a human being is given the consideration for the choice of pure food: They ask you [O, Messenger!] about what is lawful for them [as food], Say: "the good and pure foods have been made lawful for you" ([10], 5:4).Pure food is made from pure materials and free from any contaminants; it should satisfy hunger and has good nutritional value to promote health [37].Inadequate attention to pure food causes spiritual disease [30].The survey of the Quran showed that the most important indicators in pure food consist of: the consumption of lawful (Halal) foods ([10], 16:114), avoidance of Haram (forbidden) foods ([10], 7:157), use of different categories of food [38] and provision of beneficial and sufficient food ([10], 7:31).Therefore, spiritual caregivers should pay special attention to supplying pure food for patients.

Identifying the Antecedents
In addition to the numerous attributes of the concept of spiritual care in Islamic literature, three antecedents or preceding phenomena were identified in the analysis.Exploration of the texts indicates that spiritual care is based on monotheistic understanding and action.To achieve this goal, the spiritual care team should consider the items mentioned below: 4.2.1.Belief in the Divine Dignity of Humans One of the preliminaries of spiritual care is the belief in the divine dignity of humans.Humans possess intrinsic dignity as well as intrinsic honor.God has prioritized humans over many of the creations (His creations) [26].
Human dignity arises from two divine features and possesses the capacity of being the hidden spirit of the Caliph of Allah [39].In addition, the human body possesses a soul with dignity, and is an instrument and a means of spiritual evolution [40].Accordingly, the patient who is under the control of the nurse is in fact the representation of divine names.The patient is the only creature that God in a symbolic statement affirmed to have a semblance with Him [31]; such an interpretation of the spiritual care shows the impact of health on the spirit.First, the resuscitation of any human from a health professional's perspective is that health is equal for all humans ([10], 5:32) and giving service to him is the same as giving service to the family of God [36].Besides, it implies tolerance in caring for the suffering patient and giving thanks to God [39].

Accepting Islamic Anthropology
In Islamic teachings, a human is made up of a body and soul ([10], 23:14).The human soul at the time of unison with the body has plant, animal, and human stages.At the plant stage, there is growth and development, and reproduction; at the animal stage, there is thinking, love and hatred for pleasure, fear and hope, stress and calmness.The human stage is characterized by the use of wisdom, power and human abilities and tendencies in experiencing and having an understanding of deism, humility and trust in God.Therefore, it has been emphasized that in the presentation of spiritual care, it is necessary to consider health and human perfection at all stages (plant, animal, and human); in this respect, not only the freedom from sufferings and serenity (at animal stage of the spirit) is considered, but in addition to that, the reduction and elimination of sufferings is considered [40].On the other hand, because of the attachment and unison of the soul to the body at all stages (natural, plant and animal), the body is sensitive and any type of changes in the body such as rise or fall of temperature leads to pain and suffering of the soul [41].Therefore, it is necessary to consider corporeal needs in spiritual care.

Nurses Efforts of being Spiritual
Knowledge of spiritual care features and their practice is the required condition in the realization of spiritual care for nurses, but it is not a sufficient condition.However, in addition to these features, they need to be spiritual humans who provide care.In this respect, the caregivers teams need to be pious [30].Besides that, they need to have sincerity of intention.Intention is the tendency and attraction of the soul towards the ultimate goal in doing an action, which has been stated in a quotation: "in fact the achievement of anyone is according to his intention" [30].
Sincerity of intention refers to the fact that the only factor that can lead to spiritual care of the patients is that of divine motivation and following God, not hypocritically and ensuring the happiness of others [42].Among the signs of sincerity of divine intention is that the nurse, in response to her work, outside the salary motivation for the job, should not look at the patient from a profit making perspective.The nurse should not debase her precious activities by disgracing the patients and setting the goal of her activities as that of assistance to the patients, because the highest-ranking human in the eyes of God is the person who has the highest consideration for others [43].

Consequences of Spiritual Care
According to Islamic sources, presentation of spiritual care is beneficial to both patients and the nursing team.Reading the Quran and practical commitment to its teachings is beneficial to coping with illness.Commentators of the Quran agreed on the healing of mental and psychological diseases through adherence to the teachings of the Quran [21,44].Using invocation, and God's remembrance, man experiences recovery from mental diseases.As is made clear in divine sayings such as the following: "Those who believe and whose hearts find tranquility and confidence in Allah's remembrance.[O, people] be sure that real tranquility for the heart rests in Allah's remembrance, regarding one's intention and action" ([10], 13:28).Moreover, spiritual care leads to a pure (Tayyebeh) life for human beings, as Allah says: "he who leads a righteous life whether male or female, while he or she is a true believer, to them He will surely bestow a pure and good life in this world; and will pay surely reward them in commensurate proportion to the best of their service" ([10] 16:97).It is a life without anything that corrupts it; in such a life, there is permanent and enduring joviality and pervasive dignity [29].It is emphasized in Islamic literature that spiritual care, besides affecting patients, has good results for nurses such as promotion of a decent life and security for the cosmic life [31], purification from sin and attaining heavenly gifts [33].

Role of the Board Certified Chaplain
The survey of attributes of spiritual care shows that it is essential to consider chaplains to give spiritual care for Muslim patients.As we mentioned above, some of attributes of spiritual care is religious care.In this way, the trained clergy men or chaplains should be deployed in hospitals in specified times to resolve the religious issues of patients such as the meaning of illness, dying, religious laws in regard to prayer, cleanness (Ahkam-e-Taharat) and end-of-life experiences.For example, the chaplains explain the meaning of illness as a test of God ([10], 2:155), a search for awakening and return ( [10], 32:21) and as a tool for gaining a higher moral level and a path for approaching God [28], or they read some Sur as of the Quran, saying a declaration of faith, (shahadatine), and placing the dying towards the direction of Mecca for the patients experiencing the end-of-life [35].In preparing the religious care for patients, it is better, at first, for nurses or health care providers to identify the spiritual needs, and then they could can the chaplains.

Discussion
In the humanistic approach, spirituality refers to the manner in which individuals look for meaning in life, and the way they experience their connectedness to the moment, self, others, nature, and to the significant or sacred.It is based on what people experience in reality, regardless of the specific religious preference containing that spirituality [45].Then, it is not the same as religiosity, if religiosity is defined to mean participation in particular beliefs, rituals and activities of traditional religions.Therefore, it is possible to be "spiritual" even though one is not affiliated with a traditional religion [14].
In Islamic literature, spirituality means awareness of the origin of the universe, worshiping God, seeking the satisfaction of God, humility, and submission, and trust which man demonstrates in all of his actions.In this way, an individual's relationship with Allah is the focal point of Islamic spirituality.As narrated in the Quran, about Ibrahim's' spirituality: "surely my prayer and my sacrifice and my life and my death are (all) for Allah', the lord of the worlds" ([10], 6:162).Spirituality is a way that human beings experience their Hayete-tayyebeh (pure and good life) and Ghable-salim.Spirituality is therefore obtained only by religiosity.
According to Islamic text, spiritual care is a series of responsible activities to patients for spiritual health promotion, preventing spiritual disease, and remedies that include religious care and general spiritual care.The religious care in Islamic view is realized in attributes such as providing prayer conditions, gender considerations in care, nutritional care, and care of patients in end-of-life experiences.Chaplains are clergy that provide religious care; however, in healthcare settings, the board-certified chaplains, regardless of their religious affiliations, provide expert spiritual care.The attributes of general spiritual care consist of: care of relationships to have sympathetic relations with the patient in finding the patient's spiritual and physical problems and emotional needs, helping them to understand the concept of illness and giving hope to the patients (one cannot give hope to patient-they need to find that on their own, but clinicians can give compassion and respect and provide an opportunity for patients to express their suffering and distress).The activities of general spiritual care should be presented by nurses and doctors and other clinicians that have training to interact with Muslim patients.
These findings show some similarities with other studies.In the study reported by Khorrami [46], religious aspects were highlighted as the most significant issues experienced in spirituality among Iranian Muslims.Thus, the study by Zaman zade et al. [47] showed that the approaches based on religion have emphasized spiritual care.Furthermore, Heidary et al. [48] reported respect for the family and observance of the religious rituals of patients at the time of death as the elements of spiritual care.
Spiritual care in this study was based on categories such as belief in the divine dignity of humans, acceptance of Islamic anthropology, nurse's efforts to be spiritual.In the study carried out by Rahnama [49], the spirituality and religiosity of the nurse was mentioned as one of the principles of spiritual care.It was emphasized in Ramezani's study [50] that the spiritual care involves numerous positive consequences such as healing for patients and promotion of spiritual awareness for nurses.This is a finding that is consistent with the present study.In a study by Bahrienian [51], the significant and positive relation between spirituality and the reduction of stress was discovered.It is a finding that has been referred to in this study.
Spiritual care in nursing through a scientific approach attends to spiritual concerns and spiritual distress by using a diagnostic framework of spiritual assessments.It then considers the visible spiritual needs of patients during an age when science was focusing primarily on the physical aspects of the person [52].However, spiritual care in Islam incorporates all spiritual needs for human beings.In this way, it considers not only health and the elevation of human being's psyche in all of its forms (plant, animal and human), but it also reduces suffering at the greater level, which is related to the eventual life of the human psyche in the life hereafter [40].
These characteristics of spiritual care in the Islamic creed are rooted in the definition of spirituality in Islamic culture.Spirituality in Islamic literature is based on faith in Allah, a monotheistic explanation of the world and approach to God.Such a definition of spirituality is differentiated from humanist spirituality, which is obtained from psychological experiences and individual feelings under the shadow of engagement with the outside world [40].

Conclusions
One of the prerequisites for giving spiritual care to Muslim patients is to learn the required skills or spiritual competencies.Attempts to get these spiritual skills are vital.A good nurse is one who is knowledgeable about his/her duty.As emphasized in Islamic sources, it is essential for the owner of each job to be scientifically proficient in his/her occupation [53].In this study, we have reviewed the Quran and Shie'h's narrations (Hadiths), finding the concept of spiritual care.The attributes of spiritual care, its antecedents, as well as its consequences were identified.In this research, it was found that spiritual care involves spiritual capacities or skills to help patients in achieving purified life (Hayate-tayebeh).These consist of providing prayer conditions for patients, giving hope to the patients, helping them to understand the concept of illness, finding hope, nurturing relationships, and caring for patients in end-of-life experiences.It is based on categories such as belief in the divine dignity of humans and acceptance of Islamic anthropology.Spiritual care also involves numerous positive consequences such as satisfying the purified life of the patients and spiritual transcendence of nurses.

Implication for Healthcare Providers
Muslim communities are affected by Islamic teachings, thus it necessitates the delivering of spiritual care to Muslim patients who have knowledge of Islamic spirituality and spiritual care.A comprehensive definition of the concept of spirituality and spiritual care stems from Islamic literature (Shie'h).This concept analysis of spiritual care contributed to the promotion of spiritual care performance in clinical fields by removing conceptual ambiguity and confirming the true meaning of spiritual care.It will be useful to nurse educators to provide generalist spiritual care within their practice and chaplains who are the ones with the qualifications for deeper or professional spiritual care.Therefore, the skills and practices of nurses and chaplains for Muslim patients affect the quality of spiritual care.