Spirituality In Heart Disease Patients From Philosophical Perspectives: A Review

1. Introduction

Cardiovascular disease (CVD) is the leading cause of global morbidity and mortality and the high death rate due to CVD reached 17.9 million people in 2019 (WHO, 2021). The physical effects of heart disease include shortness of breath, weight gain accompanied by swelling in the feet, legs, ankles or abdomen and generally feeling tired or weak (CDC, 2024). The physical impact of heart disease affects other aspects of life such as psychosocial, spiritual, cognitive, and economic. Patients experience fear, frustration, social isolation, spiritual and cognitive challenges, and economic problems related to heart disease (Saifan et al., 2024). Physical and mental impacts cause decreased QoL in heart disease patients (Polikandrioti, Kalafatakis, Koutelekos, & Kokoularis, 2019). Patients with heart disease experienced depression in 21.7% and moderate to severe anxiety symptoms in 25.5% and moderate to severe depressive symptoms in 16.3% of patients (Pogosova et al., 2021). Increasing severity of depression worsens the patient’s quality of life (Bahall et al., 2020).

Spiritual well-being and social support lead to reduced negative psychological impact and improved Quality of Life in heart patients (Soleimani, Zarabadi-Pour, Motalebi, & Allen, 2020). Religion or spirituality can be conceptualized as (1) a coping mechanism, (2) a source of social support, and (3) a tool for behavioral control (Litalien, Atari, & Obasi, 2022), spirituality and psychological resilience can help older adults with chronic illness to counteract the impact of anxiety on life satisfaction (Shabani et al., 2023).

The philosophical perspective states that the concept of spiritual healing supports personal interpretation of holistic care (Patterson, 1998). Caring will be seen as an important paradigm for the nursing profession. (Obeidat, Abu-Abboud, Al-Duhoun, & Gheeshan, 2008). Dossey and Keegan (1989) in (O’Brien, 2018) defines the concept of holism, which underlies holistic health and holistic nursing care, including the relationship of body, mind, and spirit, as “the view that the integrated whole has a reality that is independent of and greater than the sum of its parts.” Nurses who practice care that supports such holism need to envision the spiritual needs of patients as deserving equal attention to that given to physical and psychosocial problems.

Although there have been many articles discussing spirituality in heart disease, it is important to explain the role of spirituality from a philosophical perspective, so this review aims to examine the role of spirituality in heart disease patients from a philosophical perspective and based on the theory of spiritual well-being in illness.

2. Methods

2.1. Search Strategy

Literature search was conducted on several databases, namely Science Direct, Springer Nature, ProQuest, SAGE Journal, Cochran, and ScopusI databases by identifying research articles from 2019 to 2024. Specific keywords identified using “MeSH terms” are “Heart disease”, “heart failure”, “Spiritual”, “spirituality”, “spirituality”, “quality of life”. Boolean operators are used to combine these terms such as AND and OR.

2.2. Study Selection and Assessment

The first step we did was duplicate articles were removed and continued to the stage of title and abstract screening according to the inclusion and exclusion criteria. This study included descriptive and observational studies that reported the spirituality of heart disease patients (CAD, HF, Hypertension, acute myocardial infarction, and others). The studies excluded were review types and experimental methods. PRISMA guidelines were used to screen articles in this review.

A total of 880 initial records from the databases of Springer Nature (n=557), Science Direct (n=252), Scopus (n=44), Cochran (n=30), SAGE Journal (n=8), and ProQuest (n=7). The first check was carried out to remove 21 duplicate articles. Articles were screened again using the inclusion and exclusion criteria contained in the title and abstract so that 827 were removed and 53 articles remained, then articles that had full text and article eligibility. The final result was 13 articles that could be continued to the review stage (Figure 1).

Table 1 below lists the features of the studies that were reviewed.

3. Results and Discussion

Spirituality is a matter related to God or the sacred, also encompassing humanistic concepts, a sense of individual well-being, and a sense of connectedness to something greater than oneself (verna benner carson & Harold g. koenig, 2008). Spirituality can be defined as a person’s inner sense of meaning, purpose, and deep value in life. It involves personal experiences that support peace with oneself, love for God (for believers), love for others, and harmony with the environment. Spirituality is often associated with higher, transcendental aspirations, beyond self-centered worldly interests. In contrast, religiosity is more associated with formal practices regulated by religious institutions, such as prayer, worship, and ritual. Although the two are often considered related, religiosity tends to involve adherence to theological teachings and rituals of a religion, while spirituality focuses more on inner experiences and the search for meaning in life. (Sang, 2024). There are 13 articles that we reviewed, there are several results that show spiritual values in heart disease, spiritual factors that influence heart disease and the role of spiritual values in heart disease.

Nurses who practice care that supports holism need to envision the spiritual needs of patients as deserving equal attention to that given to physical and psychosocial problems. Overall, holistic nursing is supported by and in turn supports the intimate relationship between body, mind, and spirit. (O’Brien, 2018). SWB is not just spirituality or religion itself, but rather how a person feels “well” spiritually, regardless of the religion or belief that is embraced. SWB is also not identical to mental or physical health, but is closely related to both. Thus, SWB serves as a barometer, measuring how spirituality contributes to overall well-being, including how individuals deal with challenges, both physical and mental. (Paloutzian, Bufford, & Wildman, 2012). The role of spiritual values in the clinical and psychological conditions of patients based on a philosophical perspective, namely

3.1. Philosophy of Spirituality of Heart Disease Patients from an Ontological Perspective

The treatment of heart disease patients is significantly influenced by the philosophy of spirituality; it is an important component of a holistic approach to heart disease management. In the comprehensive care of patients with heart disease, spirituality plays a significant role, as it influences their coping mechanisms, quality of life, and overall well-being. From an ontological perspective, spirituality can be considered an essential component of human life, especially in cases of chronic illness. An ontological understanding of spirituality and religiosity can play a role in dealing with the suffering, guilt, and death experienced in the daily lives of patients (Freitas et al., 2020).

Spirituality helps people with heart disease find strength and meaning in their lives, which is essential for coping with their illness. Studies show that, especially in women and older patients, higher levels of spirituality correlate with better self-transcendence and spiritual well-being. (Jasso-Soto, Pozos-Magaña, Olvera-Arreola, & Cadena-Estrada, 2014). Islamic spiritual therapy and Murottal reading have been proven to significantly reduce anxiety and depression in coronary heart disease patients, improving their quality of life (Wisuda, Bin Sansuwito, & Suraya, 2024; Wisuda, Sansuwito, Suraya, Rusmarita, & Emiliasari, 2024). The means of healing based on the Islamic ontological scheme include conventional medicine, but conventional medicine will not be seen as the cause of healing. Furthermore, religiously based means (e.g., supplication, charity, ruqyah), and the active application of Islamic values (e.g., resignation and patient) can be utilized by patients who view these additional measures as a way to draw God’s attention to their illness (Arozullah, Padela, Volkan Stodolsky, & Kholwadia, 2020). In the article we reviewed, prayer is included in the healing behavior used to achieve higher spirituality (Adetunji et al., 2023).

According to O’Brien’s concept, one component of finding spiritual meaning in illness is how personal spiritual and religious attitudes and behaviors influence an individual’s perception of the spiritual meaning of their experience. Factors related to personal faith include belief in God, peace in spiritual and religious beliefs, belief in God’s power, strength derived from personal faith beliefs, and trust in God’s care. All of these factors are included in these perspectives and behaviors. (O’Brien, 2018). Spirituality is an important part of palliative care and is especially important for heart failure (HF) patients as it helps them find meaning and purpose in their lives. Spirituality helps them cope with their condition and improves their quality of life (QOL) (Tobin et al., 2022; Young, Nadarajah, Skeath, & Berger, 2013).

To interpret spirituality, nurses need to know the factors that influence spirituality, there are two articles that explain the factors that influence spirituality, including age, education level, and marital status have a positive effect on spiritual well-being both directly and indirectly, Status symptoms act as important mediators between model variables and spiritual well-being. Comorbidity factors and status symptoms also influence spiritual well-being through health perceptions (Metin & Helvacı, 2020). HF symptoms will play a role in the extent of the spiritual challenge a patient can accept (Saifan et al., 2024). Spiritual health mediates the relationship between ego strength and adjustment to heart disease. Patients with good spiritual health are better able to adjust to their illness, suggesting that spirituality enhances their resilience and ability to cope with the challenges posed by heart disease (Besharat, Ramesh, & Moghimi, 2018).

Nurses can provide patients with heart disease with a sense of meaning, purpose, and strength to cope with their illness, spirituality greatly influences the ontological beliefs of heart disease patients. This improves their psychological and emotional well-being, helps them adjust to their illness, and improves their overall quality of life.

3.2. Philosophy of Spirituality of Heart Disease Patients from an Epistemology Perspective

Spirituality has many benefits for heart disease patients, including physical, emotional, and psychological aspects. From an epistemological perspective, examining the knowledge and beliefs underlying spiritual practices and their impact on health is part of understanding how spirituality affects patient outcomes. Although spiritual needs are very common among patients with life-threatening illnesses, only a small percentage report that the medical system addresses their spiritual needs, suggesting that there is still room for spiritual care (Vermandere, De Lepeleire, Van Mechelen, Lisaerde, & Aertgeerts, 2013).

According to epistemology, the world is not only this material world; it also consists of the spiritually evolving worlds of the senses, the angels, and the limbo. According to epistemology, all creatures praise God according to their hierarchy of spirits (Asadzandi, 2009). This belief fills the knowledge of heart failure patients to believe that spirituality is a way to connect to the Divine so that healing can be given. The article we reviewed provides information that spirituality is associated with the truth that spirituality can provide healing to heart disease patients with various impacts, namely having an impact on controlling blood pressure, reducing depression, and improving the quality of life of heart failure patients.

High levels of spirituality increase the likelihood of good blood pressure control by 4.76 times (Adetunji et al., 2023). Spiritual peace predicts decreased depressive symptoms after 6 months. Religious/spiritual struggles are associated with depressive symptoms in HF patients. (Ai & Carretta, 2021). Spiritual well-being, religious well-being, and existential well-being can promote a higher quality of life (Marznaki et al., 2024).

The studies we reviewed also had valid instruments to measure spiritual and spiritual well-being that could be measured systematically, so this could explain how heart disease patients acquire and understand spirituality. This could also explain how spiritual factors influence each other. From this review we found that spiritual factors influence the ability to appraise stressors, thus influencing the formation of meaning, which impacts coping strategies, which then influences spiritual well-being and ultimately influences quality of life (Okviasanti et al., 2023). Improvement in quality of life is positively correlated with spiritual well-being (Metin & Helvacı, 2020). Quality of life has a negative correlation with age and a positive correlation with spiritual well-being (Flint et al., 2019).

Through personal experience and reflection during illness, patients gain knowledge about their spiritual needs and well-being. Interactions with health care providers who identify and address patients’ spiritual needs often help to gain this knowledge (Okviasanti, Yusuf, Kurniawati, Anggraini, & Anif, 2021).

3.3. Philosophy of Spirituality of Heart Disease Patients from an Axiology Perspective

Values and ethics related to the spirituality of heart patients are discussed in an axiological perspective. Viewing humans holistically and the uniqueness of individuals requires nurses to think about the spiritual values believed in by patients and this is also related to the patient’s religious practices (O’Brien, 2018). Spiritual care is considered an ethical obligation in holistic health care. This means respecting the patient’s spiritual beliefs and practices and ensuring that their spiritual needs are met during treatment. (Babamohamadi, Kadkhodaei-Elyaderani, Ebrahimian, & Ghorbani, 2020; Dos Santos et al., 2022).

For heart disease patients, spiritual well-being is highly valued because it has a significant impact on their quality of life, emotional stability, and coping mechanisms. Patients with better spiritual well-being report better health outcomes and lower levels of depression and anxiety (Ginting, Naring, Kwakkenbos, & Becker, 2015; Hooker & Bekelman, 2015; Sultan, Javed, & Ishaq, 2022). The articles we reviewed showed that low spiritual care needs were associated with high perceived patient burden (Wang et al., 2022) but high levels of spiritual well-being were found in the CAD group (de Eston Armond et al., 2022). This shows that everyone has different spirituality, so further research is needed on the spiritual values and spiritual needs of patients with heart disease. This can provide appropriate care for patients. Nurses should take the time to provide opportunities for patients to talk about their religious, ethical, or philosophical beliefs, as well as any fears and anxieties related to their spiritual belief system. Nurses should also provide spiritual support, help patients whenever it is beyond their ability, and be aware that patients should seek spiritual counseling or outside help, either privately or openly (O’Brien, 2018).

4. Conclusions

Spirituality is important for nurses to understand in carrying out care for heart failure patients, to understand this it is necessary to know the concept of spirituality from the ontological perspective of spirituality and religiosity so that nurses and patients can face the suffering, guilt and death experienced in the patient’s daily life. The epistemological concept of spirituality also sees the need for knowledge to make spirituality a source of treatment for heart failure patients, spirituality can manage blood pressure, reduce depression and improve the quality of life of heart disease patients. The concept of axiology is also important to understand spirituality, because humans are unique and holistic so nurses must conduct an assessment to provide spiritual support to heart disease patients so as not to violate the values in the spiritual concept and beliefs of patients.