The role of spirituality in women with breast cancer: an integrative literature review
Intended for healthcare professionals
Evidence and practice    

The role of spirituality in women with breast cancer: an integrative literature review

Helen Kerr Senior lecturer, School of Nursing and Midwifery, Queen’s University Belfast, Belfast, Northern Ireland
Erniyati Fangidae Registered nurse, Fatululi, Oebobo, Kupang, Indonesia

Why you should read this article:
  • To recognise that spirituality is an essential component of person-centred, holistic cancer care

  • To enhance your understanding of the positive and negative effects of spirituality on emotional, functional, physical, social and spiritual well-being for women with breast cancer

  • To appreciate that patients’ spiritual needs should be assessed and appropriate interventions incorporated into a plan of care

Spirituality is an aspect of human nature and should be incorporated into a person-centred, holistic assessment in cancer care. However, spiritual assessment in this context is often overlooked. This article discusses the findings of an integrative literature review which explored the role of spirituality in women with breast cancer. Four database searches were supplemented with searches of the reference lists of included articles and grey literature. A total of 18 articles were identified and four themes emerged inductively – the role of spirituality at pre-diagnosis, diagnosis, treatment and post-treatment. Spirituality was reported to have negative and positive effects on a range of aspects of well-being, including emotional, functional, physical, social and spiritual. Spirituality is unique to each individual and nurses should provide holistic care that identifies the aspects of spirituality to which individuals attribute meaning. Nurses should ensure their practice incorporates an assessment of spirituality as part of a person-centred approach to care.

Cancer Nursing Practice. doi: 10.7748/cnp.2022.e1811

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

@kerr03

Correspondence

h.kerr@qub.ac.uk

Conflict of interest

None declared

Kerr H, Fangidae E (2022) The role of spirituality in women with breast cancer: an integrative literature review. Cancer Nursing Practice. doi: 10.7748/cnp.2022.e1811

Acknowledgement

Erniyati Fangidae was awarded an Indonesian Endowment Fund for Education (Lembaga Pengelola Dana Pendidikan) scholarship for the programme of study associated with this literature review

Published online: 09 May 2022

Background

Holistic care has long been endorsed as the approach to caring for people with cancer (National Institute for Health and Care Excellence 2004). It recognises the importance of viewing the person as a whole, while appreciating the interrelationship between the mind, body and spirit (McEvoy and Duffy 2008). Holistic care includes the spiritual dimension of personhood (Caldeira et al 2017). However, spirituality is challenging to define and has diverse interpretations. Some authors correlate spirituality with religious activity and use these words interchangeably (Mabena and Moodley 2012). However, Fisher (2011) contends that spirituality is a wider concept, encompassing religious and non-religious forms. The National Cancer Institute (2017) defines spirituality as ‘encompassing experiential aspects, whether related to engaging in religious practices or acknowledging a general sense of peace and connectedness’ and defines religion as ‘a specific set of beliefs and practices associated with a recognized religion or denomination’. Non-religious components of spirituality relate to a sense of connection with other people, self-connection and/or connection with nature which provides a purpose or meaning. Spirituality is subjective and is related to the development of feelings of peace and well-being, personal values and personal growth (de Brito Sena et al 2021).

Spiritual well-being has correlations with positive health outcomes and well-being in people with cancer (Bai and Lazenby 2015). For example, people with cancer who have high levels of spiritual well-being are reported to have a better quality of life, less anxiety and lower levels of depression (Breitbart 2002, Puchalski 2012, Samuelson et al 2012, Bai and Lazenby 2015). Unmet spiritual needs can have detrimental effects on the spiritual well-being of people with cancer (Edwards et al 2010); they are more likely to be at risk of experiencing depression and a reduced sense of spiritual meaning and peace (Pearce et al 2012).

The experience of being diagnosed with cancer can cause a spiritual crisis (Hatamipour et al 2015). As spirituality is a critical component of holistic care, spiritual needs should be assessed with appropriate interventions incorporated into a plan of care (Hatamipour et al 2015, Puchalski et al 2018). Despite this, spiritual assessment is often overlooked by nurses (Caldeira et al 2017).

Breast cancer is the most prevalent cancer in women with a reported 2.3 million diagnoses globally in 2020 (World Health Organization 2021). Approximately 1% of all breast cancers diagnosed in the US occur in men and this rarity may result in unique challenges for those who develop it (Cancer Treatment Centers of America 2019), therefore breast cancer in men is not the focus of this article. A diagnosis of breast cancer is often a shock to women (Zamaniyan et al 2016) and can have a pervasive and enduring effect on their sense of well-being. Spiritual distress can be experienced at pre-diagnosis, diagnosis, treatment, survivorship and recurrence, or for some during the dying phase (Skalla and Ferrell 2015). As nurses, it is crucial to understand the role of spirituality in women with breast cancer to ensure a holistic approach to care delivery.

Key points

  • The experience of being diagnosed with cancer can cause a spiritual crisis

  • A person-centred, holistic assessment should include the spiritual component of well-being

  • Spirituality can have a positive and negative effect on various aspects of well-being over the cancer trajectory

  • Cancer nurses should be open to engaging in conversations about spirituality with patients

  • Education programmes and staff development initiatives should focus on how nurses can support patients’ spiritual needs

Aim

To explore the role of spirituality in women with breast cancer.

Method

An integrative literature review was conducted using a systematic approach that included experimental and non-experimental studies. A five-stage framework was followed; problem formulation, literature search, data evaluation, data analysis and interpretation and presentation of findings (Russell 2005). The review involved an iterative process of constant comparison of relevant extracted data, with the identification of themes used as the classification system (Whittemore and Knafl 2005).

Search strategy

Four databases were selected, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, PsycINFO and the Cochrane Library. The search terms were developed from those used in a previous integrative review of the role of spirituality in the breast cancer experiences of African-American women (Tate 2011) and were adapted following a scope of the literature to align with the focus of this review. The search terms were linked using the OR and AND Boolean operators (1) spirituality, (2) breast neoplasm OR breast cancer. The search terms were kept broad intentionally to ensure that all relevant articles were sourced. The search strategy was limited to articles written in English between 2008 and November 2018. The reference lists of included articles and the grey literature were also searched. The initial database searches were completed independently by the two authors and were updated in October 2020.

Outcome of the literature search

The initial database searches were conducted in November 2018. From the four databases 304 articles were identified (CINAHL 116, PsycINFO 115, MEDLINE 49, Cochrane Library 24). Three articles were identified from the grey literature and none from the reference lists of included articles, resulting in 307 articles. Of these, 13 duplicates were removed leaving 294. After a review of titles and abstracts 239 articles were removed leaving 55 for further screening. Full-text versions of the 55 articles were read and a further 40 were removed, leaving 15 included articles. Full-text articles that did not address the aim of this literature review were excluded. Each stage of this process was completed independently by each author.

The database searches were updated in October 2020 to capture additional published literature, which generated three relevant articles published after November 2018 identified in CINAHL, resulting in 18 articles included in the final review (CINAHL 11, MEDLINE 1, PsycINFO 3, Cochrane Library 0, grey literature 3). Table 1 gives a summary of the 18 studies included in the review.

Table 1.

Summary of the studies included in the review

cnp.2022.e1811_0001_tb1.jpg

Extraction and critical appraisal

Relevant data were extracted from the 18 articles using a standardised data extraction tool and reviewed independently by the first author (HK). Relevant data included the study objective, design, population, intervention, outcome measure, results, country and setting. Methodological rigour for each article was assessed using the Critical Appraisal Skills Programme (2021) checklists and Joanna Briggs Institute (2022) tools. Of the 18 articles, four were appraised as having strong methodological rigour, 13 as having moderate rigour and one as having weak rigour.

Findings

The findings of this literature review provide information on the role of spirituality in women with breast cancer relating to emotional, functional, physical, social and spiritual well-being. Of the 18 studies, 13 adopted quantitative methodology and five qualitative. Research was conducted in a variety of countries in three continents, US (n=8), Iran (n=3), Canada (n=2), UK (n=2), Malaysia (n=2) and Jordan (n=1). Participants/respondents in all but one of the studies identified as having Muslim, Protestant or Roman Catholic beliefs. In one study (Park et al 2018) a range of religions was represented.

The studies represented four stages of the cancer trajectory – pre-diagnosis, diagnosis, treatment and post-treatment. Four studies reported on more than one of these stages and the remaining 14 focused on one stage. Different aspects of well-being were measured using questionnaires in the quantitative studies and interviews in the qualitative studies. The smallest sample size was three (Ahmad et al 2011) and the largest was 634 (Goyal et al 2019).

Four themes emerged inductively from the studies:

Role of spirituality at pre-diagnosis

Two articles reported that spirituality had a role at pre-diagnosis in relation to emotional and functional well-being, with a negative and positive effect. These articles defined the pre-diagnosis stage as commencing from when women attended the medical doctor and while waiting for biopsy results.

Spirituality was identified by Gall et al (2009) and Gall and Bilodeau (2017) as having an effect on emotional well-being. The US Centers for Disease Control and Prevention (2018) defines emotional well-being as the absence of negative emotions, such as anxiety and depression. Gall and Bilodeau (2017) reported that a positive attribution related to God’s love and will at pre-diagnosis contributed to participants’ positive emotional well-being throughout the cancer journey. However, Gall et al (2009) found that respondents who had a positive perception of God and more spiritual involvement, such as attending activities in a church, while waiting for biopsy results reported greater distress from diagnosis to six months post-surgery.

Spirituality was also identified as having an effect on functional well-being (Gall and Bilodeau 2017), which describes the ability to accomplish daily tasks and social roles as a result of optimal physical health (Jim et al 2015). The components used to measure functional well-being in Gall and Bilodeau’s (2017) study related to providing a sense of meaning in illness, coping, accepting cancer and enjoying life. Gall and Bilodeau (2017) found that positive spiritual attribution (event was due to God’s love or will) at pre-diagnosis was associated with positive functional well-being, which led to positive forms of coping. Negative spiritual attribution (event was due to God’s anger) was associated with lower levels of emotional and functional well-being at various times in the process of adjustment.

Role of spirituality around diagnosis

Of the 18 articles, 13 reported on the role of spirituality around diagnosis, with a positive and negative effect on emotional, functional, physical and social well-being, and a positive effect only on spiritual well-being.

Several studies reported that spirituality was associated with emotional well-being at diagnosis (Sabado et al 2010, Thuné-Boyle et al 2013, Lagman et al 2014, Al-Natour et al 2017, Gall and Bilodeau 2017, Jahanizade et al 2017). Al-Natour et al (2017) and Ahmad et al (2011) reported that the Muslim faith increased emotional well-being, while Lagman et al (2014) and Sabado et al (2010) found that Protestantism and Roman Catholicism improved emotional well-being. Gall and Bilodeau (2017) and Thuné-Boyle et al (2013) reported that the superior power of spirituality alleviated emotional disturbances such as fear, helplessness and anger. Conversely, Gall and Bilodeau (2017) and Thuné-Boyle et al (2013) reported that respondents who experienced negative religious coping, for example feeling punished and abandoned by God, showed increased levels of anxiety and depressed mood. However, the strength of the relationship between spirituality and emotional well-being was identified as not significant compared with other domains of well-being, such as physical and functional (Al-Natour et al 2017).

Spirituality was also associated with functional well-being (Sabado et al 2010, Ahmad et al 2011, Swinton et al 2011, Lynn et al 2014, Al-Natour et al 2017, Gall and Bilodeau 2017). Al-Natour et al (2017) reported that functional well-being demonstrated the strongest correlation with spirituality compared with other well-being domains. Gall and Bilodeau (2017) found that negative spiritual attribution lowered levels of functional well-being, while positive spiritual attributions were consistently related to positive indicators of emotional and functional well-being and a spiritual attribution to God’s anger, demonstrating a reverse pattern of associations with well-being.

Some studies reported that spirituality had a role in physical well-being (Wildes et al 2009, Jafari et al 2013b, Al-Natour et al 2017, Jahanizade et al 2017). Physical well-being encompasses all aspects of health, including consistency of activities such as regular physical exercise, adequate sleep and healthy diet (American Association of Nurse Anesthesiology 2022). Al-Natour et al (2017) found that spirituality, through faith, enhanced physical well-being. Jahanizade et al (2017) reported that pain could restrict individuals’ physical activity, but that spiritual care such as meditation and prayer lessened pain severity. Conversely, Wildes et al (2009) indicated that spirituality had an inverse relationship to physical well-being, meaning the higher the level of spirituality the lower the level of physical well-being.

Spirituality was reported as affecting social well-being (Gall et al 2009, Wildes et al 2009, Al-Natour et al 2017). According to the United States Institute of Peace (2022), social well-being is a ‘state in which basic human needs are met and people are able to coexist peacefully in communities.’ In one study, spirituality was identified as improving social well-being through social support mechanisms, such as being part of a congregation (Wildes et al 2009). However, Gall et al (2009) reported that having a negative image of God related to lower levels of social well-being.

Finally, spirituality was identified as enhancing spiritual well-being (Leak et al 2008, Purnell and Andersen 2009, Jafari et al 2013a, Al-Natour et al 2017). Faith is one of the domains for measuring spirituality and the connection between faith and spiritual well-being contributed to the highest score in two studies (Jafari et al 2013a, Al-Natour et al 2017).

Role of spirituality during treatment

Five studies reported on the role of spirituality in treatment related to emotional and physical well-being, demonstrating a negative and positive effect on emotional well-being and a positive effect only on physical well-being.

Three studies reported that spirituality contributed to emotional well-being (Gall et al 2009, Gall and Bilodeau 2017, Sharif and Ong 2019). Gall and Bilodeau (2017) found that women who relied on positive spiritual attribution (event was due to God’s love or will) at one week pre-surgery were the least likely to attribute the cancer to God’s anger at the treatment stage. This study also reported that attribution to God’s anger was related to greater emotional distress from the treatment stage to two years post-surgery, contributing to lower emotional well-being (Gall and Bilodeau 2017). There was a link between pre-diagnosis and treatment as women who reported more religious involvement, such as frequency of attendance at religious services and perceived importance of religion and spirituality in their lives at pre-diagnosis, exhibited increased emotional distress at treatment until one-year post-surgery (Gall and Bilodeau 2007).

Spirituality also had a role in physical well-being (Jafari et al 2013b, Lagman et al 2014). Lagman et al (2014) reported that among women on active treatment, spirituality alleviated pain severity by distracting their minds from the sensation of pain when undergoing procedures.

Role of spirituality post-treatment

Two articles reported on the role of spirituality at the post-treatment stage related to physical well-being and demonstrated a negative and positive effect (Park et al 2018, Goyal et al 2019).

A higher spiritual identity was positively related to fruit and vegetable intake, as those who prayed more frequently reported eating more fruit and vegetables and exercising more. However, those who prayed more often were also more likely to be overweight or obese, and both religious service attendance and religious identity were marginally related to engaging in less physical activity. Belief in an afterlife and private prayer were significantly positively associated with higher body mass index (Park et al 2018). Goyal et al (2019) found that greater meaning – that is, feeling a sense of purpose in life and a reason for living – did not predict better subsequent physical health status.

Discussion

Spirituality is a fundamental dimension of an individual’s health and sense of well-being when diagnosed with a malignant disease (Mabena and Moodley 2012). The findings of this literature review identify that although spirituality was reported to have a valuable role in enhancing the five aspects of well-being – emotional, functional, physical, social and spiritual – it also had a negative effect, with the exception of the spiritual aspect. This appeared to be partly determined by whether the person interpreted the diagnosis as having a positive spiritual attribution (due to God’s love or will) or a negative spiritual attribution (due to God’s anger).

Unantenne et al (2013) highlighted the role of spirituality in supporting resilience and strength to cope with living with a chronic condition. The authors emphasised the importance of spiritual support to maintain patients’ level of hope, thus enhancing their emotional and functional well-being. Nurses should recognise the potential role of spirituality in individuals’ lives and in their nursing care by completing a holistic needs assessment. Holistic care must be patient-led and person-focused and recognise that the person must be cared for as a whole rather than in fragmented parts (National Cancer Action Team 2007, McEvoy and Duffy 2008). Although various nurses can contribute to a holistic needs assessment, the clinical nurse specialist is in an ideal position to undertake this assessment (Kerr et al 2021). Following a holistic needs assessment, when appropriate, individualised interventions should be developed with the patient and outlined in a care plan; in relation to the spiritual aspect of well-being, these interventions may include supportive discussions, referrals to clergy and/or contact with nature. An openness to engaging in conversations about spirituality with patients is important (Molzahn et al 2012) and nurses should consider this as an aspect of their role. To achieve this, nurses require communication skills such as listening and the ability to explore patients’ feelings about spirituality and spiritual distress (Caldeira et al 2017). Spiritual caregiving respects individual personhood and is achieved by focusing on presence, listening, connecting with family/significant others and creating openings to engage in conversations (Edwards et al 2010). Nurses should also recognise when it is appropriate to signpost people to specialist services, such as a spiritual care team.

Obstacles to incorporating spiritual care include a lack of time, personal, cultural or institutional factors and professional education needs (Edwards et al 2010). Balboni et al (2014) reported that patients did not receive spiritual care from nurses or physicians because some believed that assessing and providing spiritual care was not within their professional role and they felt highly unprepared to integrate spirituality into care. To address this, education programmes and staff development initiatives for nurses should focus on how to support patients’ spiritual needs. As religion is one aspect of spirituality, education should incorporate a range of cultural backgrounds and religious affiliations. This might address some of the reticence expressed by nurses who reported that they did not feel well-prepared to assess and provide spiritual care (Caldeira et al 2017).

Strengths and limitations

Strengths of this literature review include the focus on the role of spirituality across the cancer trajectory, that reviewed studies were sourced from three continents and that all but one were assessed as having moderate or strong methodological rigour.

A limitation is that many participants/respondents in the studies reviewed aligned with a religion as one of the sources of their spirituality. Therefore, research of the role of spirituality in women with breast cancer who have no religious denomination would be useful to understand the broader components of spirituality.

Conclusion

The findings of this literature review identify the role of spirituality in women with breast cancer at four stages of the cancer trajectory – pre-diagnosis, diagnosis, treatment and post-treatment. Spirituality had a positive and negative effect on a number of aspects of well-being over the cancer trajectory. It is crucial, therefore, that nurses assess and, when relevant, plan and deliver culturally appropriate spiritual care to people with cancer to enhance their well-being (Lee 2019) and their ability to cope with illness (Unantenne et al 2013). This is a challenge for nurses in their efforts to provide holistic care and one which requires an active person-centred approach.

References

  1. Ahmad F, binti Muhammad M, Abdullah AA (2011) Religion and spirituality in coping with advanced breast cancer: perspectives from Malaysian Muslim women. Journal of Religion and Health. 50, 1, 36-45. doi: 10.1007/s10943-010-9401-4
  2. Al-Natour A, Al Momani SM, Qandil AM (2017) The relationship between spirituality and quality of life of Jordanian women diagnosed with breast cancer. Journal of Religion and Health. 56, 6, 2096-2108. doi: 10.1007/s10943-017-0370-8
  3. American Association of Nurse Anesthesiology (2022) Physical Well-Being. http://aana.com/practice/health-and-wellness-peer-assistance/about-health-wellness/physical-well-being (Last accessed: 4 April 2022.)
  4. Bai M, Lazenby M (2015) A systematic review of associations between spiritual well-being and quality of life at the scale and factor levels in studies among patients with cancer. Journal of Palliative Medicine. 18, 3, 286-298. doi: 10.1089/jpm.2014.0189
  5. Balboni MJ, Puchalski CM, Peteet JR (2014) The relationship between medicine, spirituality and religion: three models for integration. Journal of Religion and Health. 53, 5, 1586-1598. doi: 10.1007/s10943-014-9901-8
  6. Breitbart W (2002) Spirituality and meaning in supportive care: spirituality- and meaning-centered group psychotherapy interventions in advanced cancer. Supportive Care in Cancer. 10, 4, 272-280. doi: 10.1007/s005200100289
  7. Caldeira S, Timmins F, Campos de Carvalho E et al (2017) Spiritual well-being and spiritual distress in cancer patients undergoing chemotherapy: utilizing the SWBQ as component of holistic nursing diagnosis. Journal of Religion and Health. 56, 4 , 1489-1502. doi: 10.1007/s10943-017-0390-4
  8. Cancer Treatment Centers of America (2019) What’s the Difference? Male Breast Cancer and Female Breast Cancer. http://cancercenter.com/community/blog/2019/07/whats-the-difference-female-male-breast-cancer (Last accessed: 4 April 2022.)
  9. Centers for Disease Control and Prevention (2018) Health-Related Quality of Life: Well-being Concepts. http://cdc.gov/hrqol/wellbeing.htm (Last accessed: 4 April 2022.)
  10. Critical Appraisal Skills Programme (2021) CASP Checklists. http://casp-uk.net/casp-tools-checklists (Last accessed: 4 April 2022.)
  11. de Brito Sena MA, Damiano RF, Lucchetti G et al (2021) Defining spirituality in healthcare: a systematic review and conceptual framework. Frontiers in Psychology. 12, 1-11. doi: 10.3389/fpsyg.2021.756080
  12. Edwards A, Pang N, Shiu V et al (2010) The understanding of spirituality and the potential role of spiritual care in end-of-life and palliative care: a meta-study of qualitative research. Palliative Medicine. 24, 8, 753-770. doi: 10.1177/0269216310375860
  13. Fisher J (2011) The four domains model: connecting spirituality, health and well-being. Religions. 2, 1 , 17-28. doi: 10.3390/rel2010017
  14. Gall TL, Bilodeau C (2017) ‘Why me?’– women’s use of spiritual causal attributions in making sense of breast cancer. Psychology & Health. 32, 6, 709-727. doi: 10.1080/08870446.2017.1293270
  15. Gall TL, Kristjansson E, Charbonneau C et al (2009) A longitudinal study on the role of spirituality in response to the diagnosis and treatment of breast cancer. Journal of Behavioral Medicine. 32, 2, 174-186. doi: 10.1007/s10865-008-9182-3
  16. Goyal NG, Ip EH, Salsman JM et al (2019) Spirituality and physical health status: a longitudinal examination of reciprocal effects in breast cancer survivors. Supportive Care in Cancer. 27, 6, 2229-2235. doi: 10.1007/s00520-018-4494-5
  17. Hatamipour K, Rassouli M, Yaghmaie F et al (2015) Spiritual needs of cancer patients: a qualitative study. Indian Journal of Palliative Care. 21, 1, 61-67. doi: 10.4103/0973-1075.150190
  18. Jafari N, Farajzadegan Z, Zamani A et al (2013a) Spiritual therapy to improve the spiritual well-being of Iranian women with breast cancer: a randomized controlled trial. Evidence-Based Complementary and Alternative Medicine. 353262. doi: 10.1155/2013/353262
  19. Jafari N, Zamani A, Farajzadegan Z et al (2013b) The effect of spiritual therapy for improving the quality of life of women with breast cancer: a randomized controlled trial. Psychology, Health & Medicine.18, 1, 56-69. doi: 10.1080/13548506.2012.679738
  20. Jahanizade MR, Shahriari M, Alimohammadi N et al (2017) Effect of spiritual care on pain of breast cancer patients: a clinical trial. Medical-Surgical Nursing Journal. 6, 1, e67863.
  21. Jim HS, Pustejovsky JE, Park CL et al (2015) Religion, spirituality, and physical health in cancer patients: a meta‐analysis. Cancer. 121, 21, 3760-3768. doi: 10.1002/cncr.29353
  22. Joanna Briggs Institute (2022) Critical Appraisal Tools. http://jbi.global/critical-appraisal-tools (Last accessed: 4 April 2022.)
  23. Kerr H, Donovan M, McSorley O (2021) Evaluation of the role of the clinical Nurse Specialist in cancer care: an integrative literature review. European Journal of Cancer Care. 30, 3, e13415. doi: 10.1111/ecc.13415
  24. Lagman RA, Yoo GJ, Levine EG et al (2014) “Leaving it to God” religion and spirituality among Filipina immigrant breast cancer survivors. Journal of Religion and Health. 53, 2, 449-460. doi: 10.1007/s10943-012-9648-z
  25. Leak A, Hu J, King CR (2008) Symptom distress, spirituality, and quality of life in African American breast cancer survivors. Cancer Nursing. 31, 1 , E15-E21. doi: 10.1097/01.NCC.0000305681.06143.70
  26. Lee Y-H (2019) Spiritual care for cancer patients. Asia-Pacific Journal of Oncology Nursing. 6, 2, 101-103. doi: 10.4103/apjon.apjon_65_18
  27. Lynn B, Yoo GJ, Levine EG (2014) “Trust in the Lord”: religious and spiritual practices of African American breast cancer survivors. Journal of Religion and Health. 53, 6, 1706-1716. doi: 10.1007/s10943-013-9750-x
  28. Mabena N, Moodley P (2012) Spiritual meanings of illness in patients with cervical cancer. South African Journal of Psychology. 42, 3, 301-311. doi: 10.1177/008124631204200302
  29. McEvoy L, Duffy A (2008) Holistic practice: a concept analysis. Nurse Education in Practice. 8, 6, 412-419. doi: 10.1016/j.nepr.2008.02.002
  30. Molzahn A, Sheilds L, Bruce A et al (2012) People living with serious illness: stories of spirituality. Journal of Clinical Nursing. 21, 15-16, 2347-2356. doi: 10.1111/j.1365-2702.2012.04196.x
  31. National Cancer Action Team (2007) Holistic Needs Assessment for People with Cancer: A Practical Guide for Healthcare Professionals. NHS, London.
  32. National Cancer Institute (2017) Spirituality in Cancer Care (PDQ®): Health Professional Version: Definitions. http://www.cancer.gov/about-cancer/coping/day-to-day/faith-and-spirituality/spirituality-hp-pdq (Last accessed: 4 April 2022.)
  33. National Institute for Health and Care Excellence (2004) Improving Supportive and Palliative Care for Adults with Cancer. Cancer service guideline No. 4. NICE, London.
  34. Park CL, Waddington E, Abraham R (2018) Different dimensions of religiousness/spirituality are associated with health behaviors in breast cancer survivors. Psycho-Oncology. 27, 10, 2466-2472. doi: 10.1002/pon.4852
  35. Pearce MJ, Coan AD, Herndon JE et al (2012) Unmet spiritual care needs impact emotional and spiritual well-being in advanced cancer patients. Supportive Care in Cancer. 20, 10, 2269-2276. doi: 10.1007/s00520-011-1335-1
  36. Puchalski CM (2012) Spirituality in the cancer trajectory. Annals of Oncology. 23, Suppl 3, 49-55. doi: 10.1093/annonc/mds088
  37. Puchalski CM, King SD, Ferrell BR (2018) Spiritual considerations. Hematology/Oncology Clinics of North America. 32, 3, 505-517. doi: 10.1016/j.hoc.2018.01.011
  38. Purnell JQ, Andersen BL (2009) Religious practice and spirituality in the psychological adjustment of survivors of breast cancer. Counseling and Values. 53, 3, 165-182. doi: 10.1002/j.2161-007X.2009.tb00123.x
  39. Russell CL (2005) An overview of the integrative research review. Progress in Transplantation. 15, 1, 8-13. doi: 10.1177/152692480501500102
  40. Sabado M, Tanjasiri SP, Mata’alii S et al (2010) Role of spirituality in coping with breast cancer: a qualitative study of Samoan breast cancer survivors and their supporters. Californian Journal of Health Promotion. 8, SI, 11-22. doi: 10.32398/cjhp.v8iSI.2039
  41. Samuelson BT, Fromme EK, Thomas Jr CR (2012) Changes in spirituality and quality of life in patients undergoing radiation therapy. American Journal of Hospice & Palliative Care. 29, 6, 449-454. doi: 10.1177/1049909111428607
  42. Sharif SP, Ong FS (2019) Education moderates the relationship between spirituality with quality of life and stress among Malay Muslim women with breast cancer. Journal of Religion and Health. 58, 4, 1060-1071. doi: 10.1007/s10943-018-0587-1
  43. Skalla KA, Ferrell B (2015) Challenges in assessing spiritual distress in survivors of cancer. Clinical Journal of Oncology Nursing. 19, 1, 99-104. doi: 10.1188/15.CJON.99-104
  44. Swinton J, Bain V, Ingram S et al (2011) Moving inwards, moving outwards, moving upwards: the role of spirituality during the early stages of breast cancer. European Journal of Cancer Care. 20, 5, 640-652. doi: 10.1111/j.1365-2354.2011.01260.x
  45. Tate JD (2011) The role of spirituality in the breast cancer experiences of African American women. Journal of Holistic Nursing. 29, 4, 249-255. doi: 10.1177/0898010111398655
  46. Thuné‐Boyle IC, Stygall J, Keshtgar MR et al (2013) Religious/spiritual coping resources and their relationship with adjustment in patients newly diagnosed with breast cancer in the UK. Psycho‐Oncology. 22, 3, 646-658. doi: 10.1002/pon.3048
  47. Unantenne N, Warren N, Canaway R et al (2013) The strength to cope: spirituality and faith in chronic disease. Journal of Religion and Health. 52, 4, 1147-1161. doi: 10.1007/s10943-011-9554-9
  48. United States Institute of Peace (2022) Guiding Principles for Stabilization and Reconstruction: Social Well-Being. Section 10. http://usip.org/guiding-principles-stabilization-and-reconstruction-the-web-version/social-well-being (Last accessed: 4 April 2022.)
  49. Whittemore R, Knafl K (2005) The integrative review: updated methodology. Journal of Advanced Nursing. 52, 5, 546-553. doi: 10.1111/j.1365-2648.2005.03621.x
  50. Wildes KA, Miller AR, de Majors SSM et al (2009) The religiosity/spirituality of Latina breast cancer survivors and influence on health‐related quality of life. Psycho‐Oncology. 18, 8, 831-840. doi: 10.1002/pon.1475
  51. World Health Organization ( 2021) Breast Cancer. http://who.int/news-room/fact-sheets/detail/breast-cancer (Last accessed: 4 April 2022.)
  52. Zamaniyan S, Bolhari J, Naziri G et al (2016) Effectiveness of spiritual group therapy on quality of life and spiritual well-being among patients with breast cancer. Iranian Journal of Medical Sciences. 41, 2, 140-144.

Share this page

Related articles

Chronic pain in breast cancer survivors
The 20-year relative survival rate for women diagnosed with...

Services for women with metastatic breast cancer in the US
This article describes the experience of a nurse on an...

Approaches to producing credible and useful literature reviews
Nurses at all stages of their careers can develop...

An overview of non-Hodgkin’s lymphoma
Non-Hodgkin’s lymphoma is a heterogeneous group of...

Supporting delivery of the recovery package for people living with and beyond cancer
Survivorship is an important issue in cancer care in the UK....