Explaining the Propositions of the Sound Heart Model as Spiritual Health Theory: Research Methodology

Background: Holistic, community-oriented health services require attention to spiritual health at all levels of prevention, in the spectrum of health and disease, throughout life. Spiritual health services are professional theory-based practice. The purpose of the study is to report the research methods of explaining the propositions of the Sound Heart Model as a Spiritual Health Theory.

Methods: The theory was designed by using qualitatively derived theory based on the Concept-Integration method in six stages. An in-depth philosophical review of two decades of research indicated the need for spiritual empowerment. Concept analysis clarifies the concepts of therapeutic relationships and therapeutic content as spiritual communication, knowledge enhancement, skill training, and spiritual motivation. To validate the findings, in addition to Morse et al. suggestions, the findings were reviewed in four specialized national sessions "Chair of Behavioral Sciences", "Narrative Sciences Chair", "Pre-Summit Sessions" and "Summit Session" of "Chairs of Theorizing, Criticism and Scientific Debate" in the “Supreme Council of the Cultural Revolution”.

Conclusion: Spiritual self-care of parents, teachers and clergy is a priority. Secure attachment to the prophets and following their lifestyle is the basis of spiritual self-care. Spiritual self-care of parents, teachers and clergy creates spiritual mentoring competence. The correct religious behavior of spiritual mentors provides the possibility of model-oriented education. Spiritual communication based on compassion and empathy can create secure attachment, trust and security. Spiritual mentors should provide spiritual training without coercion and violence with "scaffolding". Mentors can facilitate the stages of faith growth and correct cognitive errors by increasing spiritual knowledge. Explaining the spiritual reason for life's sufferings increases resilience against suffering. By teaching "relationship development skills" with nature, self, people and God along with thinking about "the truth of religion", they can create a positive image of God and secure attachment to God. So that people can take refuge in God as a safe haven and feel safe.

Although there is no scientific consensus on what exactly constitutes a religion, but it is generally defined as the belief and worship of superhuman power (God) in a particular system of attitudes, beliefs and practices [1]. Some define religion as a set of socio-cultural systems, including prescribed behaviors and actions, morals, ethics, beliefs, worldviews, texts, sacred places which generally relate humanity to supernatural and spiritual elements [2]. Abrahamic religions have been introduced as systems of beliefs and theoretical knowledge, moral orders and practical laws consistent with wisdom and fitrat, in individual and social dimensions, that have been sent by God through divine prophets to guide mankind. Fitrat or human nature is the factor of scientific guidance and practical tendency toward true perfection and true happiness [3]. So faith is a multi-dimensional belief of the heart that has behavioral and emotional components as well as cognitive components. Love is the foundation of faith [4]. Secure attachment to God as belief in the presence and sufficiency of God is the basis of religiosity [5]. A secure attachment to God is formed on the basis of a positive image of God as an internalized psychological model of people's ideas and experiences about God. It is related to how a person feels about God and his understanding of how God feels about him [6]. In the positive image, God is a safe haven, the Merciful, near, kind, intimate, supportive, protective, accommodating, forgiving and soothing. Positive image of God as a religious belief gives the behavior of servants the intention of closeness to God [7]. All Abrahamic religions emphasize on belief in the unseen world and the existence of the soul. Based on this belief, religions provide guidelines for the emotions and behavior of their followers [8]. Abrahamic religions present human as a spiritual being with a soul that experiences human life [4]. "Humans are not human beings that have spiritual experience but they are spiritual beings that have human experience” [9].

Islam considers the soul as the most important aspect of human existence [3]. So based on this type of religious belief, it is expected that the epistemology of religion as a theory of knowledge, focuses on whether it is possible to know these religious beliefs or not? Religious people who wish to have rational reasoning must have arguable and provable propositions for their beliefs. They should examine the evidences related to their religious belief in order to present a well-founded proof in the form of arguments [10]. Although the epistemology method leads to the creation of different philosophical worldview. Philosophy shapes the culture and lifestyle of people. The philosophical point of view has effect on the knowledge and assumptions of theorists. Philosophy is effective on the production of science. Science has a philosophical background [11]. But in academic books of health sciences in Iran as a country with religious government nothing is taught about the soul. This non-physical dimension of human existence even has been neglected in psychology. Because psychology is responsible for the scientific study of behavior and mind processes [12]. Despite the fact that pain relief methods cannot relieve spiritual suffering, but nevertheless health science students do not learn the methods for the relief of spiritual distress [13].

• This confusion between the belief in the soul and the unseen world in the personal life of religious followers with the non-belief in the soul in their professional life as a medical team, causes a conflict between medicine and religion. This confusion creates many philosophical questions about religious beliefs such asWhat is a human being? What is the soul?
• What are the functions and abilities of the soul?
• What is the effect of believing in the soul on the process of birth and death?
• What is the difference between the concept of death in religion and science?
• What is the relationship between the soul and human suffering?
• What is the meaning of suffering?
• What is the role of the patient/ client/ family/ society in the occurrence of suffering?
• Basically, why does the Merciful God allow some of his servants to face severe suffering?
• Are actually sins the cause of human suffering as some of the Iranian Muslims believe?
• Why does the Merciful God, as the concealer of human sins (Star al-Ayoub) allow people to be accused as sinners?
• Why does the occurrence of disease make Muslim people socially stigmatized as sinners?
• What is the reason for differences in the reaction of people to their suffering?
• What factors make suffering tolerable?
• What factors allow better adaptation to traumatic experiences?
• Why pain relief methods cannot relieve spiritual suffering?
• What is the duty of the treatment team against human suffering?
• What measures can treatment team take to alleviate suffering?

Asadzandi as a member of the treatment team, searched for answers of these questions in two decades. She was able to design and validate the Sound Heart Model [11]. Her approach has been formed based on the knowledge of anesthesia and pain relief methods, care and health education theories, studies about spirituality and authentic interpretation of the Quran. In her scientific research, she has used the Quran as a holy text which is accepted by all "Islamic sects and religions". She emphasized the common concepts and beliefs of Abrahamic religions. The support board of "Chairs of Theorizing, Criticism and Scientific Debate" in the “Supreme Council of the Cultural Revolution”, selected the theory judges from clergymen and psychology professors in "Chair of Behavioral Sciences","Narrative Sciences Chair", "Pre-Summit Sessions " and "Summit Session". They made the acceptance of the Sound Heart as spiritual health theory dependent on the explanation of its propositions [4]. In fact, they addressed the issue of spiritual health from the perspective of philosophical theology, which can be distinguished from dogmatic theology. Because philosophical theology requires an effort to deal with fundamental religious beliefs and concepts in a philosophical manner with two stipulations: first, when the goal of the researcher is philosophical, the goal of the researcher should not be describing religious beliefs or discovering the rules governing it. Instead of that, understanding and explaining the subject and critically evaluating in terms of truth, coherence and rationality are considered. Secondly, the researcher should not follow a point of view that is committed to a religion, but should resort to something that is attainable for any reasonable and wise person through investigation and thinking [10,14]. This article as a data note explains the propositions of the Sound Heart Model as Spiritual Health Theory from the perspective of philosophical theology by describeing the stages of model design and validation.

Efforts were made to Understand the Soul and its Abilities

Contractual content analysis with the Walker and Avant method was conducted to study the etiology of diseases by Pasteur's microbial theory, Selye's theory of stress and adaptation in understanding psychosomatic diseases, Ader and Cohen's psycho-neuro-endocrine-immunological theory for understanding the effect of psychological states on physical health. Also, the foundations of health sciences as a diathesis-stress model in the pathology of mental disorders, schools of Vienna psychotherapy including Frankl's point of view and Bertalanfi's systemic theory, homeostasis theory, and Maslow's model of human needs were analyzed [15].

Finding: Health sciences have ignored the human soul and the unseen world. They use basic science assumptions for defining human beings as bio-psycho-social beings, health and disease, environmental factors affecting health, treatment and care methods [16].

So to know the soul and its abilities, its place in the body, and its relation to the body in a qualitative evolutionary study, the religious evidence of Islam was investigated with the Shia seminary research method with a targeted review. The concept of soul from Abrahamic religions and the concept of “Heart” from the Qur'an and Hadiths were adopted by the conceptual adoption method of Walker and Avant. Due to the different readings of the Qur'an that are mentioned in "philosophical hermeneutics", to avoid misunderstanding the Qur'an, the method of "interpreting the Qur'an with the Qur'an" and "narrative interpretation of the Qur'an" were used. The "Rejal and Derayeh science" was used to confirm the authenticity of the hadiths [3].

Finding: Humans are physiological-spiritual beings whose life begins with the breath of the soul into the body at 4 months of fetal age (verse 72, Surah Saad) and their death occurs with the complete separation of the soul from the body [3]. In the philosophical view of the Abrahamic religions, human beings as the master of creatures have a soul from the unseen world, which gives them existence. The soul is synonymous with the heart in the Quran and hadiths. “The heart is actually the soul of a person, which does its vital work with the inner powers and emotions it is equipped with." Qur'an has explained the sound heart and sick heart [3]. The connection between the soul and the body is established through a "template of the higher universe" which can separate from the body at dreaming [17]. There is a close connection between the soul and with physiological heart. The heart is the first member to which, the soul belongs. Perception, wisdom, reasoning, understanding, consciousness, judgment, decision-making, power of will and choice, feeling and movement are abilities that originate from the soul. The soul is the center of perception and knowledge, emotions, and verbal and non-verbal behaviors [18]. Asadzandi introduces the heart (soul) as the spiritual dimension of human existence and as the basis of the spiritual personality, which shapes the spiritual reactions of man to health problems and life events [5]. She wrote that "the heart, as the commander of the body, is responsible for decision making, the command and forbidding the members, and through that man understands and reacts”. She introduced spiritual health as having a "Sound Heart [19].

To Describe the Ideal State of Spiritual Health

Characteristics of Sound Heart owners were described by Schwartz-Barcott and Kim's hybrid model, which is considered a strong methodology for the evolution of the concept [20]. The research was done in three stages: theoretical review, field research and final analysis. The scientific and religious evidence (the soldiers of wisdom and ignorance hadith [21], the Envan-Basree hadith [22] and the sermon of Hammam from Nahj al-Balagha) [23] were analyzed. The fieldwork data were obtained from interviews (with patients and families, clinical nurses, psychologists, and psychiatrists) and field notes (clinical observations during the researcher's professional life, collecting field reports). In the third stage, the integration of propositions extracted from fieldwork and evidence analysis led to the description of spiritual health indicators.

Finding: The Sound Heart owners have moral virtues: Wisdom, Chastity, Courage, Justice, Generosity and forgiveness, Kindness, dignity, and intercession. They get rid of fear and anxiety about future events, regret, and sadness about their past life. They live in the present time, with patience and thanksgiving. They achieve the highest quality of life by faith and doing “righteous deeds” [24].

To Describe the Current State of Spiritual Health

In developmental research with the sound heart approach, inductive propositions were extracted through conventional content analysis of interviews with clients, patients, their families and clinical nurses. In addition to individual interviews, two focus groups were used to confirm the validity of the data. Then, with a systematic and comparative review of religious evidence, spiritual distress was extracted based on religious evidence. Spiritual distress was compared with statements made by the participants, the NANDA nursing diagnosis list and the DSM-5 list. They are classified into four dimensions of the relationship with God, self, people, and nature. The applicability of the findings was evaluated through two focus group discussions with 20 senior nursing experts.

Finding: The most important spiritual distresses were ignorance of the remembrance of God or despair of God's mercy, impurity, fear and grief, cruelty and injustice, jealousy, revenge, unforgiveness, stinginess, brutality and hard-heartedness. These spiritual distresses can complete the NANDA diagnoses list [25].

Spiritual care guidelines had been designed according to the Settler model with the religious and scientific evidence-based approach. This developmental research was conducted in hospitalized units of Baqiyatallah Hospital in 2015. The research stages included the following:

• Determining the aim and the scope of instructions, including the target population. The quality of all the spiritual care instructions available in the Ministry of Health and Medicine was checked by the Agri and Gilia tool.
• A review of the evidence and scientific articles was carried out based on the Pico method.
• Designing new instructions by implementing the four stages of the Settler model, including:
• Preparation.
• Accreditation (critique and study of articles and compilation of guidelines based on the latest texts in three Delphi rounds with the opinion of at least 15 members of the academic faculty, professors of theology and psychology, and educational trainers as expert group).
• Comparative study and determining the practicality of the instructions in bedside care and examining the benefits and risks for the patient and the nurse with a discussion in the focus group consisting of 15 experts or senior nursing experts.
• Applying and determining how to operate and how to use these instructions at the bedside. The applicability of the instructions was assessed by a focused group discussion method with 15 senior nursing experts.
• Evaluation of the quality of designed instructions was conducted by assessing the content validity of the instructions with the Delphi method. The opinions of ten faculty members of Baqiyatallah, Tehran, Iran, and Shahid Beheshti universities had been considered in three Delphi rounds [26].

Finding: Through the survey of faculty members and clinical nurses, twenty-five spiritual diagnoses of the Sound Heart Model with more frequency were selected. Evidence-based guidelines for religious spiritual care in hospitalized patients were designed and validated to convert the emotions derived from fear, sadness and regret to a sense of security, trust, hope, and optimism [27,28].

In the qualitative research with the content analysis method faith therapy was introduced as the main spiritual care to achieve a Sound Heart [29]. The impact of spiritual health on other dimensions of health was expressed [30-32].

Describing the meta-paradigm concepts of the model (human, health, environment, disease and care) was conducted based on a total ratio metric method which is comparable to Carli's perceptual and relational analysis. Philosophical analysis of international nursing care theories was done during the -Criticism of the theories, -Expression of the main and internal elements and components of the theory, -Analysis and evaluation of the foundations, principles, methods and scope of the theory, -Changing the theories by replacing Islamic foundations, principles and methods [16].

Finding: The conceptual framework of the Sound Heart Model was designed according to the main concept of "sound heart" through the connection of meta-paradigm concepts with the grounded theory strategy [11]. “According to Abrahamic religions, the universe and human beings have been created based on God’s affection. Humans have the willpower to shape their destiny by choosing a style of their relationship with God, people, themselves, and the universe. By giving a divine color to their thoughts and intentions they can attain peace and serenity in their heart. Spiritual health means having a sound heart (a calm spirit with a sense of hope and love, security and happiness) that is achievable through faith and piety. Moral vices lead to diseases. The world is run by God’s will based on prudence and mercy. All events happen with God’s authorization, and human beings have to respond to them. Nurses should try to recognize the patient’s spiritual response to illness that can appear as symptoms of spiritual distress (fear, sadness, disappointment, anger, jealousy, cruelty, grudge, suspicion, etc.) due to the suffering caused by illness. The treatment team should reduce the patient's suffering by helping the patient to see the good in every evil with the hope of God's mercy and love until they can overcome their fear and sadness by looking positively at the disease. The treatment team must be able to create courage in the patient and family to face the crisis of the disease so that they can achieve peace, satisfaction and tranquillity in their hearts” [11].

• The prescriptive model of spiritual health training for patients was designed by the three-step method of theory synthesis of Walker and Avant [33]. After the formation of the descriptive theory, focus group meetings were held with professors of health education, nursing and psychology. Content analysis of health education models and motivational theories was done. While applying education models such aHealth belief model in diabetic patients [34].
• Health promotion model in soldiers with high-risk conflict behaviors [35].
• "Precede proceed model" in military nurses with primary sleep disorder [36]. According to the constructs of the conceptual framework, after processing the basic principles of the theory a set of related and coherent concepts was organized in a related set to design the spiritual care model for patients and spiritual counseling model for healthy clients” [37].

Finding: “Fear and anxiety caused by acute diseases, despair and sorrow resulting from chronic illness, are spiritual reactions which require care. Spiritual care should be done based on a training model. The Sound heart model can predispose the conversion of emotions derived from fear and sorrow to emotions filled with confidence and security, as well as behavioral adaptation to diseases. For problem-focused and emotion-focused adaptation, the disease should be introduced as a challenge by improving the patient’s relationship with God and by developing courage and optimism. Patients can then reach Sound Hearts and healthy behavior after improving relationships with themselves, people, and nature, using religious norms and developing commitment, control, and motivation. The patient’s progress can be assessed by daily self-control. Spiritual consulters should act as mentors when performing and instructing spiritual health. They should make themselves competent and empowered to help patients and manage their harmful emotions. The model emphasizes on patient- and family-focused approach, self-care, home care, and engaging patients’ logos [33]. These models were used in twenty-nine clinical trials, which had a very good effect [38-44].

Considering the important goals of spiritual training such as helping scholars in promoting spiritual health and cultivating natural talents, research was conducted with the aim of introducing the spiritual characteristics of professors as spiritual mentors for role-modeling education. In this qualitative study, a systematic review was conducted. The interpretation of authentic Shia hadiths regarding the characteristics of the sound heart owners and articles published in the years 1990 to 2016 with the keywords: mentoring, perfect man, spiritual needs, and spiritual health were investigated in databases PubMed, Science Direct, Google Scholar, SID, Cochrane. Data were analyzed by using the Walker Avant content analysis method.

Finding: The spiritual indicators of role-model professors as spiritual mentors were determined. The findings of the research showed that mentors with follow the Prophet's lifestyle and know the truth of religion, journey through the stages of faith, self-purification, and daily spiritual self-care can play an important role in the hidden curriculum and a significant role in teaching pastoral care to health science students [45].

After that, the self-assessment questionnaire for measuring the spiritual health of professors was designed and validated. In a sequential exploratory study of tool making, by using the Schwartz-Barcott and Kim's hybrid model [20]. The initial version of the questionnaire was prepared in the form of 73 primary measurable items. To determine the validity of the questionnaire, face validity, qualitative and quantitative content (CVR and CVI), structural validity, internal consistency reliability (Cronbach's alpha) and stability were examined.

Finding: The findings showed that the CVR score in 67 items was higher than Lavache's formula (0.33). Five items without the required score were removed from the questionnaire. The results of the CVI calculation showed that all items received a CVI score higher than 0.79. The final questionnaire had 67 items. The results of exploratory factor analysis showed the existence of a 7-factor model (model of spirituality, courage, kindness, wisdom, modesty, self-respect, and justice) in the structure of items. Internal consistency of the questionnaire (with Cronbach's alpha of 0.9) showed that all items had a high correlation and were significant at the level of p < 0.05 [46].

Due to the fact that in the health system of Iran, the level of empathy, commitment, respect and receiving feedback from the results of health services were lower than the quality expected by the society, providing health services requires the spiritual empowerment of medical students. In philosophical investigation with the conceptual analysis approach the concepts of spiritual empowerment were determined according to the findings of previous research. In a Qualitatively-Derived Theory based on Morse et al.'s with Concept-Integration method, students' spiritual empowerment model was designed in six stages:

• Defining concepts representing the main phenomenon,
• Determining the level of evolution of the concepts,
• Determining the relationship between concepts,
• Detailing the central concepts,
• Determine the relationship between concepts,
• Formulating conceptual model.

The accuracy, completeness, comprehensibility, clarity and rationality of data were confirmed by Morse's suggestions, the use of authentic Islamic texts and three specialized panels with faculty members of the Academy of Spiritual Health.

Finding: Building students' confidence, - Building spiritual knowledge - Developing relationships with God, self, people and creatures - Motivation, self-confidence and self-efficacy are elements of the conceptual model of spiritual empowerment [47].

Considering the necessity of empowering the patient and the family, in a qualitative study, universal models of nursing care, prominent models of health training, and theories of motivation were content analyzed. Considering the constructs of the spiritual care model of Sound Heart, after adopting appropriate themes and clinical use of prominent models, “Parent’s Spiritual Empowerment Program” was extracted from previous research findings. It was accredited by ten professors of pediatric oncology specialists, and nursing and health education professors in three rounds of Delphi [48].

Finding: Family education should be done in coordinated teamwork by a physician, nurse, clergyman, psychiatrist, and social worker. The goal of the program has to be the development of self-care ability, and self-efficacy in parents in order to enable them for compatibility with disease problems, giving the courage to face a crisis of disease and overcoming the distress of home care. Training sessions should be managed by using educational technology, multimedia software and providing a training manual. At follow-up treatment sessions, attention should be paid to family concerns and their questions. Answering the patient’s and family’s questions about the cause of the cancer and its suffering should be tailored consistent with family beliefs based on scientific findings. The use of the model in empowering the families of children with cancer led to the improvement of spiritual health and reduced care burden, anxiety, stress, and depression of parents [49-51].

At this stage, after describing the "spiritual health and spiritual distress", and designing, validating and applying the spiritual counseling model in the client [37] spiritual care model in patients [11,33] spiritual empowerment model for families [48] students [47] and community members [52] Asadzandi entered the deeper phase of the study. In order to clarify the creation process, its causes, and consequences of spiritual health and spiritual distress. She explained the propositions of the theory. She explained the application method of the theory to provide spiritual health education and spiritual health services in health care centers. She explained the spiritual personality and the process of improving spiritual health [5]. Also in order to explain the process of creating spiritual distress, she explained spiritual pathology [53]. And the effect of spiritual interventions based on the diathesis-stress model as a protective factor. These steps were carried out as follows:

Explaining the Process of Spiritual Health with "Spiritual Personality Theory"

Explain the process of forming the ideal state of spiritual health, a mixed-method study was conducted based on the Tashakkori A, et al. [54] and Creswell J, et al. [55] model with a discovery-explanatory approach. The qualitative data from:—non-systematic review and contractual content analysis of different types of spirituality, religious spirituality, spiritual training [56-59] spiritual mentoring [60], -Quantitative data from the clinical applications of model were integrated. The validity of meta-inferences of research was measured: - in the quantitative data section through internal-external validity,-in the qualitative data section with reliability or capability index [61].

Finding: The spiritual personality is" relatively stable and important patterns of perception, feelings and emotions, verbal and non-verbal behaviors that based on a recognizable pattern shape the communication of a person with God, self, people and the world of creation. The formation of a spiritual personality is influenced by a person's style of attachment to God. The style of attachment to God affects the style of attachment to self, people and the world of creation. It also shapes the heart states and spiritual reactions to life events" [5]. Spiritual health can be achieved in the light of following the lifestyle and behavior of the Prophet (as an interpreter of the holy text and a spiritual role model) with a positive image of God and a secure attachment to God [60] (Figure 1).

Figure 1: The propositions of the sound heart model as spiritual health theory.

Explaining the Process of Spiritual Distress with "Spiritual Pathology Theory"

In another mixed method study, based on the Tashakkori A, et al. [54] and Creswell J, et al. [55] model with a discovery-explanatory approach with the aim of explaining the role of social custom in creating a tendency towards extra-religious or secular spirituality in Iranian society, - Qualitative data from non-systematic review and contractual content analysis of various types of spirituality, complementary treatment modalities, personality theory, -Quantitative data from the clinical applications of model were integrated. The validity of meta-inferences of research was measured: - in the quantitative data section through internal-external validity, -in the qualitative data section with “reliability” or “capability index” [61].

Finding: “In the Sound Heart Model, worship is a natural need and the basis of religion. “The truth of worship" is achieved by knowing the "truth of religion". Due to the existence of "various readings of Islam", it is necessary to know the "truth of the religion" from the "Prophetic tradition" (lifestyle, behavior and speech of the Prophet). "Recognizing the truth of religion" is achieved by secure attachment to the Prophet as an interpreter of the Qur'an and a spiritual role model who has a healthy spiritual personality. Acceptance of religion, at the time of intellectual maturity, should be done without imitation and coercion, based on knowing the truth of religion, with a free and informed choice. Adapting religion to the customs and lifestyle of social models, led to a change in the central tendency of people from a secure attachment to God to an attachment to someone other than God. The lack of ability to explain the purpose and meaning of suffering, introducing the sufferings as punishment for sins by cutting off secure attachment to God creates spiritual distress” [56]. Spiritual Pathology is the study of socio-cultural factors (disturbing factors) that cause misunderstanding of religion, negative image of God and insecure attachment to God. Disruption of secure attachment to God causes spiritual distress in relation to self, people, and the world of creation [53] (Figure 1).

Figure 1 shows that knowing the truth of religion causes a positive image of God and a secure attachment to God. The truth of the religion can only be obtained by secure attachment to the Prophets (moving on the path of divine love) and following the lifestyle of the Prophets (moving in the stages of faith). In this case, a person reaches self-awareness and self-compassion in relation to self. Forgiveness and generosity in relation to people, and kindness in relation to nature. Creating this secure attachment requires "scaffolding" and spiritual training without violence and "religiosity compulsion". This method of education can only be implemented by parents and educators who have been able to find "spiritual mentoring competence" through spiritual self-care. On the contrary, the misrecognition of religion based on society's custom, by creating a negative image of God and insecure attachment to God, causes all kinds of spiritual distress. If parents and counsellors do not do "spiritual self-care", they will use "violence" and "religiosity compulsion" in spiritual education, as a result, they will reduce the people's trust and attachment and lead them towards unhealthy spiritual role models. Following and imitating unhealthy spiritual role models and false social customs are important factors of spiritual pathology. Spiritual health interventions should be implemented by competent spiritual mentors. Four steps: 1-Establishing spiritual therapeutic communication, 2-Spiritual knowledge enhancement, 3-Spiritual skills training, 4-Spiritual motivation are the stages of Clinical Pastoral Education (CPE). For this purpose, in spiritual health interventions, 1- the therapeutic team members should find the competence to provide spiritual health services. Act as mentors to establish spiritual communication based on empathy, compassion and unconditional acceptance. 2- In "Spiritual Enrichment Knowledge" by "model-based learning" they should act as "spiritual scaffolding". By teaching the truth of religion, create a positive image of God and secure attachment to God. 3- They can empower the individual and family for spiritual self-care through "spiritual skill training" in relation to God, self, people and nature" and 4-Spiritual motivation.

To Explain the Process of Transforming the Current Situation into the Desired Situation (Therapeutic Content and Therapeutic Relationship)

Improving the spiritual health or treating spiritual distress of patients, clients and family should be done in a long-term process by themselves. Although spiritual counseling for clients with the self-care ability or spiritual care of patients is an important part of the duties of the treatment team, every person and family has the main responsibility. The treatment team is required to implement a spiritual self-care empowerment program.

The empowerment program of Sound Heart in Spiritual Health was designed by using Morse JM, et al. [62,63] Qualitatively-Derived Theory based on the Concept-Integration method. After an in-depth review of the texts, through the concept analysis approach, it was possible to analyze and clarify the concepts (therapeutic relationship and therapeutic content in spiritual health interventions). By exploring the texts, it was possible to examine the meanings, create questions and find their answers. So through reasoning, it would be possible to form "logical thinking" and "reasoned decision-making during implementation [64]. The qualitatively derived Theory of Morse JM, et al. [63] based on the Concept-Integration method was used to theorize the Sound Heart in Spiritual Health. This method was carried out in the following six stages:

Determining relevant and appropriate concepts that represent the main phenomenon.

Spiritual relationships are based on compassion, empathy, and unconditional acceptance for trust building.

• Spiritual therapy content includes spiritual knowledge enhancement, spiritual skill training, and spiritual motivation.
• Determining the level of evolution of the concepts based on the philosophical perspective of Islam.
• Determining the relationship between concepts according to the field of study.
• Explaining the details of the central concept (Sound Heart).
• Explain the concepts and determine the connections between them according to the details and characteristics of the concepts and their commonalities.
• Formulating the theory after describing the conceptual model [65].

The precision of the study was established based on the suggestions of Morse JM, et al. [63] in addition to using authentic Islamic texts. In order to make sure that the contents are logical, clear, and complete, the findings were discussed in four specialized national sessions: "Chair of Behavioral Sciences"," Narrative Sciences Chair", "Pre-Summit Sessions" and "Summit Session" by clergymen and psychology professors of "Chairs of Theorizing, Criticism and Scientific Debate" in the “Supreme Council of the Cultural Revolution”. The following items were considered:

• Comprehensiveness and sufficiency of data by studying rich and complete evidence until the texts can express a complete description of the phenomenon.
• Conducting a deep analysis of the evidence until rational reasoning can confirm the findings of the study. (The results should be logical, creative, systematic and evolved).
• Evolution of the discussion to express the logical and clear topics with the logic governing the research
• Validity of the data during four Delphi rounds by the expert panels
• Abstraction level by attention to all situations of the concept so that the obtained results can develop knowledge
• Creating an intuitive sense until the findings can create a new perspective and understanding of the phenomenon [66].

The mentioned model was used to empower military commanders to take care of themselves. It increased their spiritual health, spiritual intelligence and spiritual experience [67,68].

Considering the impact of model-based training and the role of spiritual counselors and caregivers in the position of spiritual mentor, the professional spiritual health questionnaire of professors was designed and validated.

Finding: Investigating the effect of implementing the spiritual empowerment program on the spiritual mentoring competence of soft war officers showed the positive effect of the program [67].

Considering the necessity of teamwork in the implementation of spiritual care and counseling, the implementation of an interprofessional spiritual health training model was designed [69].

Finding: The mentioned model in the interprofessional education of spiritual health to health science students of the Army University of Medical Sciences led to the modification of their lifestyle [70].

A mega project of design, integration, implementation and evaluation of the longitudinal program of competency-based education of spiritual health services based on the Sound Heart Model in the curriculum of the bachelor's degree in nursing and doctorate in general medicine of Baqiyatullah University of Medical Sciences were conducted based on the Kern et al.'s method in developing a curriculum for medical education. It was implemented in six stages and in the form of 12 projects separately for general medicine and nursing undergraduate students.

Identification of the problem and general needs assessment

The pathology of spiritual health services in Iran and existing problems in the field of production, dissemination and the application of spiritual health knowledge were determined. In an Islamic future research study that was conducted in 18 months based on the Manteghi model in three stages:

• Analytical phase: non-systematic review of evidence with PRISMA protocol by searching for religious and scientific evidences during the last three decades in scientific databases. Analysis of 32 articles based on Walker and Avant conceptual analysis.
• Interpretive stage: based on the personality theory and pathology theory of the Sound Heart model,
• Intuitive phase: Content analysis of data obtained from interviews with 25 national experts and listing the challenges in three sections. In order to check the strength, accuracy, completeness and the possibility of logical understanding of the findings, in addition to Morse et al.'s suggestions, two specialized panels were conducted in the Spiritual Health Department of the Academy of Medical Sciences [71].

Assessing the needs of the target learners

Identifying the needs of medical and nursing students for the knowledge, attitude and skills necessary to provide spiritual health care by designing and validating the standards of spiritual health services based on the Stetler model (preparation, accreditation, comparative review, application and evaluation). Survey of nursing and medical students regarding their need for training in spiritual health services through experience and task analysis by using a questionnaire of importance and relevance in the statistical population of Baqiyatullah University of Medical Sciences.

Determining educational goals and outcomes

Determining the professional competencies and abilities in providing spiritual health services by designing and psychometrics of the Spiritual Health Services Competency Questionnaire [72].

Determining educational strategies

For integrating spiritual health services based on clinical competence with the Sound Heart Model approach.

Implementation of the competency-based education program

for providing spiritual health services with the approach of the Sound Heart Model as a longitudinal theme in the general medicine and nursing curriculum of Baqiyatullah University of Medical Sciences.

Evaluation and feedback

Continuous monitoring and evaluation of the level of goal achievement and the impact of the implementation of the competency-based training program on spiritual intelligence, spiritual experience, spiritual health, and the competency of providing spiritual health services for medical students and feedback of the results in program modification based on SPICES strategies.

Spiritual training requires the attention of parents, teachers, and religious missionaries to the stages of cognitive-emotional-social development, the need for security, love, and respect. In the combined study, based on the Creswell J, et al. [53] model with a discovery-explanatory approach, Qualitative data of systematic review and contractual content analysis of scientific evidence related to faith development, religious identity, religious education and conceptual framework of the Sound Heart model with Quantitative data from the clinical applications of the model were integrated. The validity of meta-inferences was measured: - in the quantitative data section through internal-external validity, - in the qualitative data section with "reliability" or "capability index".

Findings: “Family-centered spiritual training requires a society-oriented educational model. Spiritual counsellors in health care centers in Iran are obliged to deepen spirituality in society. Counsellors should act as spiritual mentors. Establishing spiritual communication with the use of art and media creates a spiritual attitude and motivation. Mentors should pay attention to the effect of the behavior of family, educators, and missionaries, the views of peers, virtual space, customs, and social role models, and knowledge of religion on spiritual training. At first, they should strengthen their relationship with God by following the lifestyle of the Prophet. They should modify the behavior of the family, and the spiritual performance of educators and missionaries, adjust the views of peers, correct the errors of social customs and reduce the impact of destructive social patterns based on the life of the Prophet. They should encourage parents and teachers to spiritual self-care. They should emphasize creating a positive image of God and secure attachment to God along with creating security and love in children. Mentors in the stages of faith growth should provide the possibility of correction of cognitive errors, reduction the influence of the peer group by expressing satisfaction and respect to teenagers. They must give young people the opportunity to explain the reason for their choices, beliefs, and attitudes. They can support the youth to achieve a sound heart with wisdom, chastity, courage, justice, generosity, and kindness” [57].

Dataset validation and limitations of the datasets

In order to ensure the validity and reliability of qualitative research data, the perspective of Streubert was implemented:

Long-term engagement and continuous observation: By allocating enough time to collect data and long-term engagement with young clients and inpatients, the researcher's sense of connection was strengthened and the language, culture and perspectives of the participants were understood.

Incorporation in the research: By using multiple sources, asking for opinions from experts, the participation of the family of patients in the research, and using the guidance of professors and presenting materials in national and international congresses from the opinion of experts in related fields were used.

Revision by supervisors: The presentation of the model in academic and scientific and international circles led to the use of complementary opinions of colleagues and the publication of researcher's books in this field also contributed to this issue.

Searching for contradictory evidence: the researcher without bias tried to use the opinions of critics to modify the model.

Acceptability of the researcher: The researcher tried to be the agent of the results of the research and presented all his learnings with pure intention.

Determination: The initial findings of the research were presented to professors of nursing, and psychology, Qom Academy of Islamic Sciences and Iran Academy of Medical Sciences for review and correction.

Participant review: The model was given to a group of participants to express their corrective and supplementary opinions [73].

• This manuscript is a "data note". The guidelines for writing "data notes" are different from original articles. Therefore, this article has been prepared based on the instructions of the data note, which emphasizes the research method, its validity and reliability. The report of research findings and comparison of findings with similar research are not considered in data note articles. Of course, the final results of the research are reported in the form of Figure 1. However, the purpose of the data note article is to explain the methods of achieving the final results of the research, not to report the findings of two decades of research or to compare the researcher's results with other research. It should be noted that a theory is a set of concepts, assumptions and coherent propositions that are explained based on certain foundations (ontology, epistemology, anthropology, theology), with "Scientific and logical method". In addition to adapting to different evidence, they have the ability to respond to issues more than "competing theories". It has the power to predict, explain and change phenomena. He considers seven categories important in the theorizing process:The school or ideology that governs the theory is the general principles of the mission of life, which forms the "fundamentals and principles". Each school has its own paradigm, doctrine, methods, information gathering techniques, approach, policies and strategies.
• The paradigm or worldview governing science is the theoretical and epistemological framework governing the research category, which is accepted by a significant number of experts. The researcher theorizes based on the paradigm. Paradigm expresses the theoretical foundations of anthropology, ontology, and epistemology that shape methods and approaches.
• The theorizing method is a rational process of recognizing and changing phenomena. The method shows how the application of "basics and principles" leads to effective problem solving.
• The approach means the point of view of the group of researchers. Attitude is the historical, philosophical, psychological and social perspective of the researcher.
• Information collection techniques (library, field, observation, questionnaire, and interview) and research tools are different according to each method. For example, statistical techniques are suitable for "explanatory methods". The techniques of semantics, semiotics, and linguistics are used for "interpretive methods".
• Doctrine is actually a guiding macro-map that expresses macro-policies. Doctrine means accepted "thematic principles" that govern science, which go beyond policies.
• Scientific policies and strategies that direct scientific programs [74].

Ethical considerations

The qualitative research conducted in two decades did not require an "ethics code". In the topics where the researcher used a panel of experts and interviews, as well as to conduct clinical trials, "ethics codes for each research" were obtained from the ethics centers of related medical sciences universities. In the report of the research results by the same group, it was stated that due to the large number of researchers, it is not possible to mention them individually.

Data availability

The findings of the conducted research are available in the form of books, articles, educational files, PowerPoint, and educational videos, on the website of "Spiritual Health Working Group of Baqiyatullah University of Medical Sciences" with a link: https://www.bmsu.ac.ir/portal/home/?335134/ and also on the researcher's website with the link: http://ishcc.ir/#!/home

Conflict of interests

There is no conflict of interest.

Grant information

The researcher has not received any grant for her research.

Acknowledgment 

The researcher appreciates the spiritual support of the respected secretary of the "Supreme Council of the Cultural Revolution of Iran", the honorable chairman of the "Supporting Board for Theorizing, Criticism and Scientific Debate Chairs", the judges and critics who participated in the judging sessions of "Sound Heart Theory in Spiritual Health".

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