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nobahri A, fathi E, malekshahi beiranvand F, hatami varzaneh A. The Death awareness and Spiritual Experience of Health Care Workers during Coronavirus Outbreak. Journal of Community Health Research 2022; 11 (1) :31-35
URL: http://jhr.ssu.ac.ir/article-1-736-en.html
1- Nekoei-Hedayati-Forghani Hospital, Qom University of Medical Science, Qom, Iran
2- Assistant professor of Counseling at Hazrat-e Masoumeh University in Qom, Iran. , fathielham@ymail.com
3- Ph.D. in Psychology, Faculty of Education and Psychology, Alzahra University, Tehran, Iran
4- Assistant professor of Counseling at Hazrat-e Masoumeh University in Qom, Iran.
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: The present study aims to identify the death awareness and spiritual experience of the health care workers in Iran.

Methods: Eleven health care workers involved with Coronavirus patients were selected through purposeful sampling and had in-depth semi-structured interviews. Conventional content analysis was utilized to analyze the data.
Results: The conventional content analysis revealed four themes: 1- Increasing death awareness 2- Effective spiritual strategies; 3- Effective spiritual beliefs;
4- Pleasant and unpleasant existential experiences.

Conclusion: We can conclude that health care workers in dealing with epidemics such as coronavirus as a front-line force need spiritual heath to help themselves and the patients.

Keywords: Coronavirus Outbreak; Death awareness; Health care workers; Spiritual Experience
According to the World Health Organization (WHO), the prevalence of COVID-19 which causes acute respiratory disease continues to increase and has become an emergency in physical and mental health(1). The disease is spreading at a time when Health Care Workers (HCW) are expected to work long hours under high pressure with inadequate resources and facilities, as well as accepting the inherent dangers of interacting closely with patients and facing problems such as being vulnerable to the disease,  misinformation, which leads to an increase in their level of anxiety, and this anxiety increases sharply when they see their colleagues get sick or die(2). In general, HCWs are under severe psychological stress (3).experience moral crises because they experience great suffering from the death of their patients and colleagues, fear of infection, and infecting their residents and families(4, 5).
This pandemic caused a high frequency of death rate. This led to an increase in HCW’s experiences of death(6). Death is so threatening for many people, and the anxiety out of it is called death anxiety (7). This anxiety includes the concepts of fear of the process of death about oneself and important people in life. According to existential psychotherapy, the desire to survive in dealing with the awareness of the inevitability of death causes stress in humans(8). Encountering this core existential conflict as the most fundamental level of anxiety makes the ground for a healthy life. Throughout history, human beings have created defenses to confront and deny death. However, the problem is not solved by denying and ignoring the death, because events such as the death of loved ones, natural disasters, disease crises that occur naturally in our lives do not allow us to deny death and this method is condemned to failure(9). People choose to confront death by preventing or accepting it. But the acceptance of death may lead to significant changes in one's life.
Some studies have focused on spirituality among HCWs. The findings of a study revealed a high level of spirituality and spiritual care perceptions among HCWs in Jordan(10). In another study, the authors tell their personal experiences in the fight against the Coronavirus pandemic and call for more spirituality needed to battle the COVID-19 emergency(11). In a study, the researchers indicated that nurses offering prayer can be therapeutic for some patients(12). Generally, as the result of the COVID-19 pandemic and its impact on HCWs’ mental health, this study aimed to explore the spiritual experiences of HCWs during an outbreak.
Eleven HCWs in Qom city with purposeful sampling participated in the study after signing the consent form. The inclusion and exclusion criteria were continuously working at least for five years in the medical centers; working at least for three weeks or more in the ward with patients suffering from COVID-19; working less than five years in the medical centers; not being involved in the ward with patients suffering from COVID-19. The interviews with an interview guide were done in the counseling room of the hospital by one of the authors who have experience working as a clinical psychologist in the hospital (A. N.) and lasted up to one hour. The interviews were audio-recorded and transcribed verbatim for analysis.
To ensure credibility and accuracy in the description and interpretation of data, we actively engaged in debriefing sessions throughout data analysis and used direct quotations from the data. The triangulation of different data sources (nurses and physicians) and data analysts (two members of the research team), enhances the credibility. As for confirmability, we used data and analyst triangulation and maintained an audit trail. For transferability, we used a careful description of the context and the participants involved in our research. Lastly, for dependability, we used careful documentation and description of the processes of recruitment, data collection, and taking a team approach(13).
Conventional content analysis was utilized for the subjective interpretation of the contents of the written data(14). Codes and themes were identified through the systematic classification process.
The demographic information of Eleven HCWs is indicated in table 1.
Thematic analysis
Four main themes emerged that are explained by mentioning the quotations.
 Theme 1: Increased death awareness
The interview analysis indicated that the HCWs observed severe death in patients. They died lonely, far from their families, suddenly, with high frequency and short intervals. Even the families were afraid to receive the bodies. This experience changed their worldview toward the world, health, death, and life. Their awareness increased regarding the value of the world, health, old age, disability, nearness of death, divine power, weakness of human beings, and instability of life. They reported that their spiritual beliefs strengthened, consequently, their lifestyle changed. So that their self-monitoring, care and attention to physical and mental health, attention to loved ones, gratitude and appreciation for the blessings of health, and caring for old people increased, and their arrogance and pride

It is a strange disease. Suddenly it kills you. Well, such a disease changes one's attitude. I now know the value of every moment of my life. I try to remember that working here reminds me that nothing is sustainable (1).
Theme 2: Effective spiritual strategies
The participants mentioned two spiritual strategies as useful during the outbreak. They believed that trusting and relying on God who can save them as a strong power and spiritual connection like using prayer, supplication, dhikr, religious practices, talking with God to cope with their stressors.
I think religion was very helpful in this situation. I prayed a lot myself. I think it could have protected me and somehow kept our minds away from the corona. I considered these conditions as a kind of divine test …I feel very good (8).
Theme 3: Effective Spiritual beliefs
HCWs’ spiritual beliefs that led to start and continue working in the COVID-19 ward were believing in getting rewards for helping patients, divine satisfaction as an incentive to help, accepting of suffering, believing in being responsible to human beings, belief in the important role of patients' satisfaction and their prayers.
When I saw the prayers of the people, I felt very good and motivated, I felt that the people felt comfortable that we were by their side and their stress was greatly reduced (with tears in his eyes). (3).
Theme 4: pleasant and unpleasant existential experiences
The participants mentioned dual experiences. They had pleasant experiences like hope and satisfaction with their job, hope to get out of the condition, and unpleasant experiences like sadness, guilt feeling, moral conflicts, and injustice.
It was very hard for me that people were dying in front of my eyes. Once I was in the ward, three people died an hour apart. It was very hard for me and I felt very disappointed. But we also helped many patients who are better now. as soon as I felt that I did not do less, I felt better (2).
As mentioned in the findings section, the first theme that emerged was the rise of death awareness among HCWs, and consequently, they focused on more important goals such as communication with loved ones and the importance of human beings, attention, and health care, and avoidance of arrogance and pride. Researchers in a study indicated that death awareness leads to the improvement and promotion of family relationships and improved physical health(15). When people become aware of death both their death anxiety decreases and they become more accepting of death(16).
Another dimension of the HCWs’ spiritual experience was related to the spiritual strategies they used to comfort themselves. A study has shown that among the strategies that people use to overcome their death anxiety, comforting strategies like believing in the afterlife compared to avoidance strategies like avoiding situations related to death were more effective(17). In another study, turning to spiritual belief systems worked as a coping mechanism to relieve loss during the COVID-19 pandemic in western and Christian cultures. This indicates that spirituality as a general concept can go beyond the boundaries and connect religions.
According to the reports of the participants in the study, the spiritual beliefs led to the beginning and continuation of activities among COVID-19 patients even though challenging. No studies were found to explore the specific spiritual beliefs that help the HCWs stay in their job during the COVID-19 pandemic. But according to ethical codes for HCWs(18), most clinicians first assess the risks to their own and their family’s life, health, and safety. They may then factor in, to varying degrees, their religious beliefs and personal motivations. Next, they may consider professional factors, including the precepts in the healthcare profession’s oaths and codes, as well as other ethical and religious dicta to which they subscribe. In contrast, our study indicated that some HCWs because of their beliefs had a different priority so that they might endanger themselves to save society. This result may be explained according to the religious culture of Iran and sacrifice as an important value in this culture.
While working with patients, HCWs experienced pleasant and unpleasant spiritual experiences, such as a heartfelt satisfaction with helping patients and hope for divine mercy, and unpleasant experiences, such as anger and injustice over the death of patients and moral conflicts. Consistent with the results of the research, research conducted on HCWs during the outbreak of COVID-19 has shown that they experience more moral problems and conflicts due to the higher probability of contracting and facing work pressure and family relationships(19).
It can be implied from the findings of this study that HCWs need spiritual help in their workplace based on their lived experiences during pandemics. Educating the HCWs on concepts like death awareness, effective beliefs, coping strategies, and the experiences they might face during their work period during the outbreak of a pandemic can prepare the HCWs for future pandemics.
This study is limited to the HCWs in Qom city in Iran. It can’t be easily generalized to other cities or nations. It is suggested to do this study in other cities and nations and compare the results. Furthermore, the spiritual beliefs, strategies, and death awareness among healthcare workers can be studied through longitudinal and cross-sectional studies.
Conflicts of interest
 All authors declare to have no conflict of interest.
Author contribution
The authors all were involved in the whole article but specifically, A.N. Was involved with interviewing and Discussion part, E.F., and F.M.B. were involved with coding and theme analysis and writing the Results section. A.H.V. was involved with literature review, references, and writing the introduction part of the

 We would like to thank all our participants who kindly gave their worthy time even though they were under great pressure. Furthermore, the study was approved by the IRB of Hazrat-e Masoumeh University as a research project with Code Number: 992-23964.
Review: Research | Subject: General
Received: 2021/02/13 | Accepted: 2022/03/28 | Published: 2022/03/30

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