Table 1 Themes, sub-themes, and representative quotes

Theme 1: Impacts of Being in a Palliative Care Unit

Impacts on physical health

“Being here seriously affects my life. I have three children. I can’t care for them because I’m here. There is no one else to help me. I do everything myself. It is very difficult to lift my patient and turn her around only by myself. I could not sleep for five nights. All these make me very depressed.” (FC9)

Psychological, emotional, and spiritual impacts

“I’m psychologically exhausted. I’m here for three full months. What I hear (cries of patients, sounds of devices connected to patients, cries of family caregivers) still bothers me…” (FC2)

“In fact, I reside in another city, but I’ve left my wife and children to be here with my mother. I had to make this decision due to my deep love for her. I am now devoted to her. Witnessing my mother’s suffering is truly distressing for me.“ (FC6)

“When I first started working here, I was affected by witnessing so many patient deaths. It’s easier to accept the death of elderly patients. However, it is very difficult for us to accept the death of young patients, it is so sad.” (N1)

Economic impacts

“I am the sole breadwinner in our home; nobody else is employed. While working, I am also the one accompanying my mother here. There isn’t anyone else in the family capable of taking on these responsibilities (meaning accompanying their patient). My mother’s illness has also affected us financially. So, I have to work and earn money, but managing both tasks is very challenging.“ (FC5)

Impacts on personal development and life

“Working here showed me that life is meaningless. I’ve recognized that it’s pointless to worry about too little things. I’ve understood that there was no need to be sad and offend (others).” (N4)

“Working here has shifted my perspective. For example, I realized that one shouldn’t give excessive importance to everything in life. Eventually, life is too short. I learned to be sensitive toward my family and others. If I wasn’t working here, probably I wouldn’t be so sensitive.” (N3)

“Working here has changed me in every way. My empathy skills have improved. Here, I feel the existence of death better. This changed my perspective on life.” (N9)

Theme 2: Coping Methods

Avoidance

“Patients become one of us because they stay (in the hospital) for a long time. Over time, an emotional bond develops between us. Once, I was very saddened by the death of a young patient. After that, I made a decision that I would never establish an emotional bond with anyone here. Now I’m thinking we’re all going to die one day. So, I accepted the existence of death.” (N1)

Acceptance

Religious coping methods

“Everyone seeks a refuge when faced with a challenge. My refuge is my faith. If my religious beliefs were not strong, I would not have been able to cope with what I went through.” (FC3)

Social support and sharing

“I speak relatives of other patients here. We pour our hearts out to each other and relax. They pray for me, and I pray for them.” (FC1)

Theme 3: Importance of Spirituality and Spiritual Care

“Spirituality helps family caregivers to accept more easily. For example, a family caregiver with a weak faith might be more aggressive. They may cause distress for both themselves and the patient. However, when family caregivers have religious faith, this difficult period becomes easier. They would not cause any difficulties either for themselves or for the patient.” (N8)

“Particularly the patients’ children cannot accept that their loved one is close to death and may pass away at any time. Providing spiritual care is crucial to gradually help them adapt to this process and come to terms with it. Moreover, spirituality significantly eases the coping process for the relatives.” (N1)

“In my opinion, spirituality comes first. Without spirituality, one becomes irritable and shows no patience when encountering troublesome events. Spirituality brings endurance and patience. This is why I believe it’s very important.” (FC4)

“For me, spirituality is the value and support that my family and acquaintances show me. As they support me, everything gets easier. I feel safe and relieved.” (FC11)

Theme 4: Spiritual Care

Spiritual care practices

“Here, we don’t implement a visitor restriction. They pray near their patient and read Quran aloud. They are free to do whatever they want to do according to their beliefs. We give them all kinds of support accordingly. Also, I believe a smile is good for everyone. Talking with a smile is relieving for both patients and their relatives.” (N9)

“I say to family caregivers ‘pray and read the Qur’an instead of crying.” (N7)

“Family caregivers don’t know what to do. And we say to them ‘pray, the only thing you can do is praying’. We direct them to pray to help them get used to the death of the patient.” (N8)

“They treat us with a smile. They always ask me how I am” (FC1)

“There are Quran and prayer rugs in the cabinets here. There is a prayer room downstairs. I go there for praying.” (FC4)

Needs

“They have some religious needs. Family caregivers want to read Qur’an near their dying patient. Thus, they feel relieved. They also get relieved as we speak to them.” (N4)

“Relatives are literally looking us in the eye. They expect us to be close to them and talk to them. They especially expect us to say something hopefully and good about their patients.” (N3)

“I try to do my prayer in the patient room on a piece of cardboard. I wish there was a praying room in this unit. Additionally, it would be nice if the nurses and doctors didn’t say desperate words. When they say desperate words, one gets demoralized. They may talk more supportive.” (FC1)

“If nurses smile and ask to us ‘how are you?’, this would give us morale. We have been in the hospital for a long time. No one supported us or even spoke to relieve us.” (FC9)

Barriers

“Spiritual care is very important in palliative care. However, in the current conditions, we cannot provide both patient care and spiritual care to the patients/relatives at the same time. High workload affects us. There are 10 patients per nurse on each shift. So, we can only do our routine work, treatment. This is why I don’t have either enough strength or time to offer spiritual care.” (N6)

“There are patient rooms in this unit that never receive sunlight. Patients stay hospitalized for months in enclosed rooms without any natural light. The family caregivers also accompany their patients in such an environment for months. I believe that patients should be able to spend their final moments in comfort in every aspect. For instance, if this unit was on the ground floor and if we had a door leading to the garden, and if we could take the patients to the garden, it would bring significant relief for them.” (N9)

“Here, there are two approaches. One of them is treatment-oriented, and the other is an approach including less treatment but spiritual care. If the doctor is treatment-oriented, we can only provide treatment. We don’t have time to do anything but treatment. However, some doctors concerning about how to relieve the patient in their final time. For such doctors, we can offer spiritual care. In short, we can offer spiritual care depending on the doctor.” (N10)

“I wish I would have the competency and training for spiritual care. The only thing we could do is to direct them to pray, that’s all. The practices we know, and implement are not professional, just our daily life observations. I wish I would have more knowledge.” (N1)