Spiritual/religious Needs of Adolescents with Cancer

Adolescents, when faced with cancer and hospitalization, experience different needs that can have a profound impact on the adolescent and their family. Spirituality and religion are helpful in order to find meaning in the experience of cancer. Therefore, the aim of this study was to explore the spiritual/religious needs of adolescents with cancer in Iran. This study was an exploratory qualitative research. Adolescents with cancer, their families and nurses working in cancer unit formed the participants. The study environment was the cancer unit and the study population was adolescents with cancer in Kerman, Iran. Purposeful sampling and, semi-structured interviews with 14 adolescents with cancer and their families and six nurses were performed individually. To analyze the data, qualitative content analysis was used. From the data analysis four main themes emerged: the need for a relationship with God; the need for a relationship with the self; the need for a relationship with others; and the need for a relationship with the environment and nature. The results of this study provided a new vision in meeting the spiritual/religious needs of adolescents with cancer. According our result, adolescents with cancer, in addition to their developmental stage, need to face the other needs that can come along with the needs of this age period. Regarding these needs, it is helpful to find purpose and meaning in the experience of suffering and pain, and it can prevent spiritual distress.


Introduction
Cancer occurs 2.9 more times in adolescents than in younger children [1].In the past decade, adolescents and youth with a cancer diagnosis and undergoing treatment have been faced with unique and difficult biological and psychosocial challenges and have been identified as a group in need of spiritual/religious care [2].There is an international attention on addressing the unique needs of adolescents with cancer but there are few psychosocial interventions for them [1].
Common cancers among adolescents are very diverse and in 10%-40% of these cases, adolescents with cancer need palliative care after initial treatment.Palliative care is a type of supportive care and it enhances the quality of life of the patient and his family members when the disease cannot be treated.Palliative care in adolescence plays an extra role in the life of an adolescent because physiological, social and physical changes are considered along with adolescence, such as independence, social skills, acceptance of peers and self-impression [3].Palliative and spiritual care is not an attempt to delay or hasten death, but it is an emphasis on spiritual and psychological care to relieve resulting spiritual, social, emotional and physical distress caused by the life-limiting disease as well as an attempt to improve the quality of life [4].
Adolescents diagnosed with cancer who are likely to die increasingly focus on spirituality and religion.During this period, they have unique spiritual needs that must be met; otherwise, it can lead to spiritual distress [5].They use different adaptation strategies to find meaning in life and spirituality can provide a way of goodness and hope [4].
We did not find any research on spirituality or religion among adolescents with cancer in Iran, but most cancer patients in the United States, including the general population and physicians, believe in God and a great number of them believe that their spiritual faith can help them recover from the disease [6].More than 90% of adolescents in the United States reported that they believe in God.In several studies, it has been reported that adolescents and young adults have used religion or spirituality to cope with their concerns related to their health, and nurses should help them to positively cope with their cancer [1,7].In the study of Sian Cotton et al., they mentioned that religion and spirituality are important for adolescents and it has been estimated that 95% of adolescents believe in God.About 85%-95% have stated that religion is important in their lives and 93% believe God loves them.Moreover, 67% believed in life after death and more than 50% participated in adolescents' religious services and groups at least monthly or prayed alone [8].Patients with cancer do not want the medical team to solve spiritual cases for them, but they want to feel comfortable about spiritual cases in relation to the medical team and do not wish to face their fear with a judgmental attitude.Spiritual needs may not be obvious at all stages of the disease [6].The health care team has an important role in providing spiritual/religious care.They need to become familiar with the concepts of religion, spirituality, spiritual needs and spiritual assessment [9].These concepts are discussed in this paper.
Religion comes from the Latin word "religare" meaning "to bind together" [6].Religion is the observable aspects of people's spirituality such as beliefs, values and rituals [10].Religion is external and a formal expression of sacredness, and is measured by variables such as belief in God, the number of religious ceremonies an individual participates in, and the number of times an individual participates in prayer and meditation [8].Spirituality and religion are closely related to each other.While spirituality is related to peoples' religious practices, religion is about rituals, practices and the belief that a person has the right to do whatever he or she likes [11].
Spirituality comes from the Latin word "spiritus" meaning life, breath, wind and air, and can be referred back to the time when God gave life to Adam and Eve [6,12].Spirituality is a complex concept and is defined in different ways according to cultural and religious factors.In nursing literature, spirituality can be defined by two aspects.One aspect is related to religion which portrays a relationship to a higher power or God, and the other aspect is the existential one which talks about purpose and meaning in life and is a source of hope, peace and strength [11].
Spirituality based on culture and religion is expressed in different ways and must be considered as a domain of humans by care providers [5].All people, regardless of belief, culture, race or religion, have a spirituality that is interpreted uniquely [12].Spirituality is a relationship with a higher power, God, the world spirit, the creator of life, or any name you like for the divine energy [6].Spirituality is a belief system with invisible components that transfers the meaning, passion and joyfulness to life events and gives the person power and peace [3].Cotton says spirituality is emotional, individual and an internal expression of sacredness; however, spiritual goodness, peace and comfort are measures of religious/spiritual faith and a source of social support [8].Spirituality includes the aspect of being and can be used for both religious and non-religious people.In religious people, religion is considered as a way of showing spirituality and should be taken into account when offering spiritual care [11].Spirituality may be an important factor in coping with the disease.Spiritual/religious compatibility means to search for one important thing when there is stress associated with sacredness [3].
For some people, religion may be an essential part of spirituality, but religion may not be important to others [13].Fawcett and Noble mentioned that spirituality is a concept broader than religion and is used to find meaning and purpose in life, even by those who do not believe in any God or religious affiliation.Some people even see themselves as non-religious but they want to speak about spiritual matters with the provider of care concerning their illness [6].All non-religious and religious people have questions about transcendence or a higher power, though spirituality is a term that is applicable to people with religious beliefs and those with non-religious beliefs because, in actuality, they both have spiritual needs [14].
Currently, the term spirituality is used with religion [13].Often, the terms spirituality and religion are used interchangeably, and for adolescents, it is difficult to distinguish between spirituality and religion because of their cognitive and spiritual developmental stage.Some researchers suggest that these concepts are interlinked and an adolescent cannot distinguish between religion and spirituality because they have no clear boundaries [10].In the research of Edward, patients considered spirituality as an abstract and difficult concept to define [15].In the present study, adolescents were not able to distinguish between the concepts of religion and spirituality, and stated that spirituality is a form of religion.We decided to combine these concepts and refer to them as spiritual/religious needs.
Spiritual needs are the deep needs of an individual; if he is able to know the needs, then he can act accordingly and find meaning, value, purpose and hope in life even when life is threatened [12].All people have spiritual needs regardless of religious beliefs or personal philosophies of life [16].The spiritual needs of non-religious patients are as significant as those of religion-affiliated patients [14].Experiencing a disease, particularly a chronic one, may cause the emergence of spiritual needs that have not been previously considered.For some religions, such as Judaism, Christianity or Islam, spiritual needs are considered by a relationship with God.Although investigating physical and psychosocial needs may be easy, it is difficult to determine and investigate spiritual needs because spiritual and religious beliefs are individual and spiritual distress symptoms may not be obvious and may be ignored [16].
Spiritual needs of children, adolescents and their parents in a review included praying, receiving support from a clergyman, positive thinking, meaning and purpose, belief in the relationship with the child after his death and the opportunity to keep alive the memory of the deceased child [5].
In different studies, spiritual needs of different groups have been investigated.In the study of Hermann, needs related to religion were the first needs of those dying [13].Pehler stated that in spite of the great deal of research in the field of spirituality and spiritual care for adults, little research has been conducted in this field for children and adolescents with chronic diseases or life-threatening conditions, while published studies show that spirituality can affect the mechanism of adaptation to a chronic disease [10].Hospitalization of an adolescent with cancer is a stressful event for adolescents and their families, and as such, they need emotional, spiritual and psychosocial supports [4].There are many ways for the assessment of spirituality and spiritual needs in order to provide spiritual care [17,18].The assessment of spirituality provides a complete image of a person's spiritual state.With such information, caregivers can consider a complete and comprehensive treatment plan for the patient's spiritual needs, especially for those who are at risk of spiritual problems [18].
Adolescence is a time for the improvement of social development and social relationships such as close relationships with friends; thus, it is speculated that disease and cancer can have a profound impact on the life of the adolescents and their family members and provide them with a great deal of stressors.Hope and spirituality are helpful in order to find meaning in the experience of cancer in these patients.Spirituality can be considered as a source of comfort and hope during this period [2,4].Therefore, we should pay more attention to the needs of adolescents at the time of hospitalization.One of these needs is a spiritual need and failure to meet these needs can cause depression and reduce spiritual wellness [7].Spirituality is an individual experience; therefore, qualitative research is suitable for it because questionnaires and quantitative research may not be able to investigate a personal experience of spirituality [18].Qualitative research has the potential of providing a foundation of adolescents' knowledge in the field of spirituality and spiritual care [5].
In the cultural context of Iran, Islam is practiced by most Iranians.They believe that disease and death is a part of God's plan, and this situation is an opportunity for prayer.In Islam, religion plays an important role in the cultural life, disease and death of a Muslim.Most families in Iran operate as the traditional nuclear family.They believe that the child is a gift from God and they should protect him or her [19].The father has special respect in the family and affection is present among the family members.Adolescents may want to see their family and friends when in a bad situation or crisis, because their relatives can help bring calmness and peace to them and they can rely on their support in this situation.
The aim of this qualitative study was to explore the spiritual/religious needs of adolescents with cancer in Iran.

Methods
This study was conducted by a qualitative method and content analysis approach.Spirituality is an individual experience and qualitative research is suitable for it [18].

Participants
In a qualitative study, participants are considered as the study sample [20].Adolescents with cancer in the hospital, their families and the nurses working in the mentioned unit formed the participants in this study.The study environment was the cancer unit and the study populations were adolescents with cancer in hospitals in Kerman, Iran.
In this study, the sampling method was purposeful.The inclusion criteria of nurses and doctors were having the experience of caring for an adolescent with cancer and the inclusion criteria of adolescents and their families were diagnosing an adolescent with cancer in the past two months and being hospitalized in one of the cancer units and informing the adolescent and his family of the definitive diagnosis of cancer and the desire to participate in the study.In this regard, in order to achieve the objectives of this study, 14 adolescents with cancer and the father of an adolescent with cancer and six nurses in the cancer unit were interviewed.

Data Collection
The researchers at different shifts referred to the research environment and with the help of the head nurse identified participants who met the inclusion criteria.Then, one day prior to the interview, a half-hour session was held to help understand and explain the objectives of the study, take an informed, voluntary consent form, and determine the time and place of the interview according to the participants' opinion.Data collection continued for six months.All interviews were conducted in the hospital's oncology unit.Times of interviews varied from 40 to 60 min according to the willingness of the participants to continue the interview.Before the interview began, approval was again obtained from participants for the interview.All the interviews were conducted by the first author.
All interviews were audio-taped and then transcribed verbatim and analyzed.For the audio tape, MP3 was used and all data were typed using the software Word and analyzed manually without using any software.Initial interviews were conducted with adolescents.Interviews with adolescents began with a general statement: "Please talk about your needs since hospitalization."Then, according to the answers to this question, the next questions were asked before moving toward spiritual needs.In the next step, the researcher found that nurses also had valuable information in this field and could contribute to the richness of the data; they were also interviewed in-depth and interviews continued until no new data were obtained.Nurses' interviews began with a general statement: "Please talk about your experience in relation to adolescents hospitalized in the unit and their needs."Then, according to the answers to this question, the next questions were asked before moving toward adolescents' spiritual needs.
After conducting 14 in-depth interviews with adolescents and five interviews with nurses, data were saturated, but for more data saturation assurance, an interview was conducted with a nurse and the father of an adolescent, and given that no new data were obtained, data saturation was assured.The interview of the adolescent's father began with questions about the adolescent's needs during hospitalization and then the adolescent's spiritual needs.

Data Analysis
In the present study, qualitative content analysis was used according to the Graneheim and Lundman approach [21].All interviews were transcribed verbatim at the end of each day.In this study, the unit of analysis of the whole interview was considered.Phrases and sentences were selected as meaningful units.The researcher read interviews several times to find the meanings of words and phrases and to get a general sense.Two researchers analyzed the data independently.Meaning units were read several times.Then, in the abstraction process, the codes were derived and proper titles were allocated to them.Subsequently, the same codes were integrated, and finally codes with the same concept were put in a category after which subcategories were determined.Then, by grouping subcategories based on similarities and differences, the main categories were formed.In the last step, according to the coding, the characteristic themes of the subcategories and categories were defined.

Rigor
To determine the study's credibility, the participants were selected with different experiences and member checking, peer checking and prolonged engagements of the study were conducted.For member checking, two adolescents and two nurses who were among the participants reviewed the codes, categories and themes and stated that their views were properly interpreted.In addition, codes, categories and themes were investigated by a Ph.D. nurse, two master's nursing students and an adolescent who were not members of the study team.For data transferability, themes and categories were confirmed by two nurses and an adolescent who had the same conditions as the participants.For data conformability, an audit trail was done and all the study steps and data collection processes were recorded in detail and with great description.

Ethics
This study was approved by the Ethics Committee of Isfahan University of Medical Sciences.Before the interview, written informed consent was obtained from the participants.Participants were assured that in each step of the study they could withdraw from the study without giving any reason and it would have no effect on their ongoing treatment process.Adolescents who were selected to participate in the study were aware of their disease.

Results
The age range of the adolescents that participated in this study was15 to 20 years old and the duration of illness was between two and 18 months with an average of 10 months (Table 1).Nurses in different positions (head nurse and nurse) workings in the oncology unit were interviewed.The minimum work experience was six years and the maximum work experience was 25 years with an average of 17 years, respectively.The minimum work experience in the oncology unit was two years and the maximum work experience in the oncology unit was 17 years with an average of about eight years.The minimum participants' age was 30 years old and the maximum participants' age was 47 years old, with an average age of about 39 years old.The four themes of this study were the need for a relationship with transcendence; the need for a relationship with the self; the need for a relationship with others; and the need for a relationship with the environment and nature.

The Need for a Relationship with Transcendence
One of the spiritual/religious needs of adolescents was the need for a relationship with transcendence.This category was defined as that of religious practice and religious attitude.
Most of the participants stated that they need appropriate facilities to do religious practices such as praying to God and reading the Quran in the unit because, for them, doing religious practices can play an important role in their peace.All of the participants believed in God and the Quran was their holy book.God was considered as transcendence and a higher power.
Some statements of the participants in this field are presented thus: "I love praying to God, here there is no place to worship, if there is a certain place it is much better, no place for praying too, no other things, of course it is an old hospital, not too much expectation" [PB5].
"I have a good relationship with God, I read the Quran, pray to heal, all heal, even the old nagging woman next to me (laughs), no place to worship and pray, if it was, it was good, and God will heal all of us" [PG9].
In this field, a participant expressed that the needs to pray in the unit but there are no suitable facilities.
"If there was a prayer house it was good, there is a mosque in the yard, I want to pray here" [PB1].
Another adolescent talked about the effect of praying on his peace: "My relationship with God is good, I pray, I want a room for praying, I want to bath but it is not clean, when I pray I calm down, my hope is God, I want to be healed soon, no need to take the drugs" [PG3].
"My relationship with God is good, I pray, pray all heal, I heal, go to school and study, my hope is God, calm down by praying, I love God, see all of us, very kind, loves all of us" [PG7].
Most of the participants talked about the need to pray to God and consider their peace a result of a relationship with God and appeal to Imams.They found peace and comfort in God's love.They went to God for help and then they found peace.
In this regard, one of the nurses talked about the need to pray in these patients: "This group of patients ask us for a shrine, a mosque for praying, they want to go to Mashhad before taking their drugs, I saw on Friday morning that they are waiting for the prayer, appeal to praying" [PN1].
Another nurse talked about his experience: "One verse of healing was above his head, one reads Quran with his family, never forget to start the chemotherapy with prayer, this time appeal more to prayer and Quran, some ask about prayer orders, ablution; there was a girl who was always careful of blood not pouring on her hands or glue, that could pray, some are looking for a quiet place, but I think they all seek God, need God's help" [PN2].
So as the participants' statements show, one of their spiritual/religious needs was the need for a relationship with God.They needed a place to do religious practices in the cancer unit or hospital, to be alone with God and relax by praying, but unfortunately there were no facilities.Thus, religious practices and religious attitude were two factors that were used in order to communicate with God and they are among the most important spiritual/religious needs of adolescents with cancer.

The Need for a Relationship with the Self
One of the spiritual/religious needs of adolescents was the need for a relationship with the self.This category was defined as the need for privacy and peace and the need for glee and fun.
Most of the participants stated that they need a quiet place with no noise and that they hate crowds.The majority of nurses, according to their experience, said that a number of these adolescents need to relax, and even expressed the need for a private room.The need for privacy and peace was reported by most of the participants because most wanted to communicate with the self and God in private and relax.
In this regard, the participants stated: "I like quiet surrounding, do not like crowd, I would like to talk alone with God" [PG9].
"I like quiet surrounding, I love a quiet place, I hate crowd.Crowd bothers me" [PB5].
Also, one of the nurses stated her experience: "Some of the adolescents need to relax, some hate crowd, need to have a private room" [PN5].
In Iran, adolescents are hospitalized in adult or pediatric units because there are no adolescent wards and in these wards adolescents' needs were not met as well.Most of the adolescents needed music and joyful songs in the hospitalization unit.Adolescents talked about the need to diversify and were not satisfied with the hospital conditions.They wanted music that expressed their feelings and emotions and met their spiritual needs.The following examples were drawn from experiences of the participants in this field.
"The unit is old, no diversity here, better playing a song, here is not joyful, our spiritual needs are not considered" [PG3]."If music was been played in the unit, it would have been better, a variety is ok, I got bored in the hospital, fatigue, I do not have appetite" [PG6].
"I like playing a song in the hospital, calm down, strengthening our spirit, I desire to heal and go back home" [PB3].
As participants' statements show, another spiritual/religious need of adolescents was the need for a relationship with the self.They needed privacy and a perfect environment for a relationship with the self.Some seek privacy and a quiet environment for a relationship with the self and others need glee, fun and even happy songs.Of course, finally they consider a relationship with the self as a channel to communicate with God and relax.

The Need for a Relationship with Others
One of the spiritual/religious needs of adolescents was the need for a relationship with others.This category was defined as that which shows the need for a relationship with the family and the need for a relationship with friends and the medical team.We thought that adolescents, due to the psychological problems caused by cancer, do not have the desire to communicate with family and may want to communicate with peers according to their psychosocial stage, but despite our thoughts, they prefer to communicate with family over peers.This need can also vary between healthy adolescents and hospitalized adolescents with cancer.
A number of participants stated the need for the presence of their family members, and expressed that communicating with the family made them feel relaxed.
The participants on the need for the presence of the family said: "I would like my relatives to come here, sister and brother, my family, talk with them, my sister jokes with me, forget the hospital" [PB2].
"My mother calms me down, but I do not want to disturb her, I want to talk to her, even when she looks at me I calm down, but she is always worried for me" [PB5].
The participants' statements show that the family's presence has a positive effect on hospitalized adolescents, and it is one of their basic needs that should be considered.
Most of the participants stated that hospitalized adolescents need empathy and understanding from others and show a willingness to talk to others, and address communicating with others.These cases indicate the need to communicate with friends and the medical team and persons other than the family in addition to the family.
Nurses on the need to empathize with adolescents said: "They need someone to listen to them, strengthening their spirit, being healed, their life makes sense, we should understand them, calm them, if time allows empathize with them" [PN1].
Another nurse stated his experience: "This group of patients have more sensitive spirit to others, adolescents love someone to talk to them, first that they do not know about the disease is good, then they deny it, crying, many are disappointed" [PN3].
As the participants' statements show, adolescents need a relationship with the family to relax and also need to talk to friends and the medical team in order to express their problems and need their empathy.So, this need of adolescents should be considered.

The Need for a Relationship with the Environment and Nature
One of the spiritual/religious needs of adolescents was the need for a relationship with the environment and nature.This category was defined as that which shows the need for a proper unit environment and the need for a proper hospital environment.
Most of the participants stated that the unit and hospital environment are not suitable for an adolescent and that they need a suitable place with more facilities.The participants considered proper equipment necessary to continue the treatment during the period of the disease.They wanted a good environment for calmness and peace, because most of them stay in the hospital for a long time and need to have proper interactions with their environment, including the ward and hospital.
Adolescents on the need for a proper hospitalization environment said: "This room is too stuffy, a larger one is better, they need windows, this window is not open, the toilet condition is not good, that is not clean, I want a private room, the unit is old, no variety, no good food, too busy, no bed, a week waiting for a bed, I hate the clothing, I think it is plastic" [PG3].
Another adolescent on the need to be hospitalized in a separate environment said: "Some hospital rooms do not have windows, too bad, we have to be separated from the rest, children and old men and women are in a room, a patient under critical conditions should be separated, adolescents should be separated from the rest" [PG5].
In this regard, another adolescent also said: "We should have food diversity, old peoples' food should not be served for adolescents, for example, food spice, our families do not have a good place, stress as well, they should also be considered" [PG2].
Another adolescent said: "Most importantly, I love our room to be separated from the rest, I and two old women are in a room, this is not fair, the room is the best, no toilet, I do not want to come and contact toilet disease, health state is good" [PG10].
The participants' statements show that the unit environment should be suitable for adolescents' hospitalization and adolescents' rooms should be separated from that of other patients, and there should be facilities including a variety of clothes and food as part of the programs for an adolescent hospitalization unit.
Most of the participants stated that it is necessary for the hospital environment to have proper conditions and natural endowments, such as recreational facilities for adolescents in the hospital.They wanted a good environment such as a hospital with a yard full of beautiful flowers and grass for walking.However, a relationship with the environment and nature is an important spiritual need among religious and non-religious people.
Adolescents in this regard said: "I need entertainment, if there is a plan such as a trip it is good, at least flowers, grass, a walk-out, and good spirit, no variety" [PG9].
"Here I get bored, no entertainment, if I had a cell phone, fun, just that I do not have, watching TV is joyful, entertainment makes me not to think" [PG8].
In this regard, the father of one of the adolescents said: "The adolescents take their drug, feel nausea, are nervous, no entertainment, no green space and happiness" [PG10].
"It is not a happy environment; the hospital environment makes them sad, not happiness" [PB4].
Some nurses on adolescents' need for a relationship with the environment said: "We have limited physical space, adolescents need fun and diversity, a joyful environment, entertainment changes their spirit, they say they need fun, we do not have facilities" [PN3].
"The environment's entertainment is too little, or probably adolescents need more fun than others, but unfortunately there is no planning, adolescents need a joyful environment, happy space, that changes their spirit, do not think about their disease, not being depressed" [PN4].
"They need a happy environment, mostly depressed, withdrawn, should have a happy environment, to make changes" [PN1].
"This age group needs fun, like music, green space with live programs, or for example, a circus, or something like this to change their spirit, of course, their conditions should be considered" [PN5].
The participants' statements show that one of spiritual/religious needs of adolescents hospitalized in the cancer unit is the need to communicate with the environment and nature.The environment of hospitalization should have appropriate facilities for adolescents with cancer.On the other hand, the adolescents need a happy environment with entertainment to reduce problems caused by the disease and hospitalization.

Discussion
This study explored the spiritual/religious needs of adolescents with cancer in Iran.These needs were a relationship with God, the self, others and the environment.In a study, the relationship with the self and others, nature and music, God or a higher power, hope, meaning and purpose in life as spirituality have been considered [15].Koenig classified spiritual needs in the three categories of a relationship with God, with the self and with others [22].Spiritual needs obtained in this study are consistent with the categories of the spiritual needs of Koenig, but there was a group of other needs in relation to adolescents that was not mentioned, which is the need for a relationship with the environment and nature.Considering this factor can be important in caring for adolescents.
In the present study, most of the adolescents considered a relationship with God as a comforting factor, and would like the hospital management to provide conditions that will enable them to perform religious and spiritual practices to feel better.In one study, adolescents stated that practices such as praying, reading the Bible and listening to religious music can be helpful to them.Similar to our study, in the study of Ragsdale, one of the participants stated, "I pray at the time of radiation," and some even stated that they got closer to God during the process of the disease [7].In another study, adolescents tried to connect with a higher power and knew it as God.They knew the way of the connection through doing religious practices.The relationships with God were seen as that of hope, praying for healing, praying for others and asking for help from God.Most of them considered spirituality as speaking with God and going to church to worship [10].In one study, the majority of adolescents considered believing in God as a source of support to cope with the disease and a sense of security in the face of death.Also, they considered faith as a source of comfort during hospitalization and prayed for forgiveness from their sins [4].
As the results of various studies show, adolescents appeal to spirituality under disease and suffering conditions and consider a relationship with God as a contributing factor in their own relaxation.These findings are consistent with the results of the present study and the only difference is in the method of communication that each of the adolescents wanted to meet their spiritual/religious need through doing various spiritual practices based on their religion.
The need for a relationship with the self was another spiritual/religious need that emerged in this study.Adolescents stated that the relationship with the self is fulfilled through the need for privacy and a quiet environment, and they sometimes need a happy environment.Some adolescents need silence to communicate with the self and to finally communicate with God.Sometimes they need a happy environment to reinforce their spiritual/religious needs.The need for privacy is one of the basic needs of adolescents and hospitalization is considered a disturbing factor [3].In a similar study, adolescents needed privacy during their hospitalization process [23], which is consistent with the results of the present study.In the study of Hermann, adolescents needed to see others smile when they came to their room in a hospital [13].In the research of Sadeghi et al., adolescents needed a happy environment with entertainment [23], which confirms the results of the present study.
The need to communicate with others was another spiritual need.Most of the adolescents needed a relationship with family and friends, and some of them stated the presence of the family and friends as their comfort factor.In the study of Hermann, consistent with the present study, adolescents needed family and friends around them and to speak with them as a spiritual need.Thus, they considered the presence of family and friends as a spiritual support [13].Cancer and its treatment have a negative impact on adolescents' relationships with peers, because due to cancer treatment, changes are created in the body that can affect the adolescent's relationship with his friends [2].In the study of Pehler, a number of adolescents were upset for not having a relationship with friends because of hospitalization.Of course, a relationship with parents was very important for them.They also needed a relationship with the medical team and school [10].For adolescents with cancer, family members can act as an important source of support that could affect the response to the treatment of cancer [2].The need to communicate with the medical team and school staff is also considered very important.Since the basis of spirituality is on the relationship, the spiritual need should be considered [15].
The need to communicate with peers is a basic need for healthy adolescents which is appropriate to their developmental stage.However, according to the results of the present study, this need can be changed in hospitalized adolescents with cancer because the need to communicate with the family at the time of hospitalization is also as important as the need to communicate with friends and may be even more important.
Another spiritual/religious need of adolescents was the need to communicate with the environment and nature.They needed to have a proper hospital and unit environment.The issue of providing facilities for an adolescent's hospitalization and the need for recreational facilities and entertainment had been raised.They loved hospitals with facilities for adolescents, even an adolescents' unit separate from that of children and adults.These results are consistent with the results of Sadeghi, stating that 90% of adolescents would like to be admitted in a unit with proper facilities and there should be a unit for adolescents [23].
In the present study, similar to other studies, adolescents needed recreational facilities in the hospital, and to have access to recreational activities in the hospital environment, if there is green space and trees.In the study of Hermann, a participant considered nature as spirituality because he believed that God's Spirit is in everything that surrounds us.Adolescents loved to see grass and trees in the hospital because they represent God's Spirit.They loved to go out and walk, and even some of those who were' not able to go out liked to look out through a window [13].In the study of Olsson, adolescents and youth about 15-29 years old needed an appropriate social and physical environment proportional to their age and they considered a physical environment designed for adolescents where they have needs proportional to their age [24].
So, this spiritual/religious need of adolescents with cancer should be considered during the period of hospitalization and a proper environment should also be considered for them until less spiritual distress caused by the disease and hospitalization is experienced.

Conclusions
In conclusion, the spiritual/religious needs of adolescents with cancer can be classified into two categories of religious and spiritual needs.The need for a relationship with transcendence is classified under religious needs and the need for a relationship with the self, the need for a relationship with others and the need for a relationship with the environment and nature are classified under spiritual needs.These results provided a new vision in relation to the spiritual/religious needs of adolescents with cancer.In this vision, adolescents with cancer, in addition to the needs of their developmental stage, are also faced with other needs of this age period.The need for a relationship with transcendence was an important spiritual/religious need.In this study, transcendence was considered as God, but as mentioned earlier, all people, regardless of their religious views, need to connect with a higher power for comfort, especially when they have a disease.The need for a relationship with the self was another important need that health professionals should consider when caring for adolescents with cancer.The need for a relationship with others and the need for a relationship with the environment and nature were the other spiritual/religious needs.As we know, healthy adolescents prefer to have a relationship with peers, but this research showed that this need can be changed in adolescents with cancer during illness and disease.The need to communicate with the environment and nature, the need to communicate with the family, medical team and school, and even the need for the presence of the family and having them engage in the adolescents' care were more highly considered than the need for the presence of friends.It is therefore necessary to provide the needed facilities in terms of environmental conditions, and to make possible the presence of the family and the adolescents' meetings with friends.Also, the medical team has an important role to play in their relationship with adolescents and their families.However, their role is to help the adolescent and his families cope with cancer.

Limitation
One limitation of this study, in terms of ethics, was the failure to conduct an interview with adolescents who were unaware of their disease.Another limitation of this study was that adolescents' mothers could not be interviewed because they were very sad that their children had cancer.Lastly, in this study all, of the participants were Muslims and their spiritual needs based their religious views may be slightly different from other religious views.

Table 1 .
Demographic characteristics of participants.