INTRODUCTION

Hematopoietic stem cell transplantation (HSCT) has become the standard treatment for many diseases and offers the hope of a cure, but it is a distinctive experience for patients.1,2 HSCT-related mortality is present throughout the whole process of transplantation, from pretransplantation to recovery, including the risks related to pretransplant infection, bleeding, graft-versus-host disease, infection, relapse, and gastrointestinal complications because of immune function complexity. Long-term rehabilitation and the uncertain risk of death evoke feelings of vulnerability, helplessness, and intense fear.2,3 Prior literature has reported that patients have different coping styles when facing life-threatening diseases.4,5 A negative coping style can deteriorate the quality of life and the prognosis of patients,6 while a positive coping style can relieve the psychological pressure of patients.1

Spirituality originates from religion and can be defined as “experiencing a meaningful connection to our core selves, others, the world, and/or a greater power, as expressed through our reflections, narratives, and actions”; 7 thus, spirituality does not always contain notions of a formal religion.8 Spirituality is a major component for patients with life-threatening diseases as it provides them with comfort, personal growth, and meaning in life.9 Several studies have proven that spirituality and beliefs play significant roles in patients’ positive coping styles in the face of cancer diagnosis and treatment 10,11 and indicate better health outcomes, such as allowing patients to better adjust to their illness and better experience the meaning of life.12,13

At present, qualitative studies of HSCT mainly focus on the survival experience before, during, and after HSCT. Studies on the spiritual experiences of patients with HSCT are rare. Spiritual experiences often promote positive health outcomes as a dimension of quality of life or as an aspect of supportive care, but it is not clear what role spiritual support plays in HSCT patients. There are some limitations in single qualitative research regarding the guidance of clinical practice. Therefore, we aim to integrate qualitative and quantitative research evidence on the spiritual experiences of HSCT patients to understand the spiritual experiences and needs of HSCT patients more comprehensively and promote people-oriented nursing clinical practices.

METHODS

Based on Pluye and Hong’s 14 framework, a systematic mixed studies review (SMSR) was conducted to evaluate and integrate evidence on the spirituality of patients undergoing HSCT and to describe the role of spirituality in the experience of HSCT patients. This review integrated qualitative, quantitative, and mixed research methods to ensure a comprehensive understanding of the phenomenon.14 The application of the seven steps of the mixed studies review guidelines ensured the rigor of the review.14 In addition, we used the preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement 15 to report the results of integration.

  1. 1.

    Stage 1: Formulate a Review Question

What role does spirituality play in the experiences of patients undergoing HSCT?

  1. 2.

    Stage 2: Define the Eligibility Criteria

Published qualitative, quantitative, and mixed methods studies were included to gain a comprehensive understanding of HSCT patients’ spirituality. The inclusion criteria were as follows:

  1. (i)

    Research type: Qualitative research, quantitative research, and mixed methods studies.

  2. (ii)

    Sample: Individuals who express spirituality before or after undergoing HSCT.

  3. (iii)

    Research content: Articles were included if they mentioned or referred to any of the selected spiritual experiences, viewpoints, domains quality of life, or needs in the process of HSCT.

  1. 3.

    Stage 3: Apply an Extensive Search Strategy

The main search terms are as follows: spirituality, spiritualism, spiritual therapies, spiritual healing, exorcism, survivorship, hematopoietic stem cell transplantation, and bone marrow transplantation. See Table 1 for the specific search strategy.

  1. 4.

    Stages 4 and 5: Identify and Select Relevant Studies

Table 1 Search Strategy to Identify Articles About HSCT Spirituality (Search Date: from Record to 2019 February 23)
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Searches were conducted in the PubMed, Web of Science, Embase, CINAHL, and Cochrane Library databases (from date of record to 2019 February 23). Two reviewers (first author and last author) independently screened the abstracts of the articles identified by the search strategy. The two reviewers discussed and reached a consensus on the papers that should be included. The process of literature identification is shown in Figure 1.

  1. 5.

    Stage 6: Appraise the Quality of the Included Studies

Figure 1
figure 1

Flow diagram of individual studies screening.

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Critical appraisal was conducted in collaboration between the first author (L.Y.Z.) and the last author (X.Y.Z.) by using the Mixed Methods Appraisal Tool (MMAT) (Version 2018). All of the articles were significant in relation to the spiritual domain, and none were excluded in the quality appraisal process. Please see Table 2 for MMAT scoring; a star represents an affirmative answer to a question.

  1. 6.

    Stage 7: Synthesize Included Studies

Table 2 Description of Studies Included in the Mixed Methods Systematic Review
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The thematic synthesis framework developed by Thomas and Harden 16 was conducted in three stages (re-reading and understanding the results or the findings section of each article, identifying similar concepts across studies, and identifying themes). Specifically, the main authors immersed themselves in the data by reading and re-reading the results or the findings section of each article, identifying simple concepts across the articles, and producing a synthesis that is close to the findings of the included articles. New themes emerged and changed through discussion by the authors. In our study, two main researchers (L.Y.Z. and X.Y.Z.) from our research group repeatedly read the backgrounds, methods, results, and discussions of the original research to understand the results of the original research as much as possible. To reduce the risk of data bias, the two authors summarized similar topics and identified a more appropriate topic through discussion when they had differences.

RESULTS

Included Studies

A total of 652 records were identified, and after deduplication, 35 articles were included in this review (please see the PRISMA flow diagram in Fig. 1). These 15 qualitative studies, 19 quantitative studies, and one mixed method study were published between 1997 and 2018. The quantitative studies include quantitative descriptive studies and nonrandomized psychoeducational support intervention studies. The qualitative studies include grounded theory studies, descriptive or hermeneutic phenomenological studies, qualitative descriptive studies, thematic or content analyses, and case analyses. The mixed research method consisted of a convergent design. Please see Table 2 for the characteristics of the studies and Table 3 for the characteristics of the participants.

Table 3 Demographic Baseline of Participants
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Critical Appraisal

There are differences in the methodological quality of the studies. All of the articles were significant in relation to the spiritual domain, and none were excluded in the quality appraisal process. Please see Table 2 for MMAT scoring; a star represents an affirmative answer to a question. The reasons for scoring 4 stars are as follows: a high rate of attrition that leads to a high risk of nonresponse bias,17,18,19 small samples that may lack representativeness,20,21,22 and unclear data analysis methods.23

Inductive Analysis

The inductive analysis of the 35 studies revealed the following three themes: the spiritual experiences of HSCT patients, the spiritual coping styles of HSCT patients, and the spiritual changes brought about by HSCT (Tables 4, 5, and 6).

Table 4 Summary Table of Spiritual Experience
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Table 5 Summary Table of Spiritual Coping Style of HSCT Patients
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Table 6 Summary Table of Spiritual Changes
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Spiritual Experiences of HSCT Patients

The sample of this SMSR included respondents both with and without religious beliefs, but none of the original studies included in this SMSR separately described the spiritual experiences of patients without religious beliefs in detail. Feeling connected with God was the common spiritual experience of religious HSCT patients.1,24,25,26,27,28 This feeling was usually manifested in the aspects of a “positive view of disease” and “belief in God and destiny.” After knowing that they were ill, most religious participants viewed the illness positively; some were willing to think that their “sickness is not seen as a misfortune,” 25 and even that HSCT is a “divine test,” 27 thereby affirming that “their life has a purpose.” 28 Most of the religious participants were willing to believe in God,27, 28 although some patients thought that their illness was an atonement or a punishment for sins, which they accepted frankly.27 Quantitative evidence indicated that spiritual experiences in all sample groups were affected by complications, ethnicity, education, culture, and income.17,22,29,30,31 Harris et al.21 and Prince et al.29 indicated that the QOL of patients with the lowest spirituality level is significantly different from those with higher spirituality levels. Pereira et al.32 proposed that patients with a spiritual absence and problematic compliance had greater hazards regarding 1-year all-cause mortality.

The participants included in this SMSR thought that the current system did not meet their spiritual needs. For example, the participants with religious beliefs thought that their spiritual experience during this difficult period needed the help of a psychotherapist.33 In addition, when assessing QOL, both patients with religious beliefs and those with nonreligious beliefs tended to choose scales with spiritual items.34 Some religious participants felt that spiritual/religious struggle was due to perceived risk and limited time,23,26 which are significantly associated with gender, race, and time since diagnosis but not with QOL or medical variables.18,35

Spiritual Coping Styles of HSCT Patients

There are two forms of spiritual coping. External forms 3,25,28,36,37 of spiritual coping for religious participants include “supplication,” “reading from the Holy Book and listening to its Recitation,”25 and “receiving spiritual encouragement from family support or other survivors.” 25,28 Internal forms 1,3,25,28,33,38 of spiritual coping for religious participants include patience,25 “acceptance of fate,”1 “reliance on faith,”1 and a “genuine belief in God as the best cure for disease and sickness.”25

In contrast, external forms of spiritual coping for nonreligious participants include “seeking spiritual support from family members or friends” 36 and “finding meaning of life.”3 Internal forms of spiritual coping for nonreligious participants include “appreciating life” 3 and “self-purification.” 33

Spiritual Need Changes Brought About by HSCT

Both participants with religious beliefs and those with nonreligious beliefs usually felt “spiritual dependence increases” after HSCT.11,20,22,28,31,32,44,45 Religious participants had a greater reliance on religious and spiritual activities after HSCT,42 such as “more committed to prayers than before; an increased faith in God helped me to feel stronger.”25 The studies included in this SMSR did not elaborate on these details for nonreligious participants. A quantitative study indicated that there was a significant negative association between spiritual growth and total perceived stress.39 Older participants reported more spiritual growth than younger participants.19 Religious faith and the meaning of peace dimension of spirituality improved after HSCT but not after allogeneic HSCT.8,17,19,29,40,41 It is possible that there are more complications and symptom burdens related to allogeneic HSCT than to autologous HSCT.

DISCUSSION

Summary of Evidence

This SMSR has integrated qualitative and quantitative evidence on the spiritual experiences of patients who underwent HSCT. In this SMSR, most participants 1,25,27 were Muslims. Other participants 28,42 had diverse religious beliefs, including Presbyterian, Christian, Baptist, Catholic, Roman Catholic, Catholic, Protestant, Mormon, others, and none. The following three themes were revealed: the spiritual experiences of HSCT patients, the spiritual coping styles of HSCT patients, and the spiritual need changes brought about by HSCT. The lack of spiritual support is a key issue in the spiritual experiences of HSCT patients, although they have different spiritual coping styles. Both participants with religious beliefs and those with nonreligious beliefs usually felt “spiritual dependence increases” after HSCT.

The integration results showed that HSCT patients need spiritual support regardless of whether the participants have various religious beliefs. The content and form of spirituality are different in participants with different religious beliefs. Religion has a great influence on Muslims’ daily lives, especially during difficult times, which indicates the importance of incorporating religious needs into the nursing plans for Muslim patients and survivors.25 Ragsdale et al.28 have shown that faith participants can use their beliefs to “accept spiritual encouragement.” Patients with higher levels of religious beliefs are more willing to accept medical intervention guidelines than are those with lower levels of religious beliefs.43 Previous studies 7,12,13 have shown that religious and spiritual beliefs contribute to cancer adaptation. These findings are consistent with the integrated results of this study.

The spiritual support of patients without religious beliefs comes from the company of family, friends, or nurses. According to Liang et al.,44 families can satisfy the spiritual needs of patients by accompanying the patients. These patients share an appreciation for the people who bolster their faith. Therefore, support from patients or nurses with the same beliefs should be involved in the healthcare systems. Consequently, meeting and understanding the spiritual needs of patients and families in the healthcare systems will provide better care and higher satisfaction levels for HSCT patients. Alnasser et al. indicated that patients seek help from family members to meet their spiritual needs because hospitals do not provide such services.33 Therefore, professional spiritual services should be provided in the care plan of every HSCT patient. We suggest that priests with clinical education backgrounds as psychotherapists should be involved in the field of health care in the future. These priests can be instructed to provide suitable spiritual-based interventions for patients, which would contribute to improving the quality of life of HSCT patients.

Strengths and Limitations of the Review

To the best of our knowledge, this is the first systematic mixed studies review to integrate and assess evidence on the spiritual needs of patients undergoing HSCT. Although the search strategy was thorough, it may have missed sources in the gray literature. The included studies were conducted in countries with strong religious beliefs (Canada, Iran, Saudi Arabia, the USA), which means that the current study results may be quite different from the results of other countries. Thus, the current results are not enough to show the full picture of the role of spirituality in the experience of HSCT. Different researchers may have different integration themes due to the subjective determination of researchers. To reduce the risk of data bias in the current study, two main researchers (L.Y.Z. and X.Y.Z.) from our research group summarized similar topics and identified a more appropriate topic through discussion when they had differences.

CONCLUSION

It is certain that all patients need spiritual support during an illness. HSCT patients with different cultural backgrounds may have different spiritual experiences and spiritual coping styles. However, few medical institutions currently offer spiritual healing. Nurse psychotherapists or professional priests should be considered to provide spiritual care for patients undergoing HSCT, to help patients cope with disease pressures, promote their comfort, and improve their quality of life.