The impact of spiritual care on the psychological health and quality of life of adults with heart failure: a systematic review of randomized trials

Background Heart failure (HF) brings not only physical pain but also psychological distress. This systematic review investigated the influence of spiritual care on the psychological well-being and quality of life in adults with HF. Methods We conducted a systematic literature review following PRISMA guidelines, searching seven electronic databases for relevant randomized controlled studies without language or temporal restrictions. The studies were assessed for quality using the Cochrane Bias Risk tool. Results A total of 13 studies (882 participants) were reviewed, investigating interventions such as religion, meditation, mental health, cognitive interventions, and spiritual support. Key factors influencing the effectiveness of spiritual care implementation included integration into routine care, respect for diversity, patient engagement, intervention quality, and alignment with patient beliefs. The majority of the studies indicated that spiritual care has a potentially beneficial impact on the mental health and quality of life of patients with HF. Conclusion The findings provide valuable insights for healthcare professionals, highlighting the importance of adopting a spiritual care approach to healthcare for this population.


Introduction
HF is a prevalent and debilitating chronic disease (1), affecting millions of individuals globally (2).It is a complex syndrome characterized by the heart's inability to pump sufficient blood to meet the body's metabolic demands (3,4), resulting in symptoms such as fatigue, dyspnea, and fluid retention (5).As HF progresses, individuals may experience physical limitations, reduced exercise tolerance, and recurrent hospitalizations, significantly impacting their overall functional capacity and independence (6,7).The psychological burden is significant, with patients experiencing anxiety, depression, fear of worsening symptoms, and uncertainty about the future (8,9).Managing HF involves multifaceted medical treatments, lifestyle modifications, and psychosocial support from professionals and family (10).Despite medical advancements, HF still carries high morbidity, diminished quality of life, and increased mortality rates (11,12).The physical and psychological challenges of HF require comprehensive, patient-centered care (13).As the global population ages, the prevalence of HF is expected to increase significantly (14), highlighting the importance of exploring innovative interventions to improve adults with this condition (15).In recent years, healthcare professionals and researchers have increasingly recognized the importance of addressing psychological and spiritual aspects of health in addition to traditional medical approaches (16).Spiritual care, defined as providing support in individuals' search for meaning, purpose, and connection with something greater than themselves (17,18), has emerged as a potential complement to conventional medical management for chronic diseases, including HF (19).
Spiritual care recognizes the importance of psychological, emotional, and spiritual factors in holistic well-being and coping (20).Beyond religious aspects, it includes practices like prayer, meditation, mindfulness, counseling, and social support (21).In healthcare settings, spiritual care aims to address existential concerns, promote resilience, instill hope and purpose, and aid in coping with chronic diseases (22).Although studies have explored spiritual care's impact on health conditions, its influence on the psychological well-being and quality of life in adults with HF is an ongoing area of investigation (23).Recognizing the potential benefits of spiritual care is crucial as it offers a patient-centered addition to the current management of HF.However, evidence on the effectiveness of spiritual care interventions in this population is fragmented, with varying results across studies.
To address the gap in understanding the effectiveness of spiritual care in adults with HF and provide a comprehensive understanding of the topic, we conducted a systematic review.The objective of this systematic review was to determine the impact of spiritual care interventions on the psychological health and quality of life of adults with HF.Specifically, we aim to address the following research questions: Through this systematic review, we aimed to provide healthcare professionals, policymakers, and researchers with a comprehensive overview of the current evidence on the role of spiritual care in the management of HF.The findings may serve as a foundation for future research, leading to tailored interventions for adults with HF.

Design
Systematic review according to the recommendations of the PRISMA guidelines.Meta-analysis was not performed due to the inclusion of diverse interventions in the studies.Studies included in this review must be controlled trials (CTS) using a rigorous study design.

Identification
Electronic databases were used to search the relevant literature, such as PubMed, Web of Science, Google Scholar, Science Direct, Elsevier, Springer Link, and Wiley.The initial step involved identifying keywords and phrases relevant to the research topic: "spiritual care," "heart failure," "adults," and related terms.Search strategies were created by combining the identified keywords using Boolean operators (AND, OR).Search strategies: ("spiritual care" OR "spirituality" OR "spiritual intervention" OR "prayer" OR "meditation" OR "mindfulness practices" OR "religious rituals" OR "counseling" OR "support groups) AND ("heart failure").

Screening
Endnote 20 software was used for literature screening (24).Initially, 1459 articles were retrieved from databases.After identifying and removing 66 duplicate articles using the software, 1393 articles remained.Subsequently, the titles and abstracts of the retrieved articles were assessed, resulting in the exclusion of 1289 articles that were irrelevant to the research topic.Next, a full-text evaluation was performed on the remaining 104 articles, excluding those that did not meet the research objectives and screening criteria.
Inclusion criteria: (1) Studies that investigated the impact of spiritual care interventions on adults with HF. (2) Spiritual care interventions could encompass a variety of approaches, such as prayer, meditation, mindfulness practices, religious rituals, counseling, support groups, and any interventions that explicitly address the spiritual well-being of the participants.(3) Controlled trial study.Eligible comparators could include standard medical care, usual care without a spiritual care component, placebo, or alternative psychosocial interventions.(4) The primary outcomes of interest were related to the psychological health and quality of life of adults with HF.Psychological health outcomes could include but were not limited to measures of depression, anxiety, stress, coping strategies, and existential well-being.Quality of life outcomes could include both disease-specific measures related to HF and generic measures assessing overall well-being, physical functioning, social The two authors (nurses) screened the titles of the retrieved articles and separated potentially relevant articles.The eligibility of the relevant abstracts was reviewed independently by the two authors, who examined the abstract of each article.The two authors used standard pretest selection forms independently to assess eligibility.When necessary, other researchers would be involved to reach a consensus.

Eligibility
The 104 articles that met the initial screening requirements were analyzed in detail according to predefined inclusion criteria, of which 13 articles cared for adults with HF by either a spiritual or spiritual care intervention or by conventional care.At least one aspect of mental health or quality of life was measured using a questionnaire and other measurement tools (Figure 1).

Included articles
Following a full-text evaluation of the research objectives and selection criteria, we identified relevant literature for further analysis.These selected articles closely aligned with the research objectives in theme, sample, methods, and results.The eligible literature was utilized for data extraction, analysis, and synthesis to support research conclusions and findings.Table 1 lists the relevant literature meeting the research objectives and selection criteria.
The number of patients evaluated was small; The study did not include data about the prognosis of the patients.This study did not define the exact mechanism of action of meditation over the sympathetic system.
To determine the efficacy of hope-promoting interventions based on religious beliefs on the QOL of patients with congestive HF (CHF).
Hope-promoting intervention based on religious beliefs is a useful method for improving QOL in patients with CHF.
The sample size was small.
To compare the efficacy of two interventions addressing emotional and existential well-being in early life-limiting illness.
Identifying appropriate measures of existential distress and growth, beyond anxiety and depression, is crucial for advances in our ability to adequately assess the mechanisms that decrease existential suffering.
Not screening for distress limits understanding for Outlook's efficacy among palliative care patients; Low average distress levels hinder insights into Outlook's effectiveness for highly distressed patients; Short-term followup (1 and 3 weeks) doesn't capture longer-term impacts on patients and families.
To evaluate the efficacy of an relaxation response (RR) intervention program on the QOL and exercise capacity of CHF patients.
A short RR intervention can improve some aspects of QOL in CHF patients.
All veterans, nearly all men and with moderate CHF severity.The results are thus not generalizable to nonveterans, women, or patients with mild or severe CHF.
To evaluate the effectiveness of a Transcendental Meditation (TM) stress reduction program for African Americans with congestive heart failure (CHF).
Results indicate that TM can be effective in improving the quality of life and functional capacity of African American CHF patients.
First, some of the comparisons should be interpreted with caution because of the small sample size.Second, our results is limited.Last, Given the short followup, long-term effects of the intervention remain to be investigated.
To test the feasibility of an RCT of a holistic care model, inclusive of spiritual support, for patients with advanced heart failure (AHF).
Overall, the key message of this study is that researchers must evaluate whether the cost of running a well-designed trial of this nature is justified in the current economic climate, where funding bodies are looking for value for money.
Fewer patients were recruited than anticipated, and recruitment and data collection took much longer than expected.limitations.Where information was missing or unclear, we tried to contact the trial authors for further information.

Cochrane bias risk assessment
The Cochrane bias risk assessment tool was evaluated on seven criteria, including random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other biases.For each item, low bias, uncertainty of bias risk, and high bias were used to judge and classify the study quality (25).The two nurses worked independently, and any discrepancies were resolved through consultation with two senior researchers.

Analysis
Due to the heterogeneity of the studies, statistical analysis was not conducted.Instead, thematic analysis and narrative synthesis were employed to depict the study's content.A descriptive summary of the included studies was used to organize intervention measures, participants, and outcome indicators.The characteristics of the study interventions were compared with each integrated program group.The impact of spiritual care on the quality of life and mental health in adults with HF was reviewed narratively.

Overview of included studies
The 13 studies included were published between 2005 and 2022.The general characteristics of the selected studies are shown in Table 1.Table 2 provides a comprehensive overview of the key characteristics of the included studies in this systematic review, in study design, patient populations, interventions, and assessment outcomes.The characteristics of the included studies are summarized as follows: (1) Participants: A total of 882 patients were included in 13 studies.Diagnoses included HF (38.46%) and congestive HF (61.54%).( 2  Patients with CHF were selected and randomly assigned to study and control groups.
For the study group participants and their families, 60-min sessions of hope-promoting interventions based on religious beliefs were held twice a week for 3 weeks.

QLI.
The mean overall QOL score in the area of satisfaction significantly increased in the study group, compared to the controls, immediately and 1 month after the intervention.
There was also a similar difference between the two groups in the area of importance immediately and 1 month after the intervention.

Quality of included studies
The Cochrane Risk of Bias tool revealed moderate potential bias across all studies, focusing on critical domains such as random sequence generation and allocation concealment.The 13 studies (26-38) meticulously detailed the processes involved in generating the random sequence, utilizing methods such as random number tables and computer-generated randomization.However, 10 studies (26, 28-34, 36, 37) were unclear about adequate measures for concealing allocation.Given the nature of spiritual care interventions, blinding of participants was unfeasible in the majority of studies.Nevertheless, 5 studies (27,31,32,34,38) blinded outcome assessors in the intervention group.Regarding attrition bias, only one study mentioned attrition without specifying reasons (33).In contrast, other studies provided detailed explanations for participant dropouts.In summary, the moderate risk classification of included studies highlights the need for cautious interpretation and emphasizes the importance of considering potential biases while assessing the evidence.Figures 2, 3 provide detailed insights into each study's risk of bias.

The impact of spiritual care
A total of 13 studies (26-38) investigated the impact of spiritual care on mental health and quality of life in patients with HF. 9 of these studies (26-32, 37, 38) reported that spiritual care was associated with statistically and clinically significant improvements in mental health and quality of life.The effects of spiritual care are as follows: (1) Quality of life and satisfaction 11 studies (26-29, 32-38) evaluated the impact of spiritual care on the quality of life of patients with HF.Among them, 8 studies involving interventions such as meditation (26,32,34), religious beliefs (28,29,37), spiritual support (38) and cognitive interventions (27) demonstrated significant improvement in the life quality of the intervention group, with mean life satisfaction higher than that of the control group.3 studies (33, 35,36) showed no significant difference in the quality of life between the intervention and control groups.
(2) Emotional health 8 studies (26,27,29,31,32,34,37,38) assessed the impact of spiritual care on emotional health (anxiety, depression).In these 8 studies, the intervention group exhibited improvements in overall scores on scales related to emotional well-being, such as the POMS and CESD scale, compared to the control group, leading to an enhancement in patients' emotional health.
(3) Physical function Three studies (31-33) evaluated the impact of spiritual care on physical function.Two studies (31, 32) indicated that meditation led to improvements in physical functions, such as blood pressure levels and exercise tolerance, among the intervention group.However, one study (33) suggested that tailored Motivational Interviewing (MI) intervention showed no difference in improving physical symptoms of HF compared to standard care.
(4) Mental Health Two studies (28,30) reported the impact of spiritual care on mental health.The results showed a statistically significant increase in spiritual scores and improved mental well-being for the experimental group after the intervention (t 72 = 0.66, p = 0.511).

Discussion
The findings of this systematic review have significant implications for the field of spiritual care, especially for patients with HF.After reviewing the studies, it is evident that existing theories and models of spiritual care strongly support the role of spirituality in enhancing patients' well-being.The positive outcomes observed in mental health and quality of life support the theoretical frameworks proposing a holistic approach to patient care, considering physical, psychological, and spiritual dimensions.Furthermore, the variety of interventions utilized throughout the studies presents a new perspective on how spiritual care can be customized to fulfill the unique needs of patients with different cultural backgrounds, religious beliefs, and personal values.This indicates that spiritual care is an adaptive practice that can be adapted to different theoretical foundations while In managing patients with HF, medical treatment, lifestyle adjustments, and emotional well-being are crucial aspects.Spiritual care is a nursing approach that prioritizes the spiritual and inner needs of patients.It emphasizes the cultivation of inner calm and hope, aiming to improve their psychological well-being and quality of life (39).The study indicated that spiritual care can improve the psychological well-being and quality of life of cancer patients and their family caregivers (40,41).Vespa et al. (42) found that mindfulness training can enhance emotional and cognitive balance, as well as happiness, for early-stage Alzheimer's disease patients and their caregivers, thereby improving their quality of life.Spiritual care encompasses various religious and non-religious practices, aimed at helping patients find inner strength and meaning and establishing connections with others, nature, and a higher power (43).In this study, we have identified several key factors that influence the effectiveness of spiritual care: (1) Alignment with patient beliefs and values.Tailoring spiritual care to align with a patient's beliefs and values is essential.Studies have shown that spiritual care is more effective when it resonates with an individual's personal belief system, ensuring the intervention is meaningful and relevant to their spiritual journey (44).( 2) Quality and relevance of the intervention.The impact of spiritual care on patients is influenced by its quality, relevance, and appropriateness (31,32,37,38).Interventions like meditation, when welldesigned and relevant to the patient's needs, have demonstrated improvements in various aspects of well-being, highlighting the importance of a well-crafted intervention.(3) Patient participation.Actively involving patients in spiritual care and encouraging their participation can significantly impact its effectiveness (34).Patients who actively engage in spiritual practices and discussions often experience deeper benefits, indicating the importance of patient involvement in the process.( 4) Respect for diversity and cultural competence.The effectiveness of spiritual nursing interventions is significantly influenced by cultural, religious, and individual contexts.Recognizing and respecting the diversity of spiritual and religious beliefs among patients is crucial.Cultural competence and sensitivity ensure that spiritual care is tailored to individual cultural contexts, making it more effective and meaningful for the patient (45).( 5) Integration into routine care.To achieve the best treatment outcomes, it is crucial for healthcare providers, to integrate spiritual care into routine healthcare practices (27,30,38).When healthcare providers integrate spiritual care with medical treatments, patients experience better outcomes.
With the healthcare landscape evolving, virtual mental nursing platforms offer exciting opportunities to enhance spiritual care for patients with HF (46).This adaptability to modern healthcare contexts while retaining core spiritual care principles is a testament to the dynamic nature of the field.From a clinical perspective, incorporating technology into spiritual care interventions offers promising prospects.For example, virtual spiritual care platforms can help overcome the challenges of social distancing and limited physical interactions (47).Particularly relevant in the context of pandemics and widespread digital connectivity, these platforms provide patients with a means to access spiritual care remotely, transcending barriers like transportation, physical limitations, or geographical distances (48).This technological evolution not only improves patient access to care but also highlights the adaptability of spiritual care practices to meet the demands of modern healthcare (49).Methodologically, the introduction of virtual spiritual care platforms brings new considerations.These technologies broaden the feasibility and scalability of spiritual care interventions, potentially reaching a wider patient population (50).However, it is crucial to substantiate the effectiveness and safety of these interventions through rigorous research.Comparative studies that Risk of bias summary: review authors' judgments about each risk of bias item for each included study.
evaluate outcomes between traditional in-person spiritual care and technology-driven interventions can establish the reliability and validity of these innovative methods.Despite these advancements, it is important to acknowledge potential limitations.Patient technological literacy, device accessibility, and comfort with virtual interactions may impact the feasibility and acceptance of technology-driven interventions (51).Ensuring inclusivity is crucial, requiring investigations into these aspects to prevent any 10.3389/fmed.2024.1334920unintended exclusion of certain patient groups (52).Additionally, the ethical considerations of utilizing virtual mental nursing platforms in spiritual care must be addressed, encompassing concerns related to data privacy, algorithm transparency, and patient autonomy (53,54).
The methodological considerations arising from the reviewed studies offer insights into the rationality and feasibility of spiritual care interventions.The range of spiritual care interventions used in studies highlights their adaptability to meet the unique needs of patients.Additionally, the use of validated assessment tools for spiritual care, such as those focusing on depression, quality of life, and coping mechanisms, enhances the credibility and reliability of the findings.However, the limitations identified in the reviewed studies prompt considerations for future research in this field.While the positive outcomes of spiritual care interventions are promising, biases stemming from small sample sizes and singlesite studies underscore the need for larger, multicenter trials.Furthermore, the cultural and religious diversity among patients necessitates more research on specific populations to determine how different belief systems and practices interact with spiritual care interventions.Exploring the impact of interventions across various cultural backgrounds and religious affiliations can offer a nuanced understanding of how spirituality influences patient outcomes.Additionally, the potential mediating role of spirituality in influencing patients' adherence to medical treatments and lifestyle modifications warrants further investigation.
There are some limitations in this study.First, there is methodological heterogeneity in the studies included.There are some differences in study sample size, intervention methods, and assessment tools, which may affect the accuracy of the analysis.Second, most studies have focused on patients in specific regions or cultures, which limits the generalisability and generalization of the findings.Finally, The number of included studies is limited and more studies are needed to strengthen the robustness of our findings.Therefore, the current review cannot rule out possible publication bias.Nevertheless, these results have important implications for practice, policy, and future research.For example, these findings may prompt medical professionals to re-examine and improve the care they give to patients with HF.In addition, these results may guide future research and encourage further exploration of interventions related to mental health and quality of life in patients with HF.

Conclusion
In conclusion, this systematic review highlights the positive influence of spiritual care interventions on the psychological health and quality of life of patients with HF.It emphasizes the need for tailored interventions, healthcare professional involvement, and continued research to better understand and optimize the impact of spiritual care in this patient population.The review bridges the gap between theoretical foundations and practical applications, emphasizing the adaptive nature of spiritual care that accommodates the diverse cultural and religious backgrounds of patients.
a) What are the different types of spiritual care interventions applied in the management of adults with HF? b) What are the effects of spiritual care interventions on the quality of life and subjective well-being of adults with HF? c) What factors influence the effectiveness of spiritual care for patients with HF?
) Study Group interventions: In addition to routine care, the study group included four spiritual interventions: Religion (n = 3), meditation (n = 4), mental health and cognitive interventions (n = 3), and spiritual support (n = 3).(3) Control group interventions: Most control groups received traditional usual care from their respective care providers, characterized by medical/drug-optimized therapy and HF-specific preventable risk factor modification strategies prescribed by cardiologists following Heart Association clinical practice guidelines.(4) Outcome measures: In selected studies, assessments were made on a variety of scales: Life Satisfaction and Well-being: Life Satisfaction Questionnaire (LSI-Z), Beck Depression Inventory (BDI) and QoL Enjoyment and Satisfaction (Q-LES-Q-SF); Heart Failure-Specific Quality of Life: Minnesota Living with Heart Failure Questionnaire (MLHFQ), Kansas City Cardiomyopathy Questionnaire (KCCQ) and Minnesota Living with Heart Failure Questionnaire (MLWHFQ); Self-Care and Heart Failure Management: Self-Care of Heart Failure Index (SCHFI v.6.2) and Heart Failure Somatic Perception Scale (HFSPS); Spirituality and Well-being: Connor-Davidson Resilience Scale, Parsian and Dunning Spirituality Questionnaire and Peace-Spiritual Scales; Psychological Health and Emotional Wellbeing: Rosenberg Self-Esteem Scale (RSES), Quick Inventory of Depressive Symptomatology (QIDS-SR16), Hospital Anxiety and Depression Scale (HADS), Cardiac Depression Scale (CDS), Profile of Mood States (POMS), Center for Epidemiologic Studies Depression Scale (CES-D), Functional Assessment of Chronic Illness Therapy Spiritual Well-Being Scale (FACITsp) and Memorial Symptom Assessment Scale (MSAS); Heart Failure Physiology and Function: VO2 and VE/VCO2 Slope, Left Ventricular Ejection Fraction (LVEF), Left Ventricular Diastolic Dimension index (LVDDi) and Brain Natriuretic Peptide (BNP); Health-Related Quality of Life (HRQoL): Health-Related Quality of Life (HRQoL), Short Form 36 (SF-36), Chinese versions of the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness

FIGURE 2
FIGURE 2Risk of bias graph: review authors' judgments about each risk of bias item presented as percentages across all included studies.

TABLE 1
Main characteristics of the included studies.
this study could not hold educational meetings in verbal way because of stress and high mortality of COVID-19, which was beyond the control of the researcher.Curiati et al. (32)Brazil.To test whether meditation can reduce sympathetic activation, evaluated by norepinephrine blood levels (NE), and improve quality of life in older persons with CHF.

TABLE 2
Interventions and outcomes.
(ESS)and Quality of Life Well being Scale-Self Administered (QWB-SA); Overall Quality of Life and General Well-being: Quality of Life Index (QLI), Quality of Life at the End of Life (QUAL-E) Overall Quality of Life and General Well-being: Quality of Life Index (QLI), Quality of Life at the end of Life (Qual-e) and Functional Assessment of Cancer Therapy -General (FACT-G). Scale