1. Background
In late 2019, a novel disease emerged worldwide and was quickly declared a pandemic by the World Health Organization in March 2020. This pandemic represents not only the most extensive health crisis in recent history but also a profound social and humanitarian crisis, resulting in numerous deaths, instances of injustice, discrimination, and widespread unemployment across the globe (1, 2). The COVID-19 pandemic brings not just the risk of death and hospitalization but also impacts a significant portion of the population who avoid work due to infection risk or fear thereof, leading to various negative consequences in many aspects of life (3).
In such situations, individuals' physical and mental equilibrium is disrupted, prompting the need for mechanisms like internal and external support to restore balance. The successful application of these mechanisms can lead to positive adaptation and coping strategies (4). One such internal support mechanism is spirituality, a dynamic and evolving process in every individual. This process involves an increasing engagement with life's meaning, goals, and values (5). Anthropological and psychological perspectives suggest that humans inherently seek meaning in their lives (6).
Spirituality, an intrinsic and dynamic aspect of humanity, involves the pursuit of ultimate meaning, purpose, and transcendence, and the experience of connections with oneself, family, others, the community, society, nature, and the sacred or significant. Spirituality is manifested through beliefs, values, traditions, and practices (7, 8). The literature indicates that spirituality is a traditional method for coping with illness (9). For example, spirituality and spiritual practices have been shown to be effective in recovering from diseases, reducing negative emotions such as depression, and assisting individuals in dealing with difficult and stressful circumstances. This adaptability is well documented (10, 11). Approximately 65% of patients with conditions like depression and anxiety express a desire for spirituality to be included in their treatment (12). Spirituality is acknowledged as a potent coping mechanism for dealing with adverse and life-altering events (13). It invokes inner strengths in healthcare recipients to manage illness (14).
Regarding COVID-19, spirituality can serve as a tool for coping with the disease's negative symptoms, which are commonly observed in the general public and particularly in patients exhibiting psychological symptoms (15). In this pandemic, spirituality can aid in the prevention and treatment of the disease by imbuing patients' lives with meaning, encouraging their pursuit of recovery, helping them overcome limitations, and enhancing their adherence to treatment (16). By maintaining an optimistic and hopeful outlook, patients can continue their treatment without fearing the recurrence of the disease, ultimately improving their quality of life amidst difficulties (17)).
Nurses play a vital role in supporting patients' spiritual well-being, and addressing their spiritual needs is a fundamental aspect of nursing responsibilities (18). However, some nurses are less engaged in providing spiritual care to patients due to factors such as time constraints, differences in spiritual beliefs between them and their patients, and a lack of training (19). Other studies have identified the absence of a clear definition of spirituality and ambiguity in guidelines regarding the role of nurses in spiritual care as reasons for the insufficient attention to spirituality (20, 21). Additionally, in crisis situations like COVID-19, where the demand for spiritual support increases, nurses face a significant care burden. Nonetheless, research in this area remains limited (18). Thus, the findings of this study could be beneficial in preparing nurses for spiritual care in crises and acquainting them with patients' spiritual experiences.
Although COVID-19 has had detrimental effects on all aspects of people's lives and society, the crisis has also prompted a reevaluation of spirituality. The spiritual inclinations of patients during this crisis have provided them with an opportunity to reconsider their views on spirituality, the meaning of life, and related concepts such as death, thereby facilitating the reshaping and development of their spiritual beliefs. In research focusing on patients' perspectives, it was found that attention to spirituality and the provision of spiritual care have increased their well-being (22). Hence, despite the pain and suffering caused by the disease, it is worthwhile to explore the perspectives of patients who have recovered from COVID-19. A review of the literature by the researchers indicated a lack of studies on the spiritual experiences of these patients, pointing to the necessity for further investigation in this area.
2. Objectives
This study was therefore undertaken to elucidate the spiritual experiences of patients who have recovered from COVID-19.
3. Methods
3.1. Study Design
To achieve a profound understanding of the subject matter and explore the participants' lived experiences, qualitative phenomenological studies are indispensable. This qualitative study was carried out to elucidate and interpret the spiritual experiences of patients who have recovered from COVID-19, utilizing Van Manen’s phenomenological method. Diverging from traditional phenomenological interpretive approaches, Van Manen introduces six steps for textual development and analysis (23), which are detailed in the data analysis section of this paper.
3.2. Sampling and Setting
The study participants were identified through purposive snowball sampling. The initial two participants were individuals who had recovered from COVID-19 and had been hospitalized for cardiac disease in a teaching hospital in Urmia, Iran. Subsequent participants were chosen through purposive sampling based on recommendations from the initial participants or from those admitted to the selected hospitals. The inclusion criteria mandated a history of hospitalization and recovery from COVID-19, a willingness to participate in interviews, the capability to express and share experiences, and the absence of auditory or visual impairments. Sampling concluded when data saturation was achieved, indicated by no new codes emerging during the analysis of the last two interviews.
3.3. Participants
In total, 16 individuals who had recovered from COVID-19 participated in this study; nine were women, and seven were men. Their average age was approximately 52 years, with ages ranging from 34 to 68 years. Of these, 87.5% were married, and the remainder were single. Education levels varied: Seven had not completed high school, four held high school diplomas, and five had attained university degrees. Table 1 provides detailed information about the participants.
Table 1.Descriptive Characteristics of the Participants
| Patient ID | Age (y) | Gender | Education Level | Marital Status a |
|---|---|---|---|---|
| P1 | 68 | Male | High school dropout | M |
| P2 | 35 | Female | Higher education | M |
| P3 | 56 | Male | High school dropout | M |
| P4 | 34 | Female | Higher education | M |
| P5 | 67 | Female | High school dropout | S |
| P6 | 52 | Female | High school diploma | M |
| P7 | 66 | Male | High school dropout | M |
| P8 | 43 | Female | Higher education | M |
| P9 | 51 | Female | High school dropout | M |
| P10 | 45 | Male | High school diploma | S |
| P11 | 65 | Female | High school diploma | M |
| P12 | 56 | Male | High school dropout | M |
| P13 | 35 | Male | Higher education | M |
| P14 | 48 | Female | High school diploma | M |
| P15 | 63 | Female | High school dropout | M |
| P16 | 54 | Male | Higher education | M |
a P, participant; M, married; S, single.
3.4. Data Collection
Data were gathered through in-depth, semi-structured interviews. Before the interviews commenced, the study's objectives were thoroughly explained to the participants, who then provided verbal consent for the recording of the interviews. They were also informed of their right to withdraw from the interview at any time. The interviews took place between November 2020 and June 2021. For patients hospitalized for conditions not related to COVID-19, the interviews occurred in the hospital. In other cases, interviews were held at locations chosen by the participants, such as in their cars or at their doorsteps. The researcher and the participant mutually agreed upon the interview times. The interviews lasted on average 50 minutes, ranging between 35 and 90 minutes. During hospital ward interviews, efforts were made to minimize disturbance to others; consent was obtained from other patients in the ward, doors were closed, and screens were used to ensure patient privacy while minimizing loud noises as much as possible. Guided by the study's objectives, the interview began with open-ended questions like: “Please tell us about your experience with COVID-19,” and “how did you cope with the illness?” The conversation evolved based on the participants' responses, with the sequence of questions varying among participants depending on their answers. Keeping the main research question in mind, the interviewer explored the patients’ spiritual experiences. Participants were encouraged to describe their experiences in their own words. Follow-up questions such as: “How did spirituality affect your recovery?”, “Can you share your most significant spiritual experiences?”, “In what ways did spirituality or remembering God assist you during your illness?”, “Did your relationship with God change during your illness?”, and “how did a spiritual perspective alter your view of life?” were asked to delve deeper. Probing questions like “could you elaborate?”, “Can you provide an example?”, or “what do you mean by that?” were posed to ensure thorough interviews. The interviews were transcribed manually and then typed out verbatim.
3.5. Data Analysis
Data analysis was conducted using Van Manen’s six-step method, detailed as follows: Step one involved turning towards the essence of the lived experience. Step two entailed exploring the experience as it is lived. Step three focused on identifying the core themes that define the phenomenon. Step four was dedicated to the art of writing and rewriting. Step five emphasized maintaining a robust and directed engagement with the phenomenon. Step six involved balancing the study findings by considering the relationship between the parts and the whole (24). The recorded interviews were replayed, transcribed verbatim, and meticulously reviewed several times by the first author, who then summarized his initial interpretations in a few paragraphs, thereby achieving immersion in the data. Sentences and statements that described the phenomenon were highlighted, and themes were subsequently extracted. This process involved frequent referral to the interview text by the study team to clarify the connections between themes, resolving any discrepancies through discussion. Throughout the study, the researcher continually reflected on the research question, facilitating the extraction and interpretation of themes. Ultimately, eleven subthemes and four themes were identified through reflective engagement with the data and thorough review of the interview texts.
3.6. Trustworthiness
In qualitative research, the validity of data is ensured through credibility, dependability, confirmability, and transferability (25). To uphold credibility, the interview texts were shared with participants for their feedback, which was then incorporated. The research team critically reviewed all phases of the study, integrating their suggestions at each stage. Extended engagement with the data further contributed to credibility. Additionally, the researcher's background in conducting qualitative research bolstered the study's integrity.
To ensure dependability, all research stages underwent a member check and an external review by individuals knowledgeable in research methodologies, with their feedback being applied. An assistant professor of Islamic education was also added to the research team to endorse the data analysis process.
Confirmability and transferability were assured by meticulously documenting every research stage, including data collection, interview recording and transcription, data analysis, and theme extraction, all of which are available upon request. The researcher aimed to ground the results in data derived from interviews and participant quotes. To avoid bias, a journalistic approach was employed to minimize the impact on the data and interviews. This approach helped the researcher remain impartial during interviews, carefully avoiding any influence on the participant's responses through verbal and non-verbal cues, and noting any potential biases for self-reminder.
4. Results
The analysis of data derived from the experiences of patients who recovered from COVID-19 revealed four themes and eleven subthemes, as outlined in Table 2.
Table 2.Themes and Subthemes, and Codes
| Themes and Subthemes | Codes | Frequency |
|---|---|---|
| 1. The miracle of spirituality | ||
| 1.1. Healing the soul with spirituality | Medicine heals the body and spirituality heals the soul | 17 |
| Taking care of the patient’s soul through spirituality, the same as of the body | 11 | |
| Feeling the need for spirituality during illness to appease the soul as well as the body | 25 | |
| 1.2. The magic of praying and spirituality | The miracle of recovery and deliverance from death | 21 |
| The miraculous effect of spirituality on recovery and deliverance from death | 15 | |
| Easy endurance of illness through spirituality | 18 | |
| God answering prayers for recovery | 14 | |
| The magic of prayer for recovery | 30 | |
| 2. Discovering a new meaning for life | ||
| 2.1. Rethinking death | Serious exposure to death | 17 |
| Illness as an opportunity for better understanding death | 18 | |
| 2.2. Rethinking the meaning of life | Understanding the transience and briefness of life | 11 |
| Illness as a warning from God at this stage of life | 17 | |
| Missed opportunity of living a life with spirituality | 18 | |
| 2.3. Dealing with life problems differently | Increased resilience to problems | 15 |
| Life’s problems not worthy of receiving excessive attention | 16 | |
| Less strictness in daily life | 22 | |
| 3. Reinforcing spiritual beliefs | ||
| 3.1. Approaching God | Resorting to God more due to the hardships of the disease | 9 |
| Resorting to God more due to the loneliness caused by COVID-19 | 32 | |
| Resorting to God more due to the possibility of death | 25 | |
| Resorting to God more due to fear of death | 35 | |
| Resorting to God more due to witnessing healthy and famous people die | 18 | |
| 3.2. Greater understanding of God’s power | God showing Its power through COVID-19 | 13 |
| Better understanding God’s power | 14 | |
| 3.3 Connecting with spirituality | Rigorously performing religious practices | 19 |
| Holding on to God’s thread | 15 | |
| 4. Spiritual rebirth | ||
| 4.1. Second chance | Returning to life from the brink of death and its impact on one’s attitude | 12 |
| Returning to life as a blessing from God | 11 | |
| Opportunity to live again given by God | 14 | |
| 4.2. Increased feeling of gratitude | Being thankful for being healthy | 23 |
| Appreciating the family, loved ones and others | 17 | |
| 4.3. Planning to start an empathetic life | Extra worshiping efforts | 15 |
| Expressing more kindness to others | 11 | |
| Starting a new life | 31 | |
| Planning to spend more time with the family | 27 |
4.1. Theme 1: The Miracle of Spirituality
This theme emerged as participants perceived spirituality as fundamental to their recovery. It comprises two subthemes: “Healing the soul with spirituality” and “the magic of praying and spirituality.”
4.1.1. Healing the Soul with Spirituality
Recovered patients viewed spirituality as essential for their mental well-being, not just their physical health. They believed spirituality served as a balm for the soul. One patient shared:
“As the body requires medicine and healing, so does the soul. Spiritual practices are the soul's healer. Spirituality brought peace and calm to my soul during my illness” (P16 male, 54 years).
4.1.2. The Magic of Praying and Spirituality
Participants experienced and described various aspects of this phenomenon. For example, one participant recounted:
“I prayed earnestly, and, fortunately, God heard me and responded to my prayers. Praying worked wonders and brought me back to life” (P6 female, 54 years).
Another shared:
“I was on the brink of death, believing I would not survive. Escaping from COVID-19 felt like a miracle, which I attribute entirely to spirituality” (P5 female, 67 years).
4.2. Theme 2: Discovering a New Meaning for Life
The spiritual journey during their COVID-19 infection led patients to discover new meanings in life that they had previously overlooked. This theme is divided into three subthemes: Rethinking death, rethinking the meaning of life, and adopting a new approach to life's challenges.
4.2.1. Rethinking Death
Like many aspects of human life, perceptions of death can be influenced by various factors and its significance may evolve over time. A participant shared his reflections, saying:
“Before contracting COVID, I believed I wasn't afraid of death and would face it calmly when it arrived. This belief held until I actually faced COVID. It was then I realized my perception was far from reality, likely because I had never truly encountered death before” (P13 male, 35 years).
4.2.2. Rethinking the Meaning of Life
Following their experience with COVID-19, patients reconsidered what life means to them. They recognized spirituality as a crucial aspect of their identity that had been missing before the illness. One patient remarked:
“I view my life before this illness as wasted. The meaning of life isn't what I previously thought. Without spirituality, life lacks significance and is squandered” (P6 female, 52 years).
4.2.3. Dealing with Life Problems Differently
The experience of COVID-19 led patients to change how they handle life’s challenges, increasing their resilience. One participant noted:
“After this illness, I’ve made changes in how I live. For example, I no longer dwell on problems or take them too seriously. It's not how I thought before. One shouldn't take issues so seriously but rather learn to endure them” (P3 male, 56 years).
4.3. Theme 3: Reinforcing Spiritual Beliefs
The COVID-19 outbreak heightened the patients' awareness of human vulnerability and the greatness of God, leading them to deepen their spiritual beliefs. This theme encompasses subthemes such as approaching God, gaining a better understanding of God’s power, and connecting more profoundly with spirituality.
4.3.1. Approaching God
The experience of illness, isolation, and loneliness, along with the fear of death and witnessing the deaths of younger individuals, spurred patients to seek and draw closer to God. One participant expressed:
“The more I contemplated the impact of such a tiny virus, the more I appreciated the power of God” (P16 male, 54 years).
4.3.2. Greater Understanding of God’s Power
Some participants viewed COVID-19 as an expression of God's wrath and omnipotence. They believed the disease was a divine intervention, underscoring that only God possesses the power to save humanity. One participant articulated:
“Through this illness, I recognized the existence of a supreme power governing the world, manifesting its might to humanity through a small virus. We stand powerless against God's might, reaffirming that only God can safeguard our lives” (P8 female, 43 years).
4.3.3. Connecting with Spirituality
Many patients found solace and strength in their faith, believing that adherence to spirituality was a path to recovery from COVID-19. This conviction led them to engage more earnestly in spiritual practices even after recuperation. One patient shared:
“I made numerous supplications to God for recovery, vowing to pray and fast regularly if I were healed. I pleaded for God's assistance in my healing, and now, I am committed to fulfilling those promises” (P9 female, 51 years).
4.4. Theme 4: Spiritual Rebirth
The illness catalyzed a spiritual transformation in the patients, akin to a rebirth. Although they had engaged with spirituality previously, their experience during the illness marked a profound change. This theme encompasses three subthemes: A second chance at life, an increased sense of gratitude, and intentions to lead an empathetic existence.
4.4.1. Second Chance
Many regarded their brush with death and subsequent recovery as a divine reprieve, granting them a renewed opportunity to live more meaningfully. A patient reflected:
“Surviving this disease was a divine grace, rescuing me from death's brink and offering me a second chance to lead a better and more fulfilling life” (P10 male, 45 years).
4.4.2. Increased Feeling of Gratitude
Post-recovery, patients acknowledged health as a paramount blessing and recognized the need to cherish and protect it. They also realized the value of family and close relationships, expressing gratitude for their support. A participant remarked:
“Henceforth, I will cherish and safeguard my health more than ever. Health is a divine gift that requires care and reciprocation through acts of kindness towards others” (P11 female, 65 years).
4.4.3. Planning to Start an Empathetic Life
Post-recovery, patients planned to embark on a life grounded in spiritual values, demonstrating their faith through worship and acts of kindness. A patient expressed:
“I’m determined to begin anew, showing kindness to others and my loved ones, openly sharing my feelings. I intend to be as benevolent as possible” (P2 female, 35 years).
5. Discussion
This study sought to delve into the spiritual experiences of individuals who recovered from COVID-19, employing Van Manen’s phenomenological method. From the data analysis, four primary themes emerged: “The miracle of spirituality,” “discovering a new meaning for life,” “strengthening spiritual beliefs,” and “rebirth of spiritual life.” participants highlighted the profound impact of spirituality on their healing journey, using terms like “magic” and “miracle” to emphasize the influence of spirituality and prayer on their recovery, facilitating a deeper understanding of the topic. Spirituality enabled them to navigate the challenges posed by the disease and ultimately aided in their recovery. The reliance on spirituality intensified among the patients upon contracting COVID-19, corroborating findings from other studies on this topic (26, 27). According to the participants, spirituality not only facilitated their physical recovery but also served as a solace that soothed their souls. Several studies have documented the positive effects of prayer and spirituality on disease recovery. Echoing the findings of this research, Roman et al. suggested that spirituality acts as a bolstering factor and a coping mechanism, enhancing patients' ability to handle adversity through improved strategies and bolstering their optimism for the future (28). Although the specific role of spirituality in combatting COVID-19 remains to be fully understood (29), evidence indicates that spirituality is a prevalent approach among individuals dealing with illnesses, with 65 percent of those suffering from depression and anxiety expressing a desire for spirituality to be integrated into their treatment (9, 12). Moreover, recent findings affirm that individuals with terminal conditions and those nearing the end of life derive considerable comfort from prayer. The mere presence of someone to offer a hand to hold and provide companionship in their final moments is profoundly comforting (30-32).
Another outcome of the patients' spiritual journey during their illness was the uncovering of a new meaning for life. Faced with the adversities of their condition, patients saw their recovery and return to health as divine gifts and opportunities for embarking on a life imbued with new significance. By reassessing life and embracing spirituality, they attributed fresh meaning to their existence, moving beyond the confines of material concerns towards spiritual enlightenment. It appears that encountering COVID-19 prompted some patients to revisit neglected values, motivating them to shape their futures with a focus on spirituality and introspection about their previous way of life. One significant revelation for them was a newfound approach to life's challenges, adopting a more reasoned stance. The close brush with death made them realize its proximity, prompting a deeper examination of their actions and behaviors than before. Consistent with the findings of this study, other research indicates that spirituality aids patients in more effectively managing adversities during illness (18, 33-35).
Strengthening spiritual beliefs was yet another consequence of grappling with COVID-19, leading to an enhanced connection with God, a more profound understanding of divine power, and a deeper engagement with spirituality. The drive to surmount the illness, fueled by fears of mortality, solitude in sickness, the ordeal of suffering, pandemic-induced stress, and witnessing the deaths of young and notable individuals, heightened their recognition of divine omnipotence and the existence of a supreme being. Consequently, they devoted themselves more fervently to religious and spiritual practices, clinging to the belief in a powerful, divine support. Seeking solace in faith, engaging in religious rituals, and pleading for divine intervention emerged as prominent expressions of their spirituality. They intensified their connection with the divine, seeking deliverance from the affliction. Aligning with this perspective, Modell and Kardia highlighted the role of spirituality, especially religious practices, as a beacon of hope for patients, contributing to their recuperation and optimism (36). Another study noted that the ordeal and fear associated with the disease amplified the spiritual inclination among COVID-19 patients (37).
Another significant theme identified from the data was the rebirth of spiritual life. Patients regarded their recovery from the illness as a divine gift, attributing their newfound lease on life to their prayers and devotional practices. This perceived second chance led them to value their health more profoundly. Many resolved to lead lives marked by empathy, engaging in acts of charity, showing kindness towards others, dedicating time to family, and participating in religious activities as expressions of their faith. Their spiritual existence was rejuvenated within their physical lives in a more profound manner than before, marking a deep internal transition from a focus on the corporeal to the elevation of the soul. Research has shown that life-threatening events, such as serious illnesses, can prompt a revival of fundamental beliefs and a spiritual rebirth that transforms individuals and prompts them to forge a new way of living (38, 39). Consistent with these findings, other studies on COVID-19 have noted a heightened inclination towards spirituality over physical existence among recovered patients, leading them to embark on spiritually oriented new beginnings (37, 40).
During the initial outbreaks of COVID-19, for various reasons, many patients found themselves isolated, lacking spiritual support from family members and even healthcare providers. Thus, to deepen and refine our understanding of patients' spiritual experiences and to unlock further insights, it was imperative to undertake research in this area. This study was carried out and yielded promising outcomes, demonstrating that patients, through their spiritual journey during COVID-19, found solace and comfort. Therefore, the insights gained from this study can aid in devising innovative approaches and developing targeted strategies to better prepare healthcare systems for managing similar crises in the future.
5.1. Limitations
This study was conducted in Urmia, Iran, with all participants being Muslim. The homogeneity in religious background and beliefs among the study population limits the broader applicability of the findings. While spirituality is defined differently across cultures and societies, in the cultural context of Iran, which is characterized by longstanding and deeply rooted religious and spiritual traditions, distinguishing between spirituality and religiosity may pose challenges. Considering the study’s focus on spirituality and beliefs, some participants might have hesitated to fully disclose their experiences, despite encouragement to freely share. This hesitation could stem from a concern that discussing their spiritual experiences might seem to undermine the scientific contributions of the medical team, leading them to approach sharing their experiences with caution. Additionally, pandemic-related restrictions on intra-city travel posed challenges in reaching hospitals and conducting interviews.
5.2. Conclusions
Despite its numerous challenges, the COVID-19 pandemic has fostered a spiritual awakening among some patients amidst this crisis. This phenomenon reignited an interest in spirituality, with patients crediting their healing to the transformative power of spirituality and prayer. Through reflecting on life and death, survivors adopted new approaches to life’s challenges, uncovering new meanings in their existence. The trials of sickness, along with feelings of loneliness, isolation, and the witnessing of deaths among the young and notable, drew them closer to God, enhancing their recognition of divine power and reaffirming spirituality as a neglected aspect of their lives. In response, they planned to embark on more empathetic lives post-recovery, prioritizing spiritual practices, including religious activities, acts of kindness, expressions of love towards their families, and dedicating more time to loved ones. Consequently, spirituality emerges as a potent coping strategy for those affected. Thus, the incorporation of spiritual care into patient management should be more earnestly considered by healthcare administrators in navigating the aftermath of this crisis.
