Spiritual Needs and Satisfaction with Life: An Exploration of Mediating Pathways

Spiritual Needs and Satisfaction with Life: An Exploration of Mediating Pathways | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Spiritual Needs and Satisfaction with Life: An Exploration of Mediating Pathways Gary Kwok, Alan Astrow, Daniel Sulmasy, Katie Devine This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4415737/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 06 Nov, 2025 Read the published version in Supportive Care in Cancer → Version 1 posted 9 You are reading this latest preprint version Abstract Objectives This cross-sectional study seeks to understand how unmet spiritual needs are associated with lower satisfaction with life by investigating the mediating roles of perception of quality of care and satisfaction with care among a sample of racially/ethnically and religiously diverse hematology and oncology patients. Methods We constructed a path analysis relating spiritual needs, perception of quality of care, satisfaction with care, and satisfaction with life. Results Seven hundred twenty-seven hematology and oncology patients ( M Age = 59.0, 67.8% female) were recruited from four outpatient hematology/medical oncology sites. We found support for a serial multiple mediation hypothesis in which spiritual needs were indirectly associated with satisfaction with life through perception of quality of care and satisfaction with care. Specifically, higher spiritual needs were associated with a lower perception of quality of care ( b = -0.73, p < 0.001), which, in turn, was associated with lower satisfaction with care ( b = 0.26, p < 0.001) and subsequently resulted in lower satisfaction with life ( b = 0.40, p < 0.001). Conclusions The findings suggest that non-biomedical elements are important mechanisms through which spiritual needs are indirectly associated with satisfaction with life through the care cancer patients receive. In addition to addressing the quality of care, providers should pay attention to patients’ spiritual needs (e.g., ask questions regarding spiritual needs as part of psychosocial history, refer to chaplains, etc.). Improving spiritual needs may lead patients to experience higher-quality care and, subsequently, a better quality of life. Supportive Care Patient Satisfaction Quality of Life Quality of Health Care Spirituality Figures Figure 1 Background Spiritual beliefs and concerns are essential components of high-quality cancer care [ 1 ] and quality of life [ 2 ] across all disease trajectories. Research has shown that unmet spiritual needs are prevalent among cancer patients regardless of religious affiliation and participation [ 3 , 4 ]. For example, A study has shown nine out of ten cancer patients have one or more spiritual needs [ 5 , 6 ]. Many patients are interested in having their spiritual needs addressed by their physicians and healthcare providers [ 7 – 11 ]. Consequentially, unmet spiritual needs are associated with lower quality of care [ 3 ], patient satisfaction [ 3 , 12 , 13 ], and quality of life [ 14 ]. Improved spirituality can lead to higher satisfaction with life through lessening negative emotions (e.g., depression, anxiety, and anger) and increasing positive emotions such as hope, love, and happiness [ 15 ]. It is also important to note the differences between spirituality and religiosity. While religiosity is the search for significance through beliefs and practices within the context of institutions [ 16 ], spirituality extends beyond meaning, purpose, and transcendence [ 17 ] and any individual can experience spirituality [ 18 ] through vocation, family, or nature [ 17 ]. Providing care that enhances cancer patients' spiritual well-being and addresses their spiritual needs is an important aspect of holistic care. This has been highlighted by established associations between spirituality, quality of care, and well-being found in prior research. For example, a systematic review finds spiritual well-being is positively associated with the patient’s quality of life [ 19 ]. On the other hand, a study has found that increased spiritual needs are associated with less satisfaction with patient care and lower perceived quality of care among cancer patients [ 20 ]. Studies have also shown that higher quality of care and patient satisfaction are associated with better quality of life [ 21 , 22 ]. Although studies have suggested preliminary associations, the pathways to which explaining how these factors are related to each other have not been fully understood. For example, there have been no direct tests of the potential effects of spiritual needs, quality of care, and satisfaction with care leading to satisfaction with life. These findings together suggest that further exploration of their relationships is needed. The present study aimed to investigate potential mediating factors linking spiritual needs to life satisfaction. Specifically, this study explores different potential exploratory pathways linking spiritual needs to satisfaction with life through the care they receive. Overall, we hypothesized that greater spiritual needs would be related to lesser satisfaction with life as supported by previous studies. Using a serial multiple mediation model, we hypothesized that this relationship would be mediated by the perception of quality of care and subsequent satisfaction with care. Methods Participants and procedure The present study utilized data from a prior study that examined the spiritual, psychosocial, and religious needs among a racially and ethnically diverse hematology/medical oncology patient population [ 20 ]. Patients were recruited from four outpatient hematology/medical oncology sites in the New York Metropolitan area. Recruitment details are reported in Astrow et al. [ 20 ]. Briefly, participants were eligible if they were older than 18 years, spoke English, Spanish, Russian, or Chinese, and presented for a routine visit (i.e., not initial evaluation). After providing written consent, participants completed the questionnaire in their preferred language. The Institutional Review Board at the main study site approved this study (IRB# 12/04/XA06). Measures Spiritual Needs . Spiritual needs were assessed using the subscale from the Spiritual Needs Assessment for Patients (SNAP) scale [ 23 ]. The Spiritual Needs subscale contains 13 measures of spiritual needs and Cronbach’s alpha was .94. Sample items include “How much would you like help with finding meaning in your experience of illness?” or “How much would you like to talk with someone about the meaning and purpose of human life?” All items were rated on a 4-point Likert scale (1 = “Not at All” to 4 = “Very Much”) and higher scores indicate greater needs. Satisfaction with Life . Satisfaction with Life was assessed using the 5-item Satisfaction with Life Scale [ 24 ]. Sample items include “In most ways my life is close to my ideal” and “The conditions of my life are excellent.” Participants rated the items on a 7-point Likert scale (1 = “Strongly Disagree” to 7 = “Strong Agree”) and higher scores indicate higher levels of satisfaction with life. The internal reliability in the present sample was adequate (Cronbach's α = 0.89). Satisfaction with Care and Perception of Quality of Care . Satisfaction with care and perception of quality of care were measured using the Quality of End-of-Life Care and Satisfaction with Treatment (QUEST) scale [ 25 ]. The Satisfaction with Care subscale has 6 items; internal reliability was adequate (Cronbach’s alpha = .93). Sample items include “How satisfied have you been with your doctor’s bedside manner or common courtesy?” Participants rated the items on a 5-point Likert scale (1 = “Very Dissatisfied” to 5 = “Very Satisfied”) and higher scores indicate higher levels of satisfaction with care. The Perception of Quality of Care subscale contains 9 items and the Cronbach’s alpha was 0.76. Sample items include “How often have the doctors spent enough time with you or arrived late when they promise to come see you.?” Participants rated the items on a 5-point Likert scale (1 = “Never” to 5 = “Always”). Five reversed items were recoded and higher scores indicate higher perceived levels of quality of care. Data analysis plan Path analysis was conducted using STATA 14 [ 26 ]. We first tested the satisfaction with care as a mediator (i.e., spiritual needs ➔ satisfaction with care ➔ satisfaction with life; Model 1). In Model 2, we tested the perception of quality of care as a mediator (i.e., spiritual needs ➔ quality of care ➔ satisfaction with life). In Model 3, we tested the full mediation through the perception of quality of care and satisfaction with care (i.e., spiritual needs ➔ quality of care ➔ satisfaction with care ➔ satisfaction with life). The root mean square error of approximation (RMSEA) [ 27 ], standardized root mean residual (SRMR) [ 28 ], comparative fit index (CFI) [ 28 ], and the Tucker–Lewis index (TLI) [ 29 ] were used to assess model fit. Low values are desired for RSMEA and SRMR (< .10 for moderate fit and .90 good; >.95 excellent) are desired for the CFI and TLI [ 28 , 30 ]. We excluded n = 123 patients with five or more missing items on the SNAP spiritual needs subscale from the analysis [ 20 ]. For those patients who failed to complete one to four items, we imputed their missing values using the Multivariate Imputation by Chained Equations (MICE) package from R [ 31 ]. Bootstrapping was used to obtain 95% confidence intervals to assess the significant indirect effects[1] 1. The model tested included race, gender, and diagnosis as covariates . Results A total of N = 727 patients participated in the study ( M Age = 59.0, SD = 16.8; 67.8% female). The patient demographics breakdown was 49% non-Hispanic white, Black (25%), 14% Asian, and 13% Hispanic. 57% of participants reported English was the primary language spoken at home, followed by Russian (15%), Chinese (11%), and Spanish (9%). 23% of patients reported breast cancer, while 8% reported lung cancer and 7% reported colon cancer. Other diagnoses included: Ovarian cancer – 3.2%, prostate cancer – 2.9%, blood cancers – 9.5%, low blood count – 15.7%, bleeding or clotting problems – 4.7%, and others – 26.3%. Only 10.3% did not finish high school while about half (47%) were married. The complete description of the sample can be found in the parent study [20]. [Insert Table 1] Descriptive statistics and bivariate correlations are presented in Table 1. While 23.7% reported high spiritual needs (scored above 39), 15.7% reported dissatisfied or extremely dissatisfied with life (score below 15) [32]. On the other hand, only 4% and 1.4% reported being dissatisfied or extremely dissatisfied with care and encountered poor or very poor care (scored below 16 and 23, respectively). Higher spiritual needs were associated with lower satisfaction with life ( r = -0.11, p < 0.01), lower satisfaction with care ( r = -0.13, p < 0.01), and worse perception of quality of care ( r = -0.13, p < 0.01). Table 2 shows the model fit statistics for each model: Model 1) satisfaction with care as mediator (i.e., spiritual needs ➔ satisfaction with care ➔ satisfaction with life); Model 2) perception of quality of care as mediator (i.e., spiritual needs ➔ quality of care ➔ satisfaction with life); and Model 3) full mediation through the perception of quality of care and satisfaction with care (i.e., spiritual needs ➔ quality of care ➔ satisfaction with care ➔ satisfaction with life). All models indicated good to moderate model fit with the exception of Model 2 (e.g., CFI = 0.68; TLI = 0.52). [Insert Table 2] The model's parameter estimates are shown in Fig. 1, and the corresponding coefficients for all the paths in the full model (Model 3) are presented in Table 3. First, Models 1 and 2 had similar significant indirect effects (estimate Model 1 = -0.015, 95% CI = -0.029 to -0.003; estimate Model 2 = -0.016, 95% CI = -0.025 to -0.004). For the full model, the total indirect effect of spiritual needs on satisfaction with life was significant (estimate Model 3 = -0.020, 95% CI = -0.034 to -0.006; see Table 3 for standardized estimates). The specific indirect effect through satisfaction with care (i.e., spiritual needs ➔ satisfaction with care ➔ satisfaction with life) was not significant (estimate = -0.005, 95% CI = -0.014 to 0.003). Similarly, the indirect effects through the perception of quality of care (spiritual needs ➔ quality of care ➔ satisfaction with life) were not significant (estimate = -0.007, 95% CI = -0.016 to 0.002). [Insert Fig. 1] However, the relationship between spiritual needs and satisfaction with life was mediated through the perception of quality of care and satisfaction with care (i.e., spiritual needs ➔ quality of care ➔ satisfaction with care ➔ satisfaction with life). This specific indirect effect pathway was significant (estimate = -0.008; 95% CI = -0.014 to -0.002; see Table 3 for standardized estimates); greater spiritual needs were associated with a lower perception of quality of care ( b = -0.73, p < 0.001), which, in turn, was associated with lower satisfaction with care ( b = 0.26, p < 0.001) and consequently associated with lower satisfaction with life ( b = 0.40, p < 0.001). In sum, the total effect of spiritual needs on satisfaction with life was significant (estimates = -0.068, 95% CI = -0.117 to -0.020; see Table 3). We also tested an alternate model with satisfaction with care preceding perception of quality of care (i.e., spiritual needs ➔ satisfaction with care ➔ quality of care ➔ satisfaction with life) and it was not significant (estimate = -0.003; 95% CI = -0.006 to 0.001). [Insert Table 3] Discussion This study examined the pathways through which spiritual needs, quality of care, and patient satisfaction influence patients’ satisfaction with life. We explored the relationships between spiritual needs and patient care and found support for mediation hypotheses that spiritual needs were indirectly associated with patients’ satisfaction with life through their perception of the quality of care that they had received which led to satisfaction with the care. Specifically, greater spiritual needs were associated with a lower perception of quality of care, which, in turn, was associated with lower satisfaction with care, resulting in lower satisfaction with life. The result aligned with the current literature suggesting that spiritual needs are negatively associated with satisfaction with care and perceived quality of care [ 20 ], while quality of care and patient satisfaction are positively associated with patient’s quality of life [ 21 , 22 ]. A cancer diagnosis can be a daunting experience and the role of spirituality is closely tied to patients’ interpersonal relationships with providers and the psychosocial care available [ 33 ]. The spiritual and interpersonal significance of patient-provider relationships has substantial implications on patients’ satisfaction and quality of life. We also found that the perception of quality of care and satisfaction with care alone were not associated with satisfaction with life suggesting that rather than simple mediators, the impact of perception of quality of care and satisfaction with care are interconnected in impacting patient’s quality of life. Furthermore, when we tested satisfaction with care preceding quality of care (i.e., spiritual needs ➔ satisfaction with care ➔ quality of care ➔ satisfaction with life), we found no association suggesting a specific sequence in perception preceding their assessment of the care that they have received [ 34 , 35 ]. Clinical implications Our findings showed that increased spiritual needs have important associations with life satisfaction, specifically through the provision of care. Healthcare and psychosocial providers (e.g., oncologists, nurses, social workers, psychologists, etc.) working with racially and ethnically diverse cancer patients should pay attention to patients’ spiritual needs because it impacts the way patients view and experience the care they are receiving. Patients with low levels of spiritual well-being often express hopelessness and may have more frequent follow-up visits [ 36 ]. Research has also shown that patients think it is appropriate for providers to inquire about their spiritual needs and other religious beliefs as part of their complete psychosocial history [ 3 , 20 ]. Patients welcome clinical practices related to spiritual care which embeds within the larger holistic care approach. Ultimately, providers can serve an important role in improving patients’ lives through addressing spiritual needs. Clinical providers may encourage patients to disclose their cancer-related spiritual needs in a culturally sensitive way as part of the psychosocial history interview. The use of acronyms like “FICA” (F: faith and beliefs; I: importance of spirituality in your life; C: spiritual community of support; and A: how does the patient wish these addressed) can guide providers in asking about spiritual needs [ 37 , 38 ]. There are also other general guidelines and open-ended questions to initiate discussions of the meaning of illness and spirituality with patients [ 39 ]. Providers can facilitate these inquiries through active listening, availability, understanding, and making referrals when necessary [ 40 , 41 ]. It is also important to distinguish the role of spirituality from religiosity because many clinical providers (e.g., physicians) may not understand what spiritual care is and subsequently believe it is outside their scope of practice. Similarly, patients do not want spiritual guidance from their doctors but rather facilitate access to this care [ 42 ]. Physicians and clinicians may make referrals to specialty practitioners such as chaplaincy to help patients process cancer-related distress [ 41 ]. Chaplains can assess and provide intervention to ameliorate distress, death anxiety, peace of mind, and issues of meaning [ 43 ]. Chaplains can also provide guidance that helps patients reconnect with their spiritual community [ 44 ]. The clinical care team can work together to address patients’ distress; for example, the chaplain can provide his/her findings and recommendations in the patient’s chart so that the rest of the team can better support the patient [ 43 , 44 ]. For psychologists and social workers, spiritual needs can lead to distress that causes psychological and physical symptoms, such as depression, anxiety or acute pain [ 45 ]. Asking question patients about their spirituality is an important element in therapy because it gives the providers an understanding of their patients’ presenting issues [ 46 ]. Psychosocial providers can use their skills and knowledge toward the patient’s spiritual needs and to work effectively with chaplains and other members of the team [ 47 , 48 ]. Although addressing spiritual needs is important in clinical care, many staff reported having infrequent discussions of spiritual issues with patients and making infrequent referrals to chaplains [ 49 ]. Barriers to assessing and addressing spiritual needs include the lack of time, inadequate training in spiritual assessment, and the lack of spiritual inclination or awareness [ 49 , 50 ]. In addition to tools such as FICA [ 37 , 38 ], we can create changes by incorporating spiritual care into recommended guidelines and offering additional training to healthcare and psychosocial providers. Study limitations The current study has a few limitations. First, the cross-sectional nature of this study does not demonstrate a causal relationship between spiritual needs and satisfaction with life. Second, this is a secondary data analysis where constructs and measures were predetermined. For example, we could not control for cancer stages or prognoses because they were not captured in the parent study; for example, spirituality is an integral part of the end-of-life care [ 51 ] and thus cancer stages could potentially confound the current findings. Moreover, spiritual need is a complex construct and our measure may not fully capture what spiritual needs entail. Although we used validated measures, our assessment precluded us from understanding if any culturally specific spiritual needs may impact one population more so than the others [ 20 ]. For example, studies have shown that spirituality as a coping mechanism is culturally specific [ 52 , 53 ], suggesting cross-cultural differences among racial/ethnic groups. Future research should utilize a mixed-methods design to address this gap using quantitative (e.g., self-reported questionnaires) and qualitative data (e.g., interviews or focus groups) to provide more robust context and meaning. Also, studies may benefit from using more advanced statistical methodologies such as Structural Equation Modeling (SEM) to account for measurement errors within these complex constructs. Conclusions The results from this study contribute to the literature by examining a unique indirect pathway from spiritual needs to satisfaction with life through the perception of quality of care and satisfaction with care. The current analyses added to the parent study [ 20 ] by introducing the extended impacts of unmet spiritual needs in clinical care settings; patients with unmet spiritual needs would often experience poorer care, leading to poor life outcomes. A better understanding of these relationships can shed light on the fact that the provision of care has impacts beyond the clinical setting. Lastly, as spirituality is a critical component of holistic and person-centered care, spiritual need assessments and interventions should be considered and incorporated into care plans for cancer patients [ 44 , 54 ]. Healthcare and psychosocial providers are essential in implementing patient needs assessments and facilitating interventions (e.g., through FICA or referral to Chaplins) to give patient-centered high-quality care and a better quality of life beyond. Making chaplain referrals and having constant communications reflect the focus on holistic care among a vulnerable population. Declarations Acknowledgments/Funding : The study was supported by a grant from the Maimonides Research Fund and a generous gift from Ms. Dorothy Kryger. Financial interests: The authors have no relevant financial or non-financial interests to disclose. Conflicts of interest : The authors declare that they have no competing interests. Ethics approval: This article does not contain any studies with animals performed by any of the authors. All procedures performed in studies involving human participants were in accordance Informed Consent: Informed consent was obtained from all individual participants included in the study. Data Sharing : The data that support the findings of this study are available from the corresponding author upon reasonable request. The data are not publicly available due to privacy or ethical restrictions. References Peteet JR, Balboni MJ (2013) Spirituality and religion in oncology CA Cancer J Clin 63: 280-289 WHOQOL SRPB Group (2006) A cross-cultural study of spirituality, religion, and personal beliefs as components of quality of life Soc Sci Med 62: 1486-1497 Astrow AB, Wexler A, Texeira K, He MK, Sulmasy DP (2007) Is failure to meet spiritual needs associated with cancer patients' perceptions of quality of care and their satisfaction with care? J Clin Oncol 25: 5753-5757 Balboni TA, Vanderwerker LC, Block SD, Paulk ME, Lathan CS, Peteet JR, Prigerson HG (2007) Religiousness and spiritual support among advanced cancer patients and associations with end-of-life treatment preferences and quality of life J Clin Oncol 25: 555-560 Höcker A, Krüll A, Koch U, Mehnert A (2014) Exploring spiritual needs and their associated factors in an urban sample of early and advanced cancer patients Eur J Cancer Care (Engl) 23: 786-794 Pearce MJ, Coan AD, Herndon JE, 2nd, Koenig HG, Abernethy AP (2012) Unmet spiritual care needs impact emotional and spiritual well-being in advanced cancer patients Support Care Cancer 20: 2269-2276 Maugans TA, Wadland WC (1991) Religion and family medicine: a survey of physicians and patients J Fam Pract 32: 210-213 Daaleman TP, Nease DE, Jr. (1994) Patient attitudes regarding physician inquiry into spiritual and religious issues J Fam Pract 39: 564-568 Astrow AB, Sulmasy DP (2004) Spirituality and the Patient-Physician Relationship JAMA 291: 2884-2884 King DE, Bushwick B (1994) Beliefs and attitudes of hospital inpatients about faith healing and prayer J Fam Pract 39: 349-352 Hart A, Jr., Kohlwes RJ, Deyo R, Rhodes LA, Bowen DJ (2003) Hospice patients' attitudes regarding spiritual discussions with their doctors Am J Hosp Palliat Care 20: 135-139 Clark PA, Drain M, Malone MP (2003) Addressing patients' emotional and spiritual needs Jt Comm J Qual Saf 29: 659-670 Williams JA, Meltzer D, Arora V, Chung G, Curlin FA (2011) Attention to inpatients' religious and spiritual concerns: predictors and association with patient satisfaction J Gen Intern Med 26: 1265-1271 Balboni TA, Paulk ME, Balboni MJ, Phelps AC, Loggers ET, Wright AA, Block SD, Lewis EF, Peteet JR, Prigerson HG (2010) Provision of spiritual care to patients with advanced cancer: associations with medical care and quality of life near death J Clin Oncol 28: 445-452 Shirkavand L, Abbaszadeh A, Borhani F, Momenyan S (2018) Correlation between spiritual well-being with satisfaction with life and death anxiety among elderlies suffering from cancer. In: Editor (ed)^(eds) Book Correlation between spiritual well-being with satisfaction with life and death anxiety among elderlies suffering from cancer, City. Hill PC, Pargament KI, Hood RW, McCullough J, Michael E., Swyers JP, Larson DB, Zinnbauer BJ (2000) Conceptualizing Religion and Spirituality: Points of Commonality, Points of Departure Journal for the Theory of Social Behaviour 30: 51-77 Oman D (2013) Defining religion and spirituality. In: Paloutzian R, Park C (eds) Handbook of the Psychology of Religion and Spirituality. Guilford Press, pp. 23-47. Balboni TA, VanderWeele TJ, Doan-Soares SD, Long KNG, Ferrell BR, Fitchett G, Koenig HG, Bain PA, Puchalski C, Steinhauser KE, Sulmasy DP, Koh HK (2022) Spirituality in Serious Illness and Health JAMA 328: 184-197 Bai M, Lazenby M (2015) A systematic review of associations between spiritual well-being and quality of life at the scale and factor levels in studies among patients with cancer J Palliat Med 18: 286-298 Astrow AB, Kwok G, Sharma RK, Fromer N, Sulmasy DP (2018) Spiritual Needs and Perception of Quality of Care and Satisfaction With Care in Hematology/Medical Oncology Patients: A Multicultural Assessment J Pain Symptom Manage 55: 56-64.e51 Engel M, Brinkman-Stoppelenburg A, Nieboer D, van der Heide A (2018) Satisfaction with care of hospitalised patients with advanced cancer in the Netherlands Eur J Cancer Care (Engl) 27: e12874 Sharifa Ezat WP, Fuad I, Hayati Y, Zafar A, Wanda Kiyah GA (2014) Observational study on patient's satisfactions and quality of life (QoL) among cancer patients receiving treatment with palliative care intent in a tertiary hospital in Malaysia Asian Pac J Cancer Prev 15: 695-701 Sharma RK, Astrow AB, Texeira K, Sulmasy DP (2012) The Spiritual Needs Assessment for Patients (SNAP): development and validation of a comprehensive instrument to assess unmet spiritual needs J Pain Symptom Manage 44: 44-51 Diener E, Emmons RA, Larsen RJ, Griffin S (1985) The Satisfaction With Life Scale Journal of Personality Assessment 49: 71-75 Sulmasy DP, McIlvane JM, Pasley PM, Rahn M (2002) A Scale for Measuring Patient Perceptions of the Quality of End-of-Life Care and Satisfaction with Treatment: The Reliability and Validity of QUEST Journal of Pain and Symptom Management 23: 458-470 StataCorp (2015) Stata Statistical Software: Release 14. In: Editor (ed)^(eds) Book Stata Statistical Software: Release 14, City. Steiger JH (1990) Structural Model Evaluation and Modification: An Interval Estimation Approach Multivariate Behavioral Research 25: 173--180 Bentler PM (1990) Comparative fit indexes in structural models. Psychological Bulletin 107: 238--246 Tucker LR, Lewis C (1973) A reliability coefficient for maximum likelihood factor analysis Psychometrika 38: 1--10 Hu Lt, Bentler PM (1999) Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives Structural Equation Modeling: A Multidisciplinary Journal 6: 1--55 Buuren S, Groothuis-Oudshoorn C (2011) MICE: Multivariate Imputation by Chained Equations in R Journal of Statistical Software 45 Pavot W, Diener E (2008) The Satisfaction With Life Scale and the emerging construct of life satisfaction The Journal of Positive Psychology 3: 137-152 Hebert RS, Jenckes MW, Ford DE, O'Connor DR, Cooper LA (2001) Patient perspectives on spirituality and the patient-physician relationship Journal of general internal medicine 16: 685-692 Brédart A, Razavi D, Robertson C, Didier F, Scaffidi E, Fonzo D, Autier P, de Haes JCJM (2001) Assessment of Quality of Care in an Oncology Institute Using Information on Patients’ Satisfaction Oncology 61: 120-128 Davidson R, Mills ME (2005) Cancer patients’ satisfaction with communication, information and quality of care in a UK region European Journal of Cancer Care 14: 83-90 Cannon AJ, Darrington DL, Reed EC, Loberiza FR, Jr. (2011) Spirituality, patients' worry, and follow-up health-care utilization among cancer survivors J Support Oncol 9: 141-148 Astrow AB, Puchalski CM, Sulmasy DP (2001) Religion, spirituality, and health care: social, ethical, and practical considerations Am J Med 110: 283-287 Post SG, Puchalski CM, Larson DB (2000) Physicians and patient spirituality: professional boundaries, competency, and ethics Ann Intern Med 132: 578-583 Vachon MLS (2008) Meaning, Spirituality, and Wellness in Cancer Survivors Seminars in Oncology Nursing 24: 218-225 Hamilton DG (1998) Believing in patients' beliefs: physician attunement to the spiritual dimension as a positive factor in patient healing and health Am J Hosp Palliat Care 15: 276-279 Mandziuk PA (1994) The doctor-chaplain relationship West J Med 160: 376-377 Best M, Butow P, Olver I (2014) Spiritual support of cancer patients and the role of the doctor Supportive Care in Cancer 22: 1333-1339 Cooper RS (2011) Case study of a chaplain's spiritual care for a patient with advanced metastatic breast cancer J Health Care Chaplain 17: 19-37 Puchalski CM, King SDW, Ferrell BR (2018) Spiritual Considerations Hematol Oncol Clin North Am 32: 505-517 Puchalski C, Ferrell B, Virani R, Otis-Green S, Baird P, Bull J, Chochinov H, Handzo G, Nelson-Becker H, Prince-Paul M, Pugliese K, Sulmasy D (2009) Improving the quality of spiritual care as a dimension of palliative care: the report of the Consensus Conference J Palliat Med 12: 885-904 Lomax JW, 2nd, Karff RS, McKenny GP (2002) Ethical considerations in the integration of religion and psychotherapy: three perspectives Psychiatr Clin North Am 25: 547-559 Moss EL, Dobson KS (2006) Psychology, spirituality, and end-of-life care: An ethical integration? Canadian Psychology / Psychologie canadienne 47: 284-299 Kaut KP (2002) Religion, Spirituality, and Existentialism Near the End of Life: Implications for Assessment and Application American Behavioral Scientist 46: 220-234 Ellis MR, Vinsor D, Ewigman B (1999) Addressing spiritual concerns of patients: family physicians' attitudes and practices Journal of Family Practice 48: 105-109 Ellis MR, Campbell JD, Detwiler-Breidenbach A, Hubbard DK (2002) What do family physicians think about spirituality in clinical practice? Journal of Family Practice 51: 249-258 Steinhauser KE, Christakis NA, Clipp EC, McNeilly M, McIntyre L, Tulsky JA (2000) Factors considered important at the end of life by patients, family, physicians, and other care providers Jama 284: 2476-2482 Cooley ME, Jennings-Dozier K (1998) Cultural assessment of black American men treated for prostate cancer: clinical case studies Oncology nursing forum 25: 1729-1736 Juarez G, Ferrell B, Borneman T (1998) Influence of Culture on Cancer Pain Management in Hispanic Patients Cancer Practice 6: 262-269 Puchalski CM (2012) Spirituality in the cancer trajectory Ann Oncol 23 Suppl 3: 49-55 Footnotes The absence of zero in the confidence intervals suggests a significant indirect effect. Tables Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 06 Nov, 2025 Read the published version in Supportive Care in Cancer → Version 1 posted Editorial decision: Revision requested 06 Apr, 2025 Reviews received at journal 05 Apr, 2025 Reviewers agreed at journal 25 Mar, 2025 Reviews received at journal 25 Jun, 2024 Reviewers agreed at journal 20 Jun, 2024 Reviewers invited by journal 17 Jun, 2024 Editor assigned by journal 17 Jun, 2024 Submission checks completed at journal 22 May, 2024 First submitted to journal 13 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4415737","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":305356284,"identity":"45fa30fb-29cc-4237-8595-6f3f6c9e0ac0","order_by":0,"name":"Gary Kwok","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5klEQVRIiWNgGAWjYNCCAwwMEuw9DMxAJmMb8Vp4zpCsRSIHoqWBkGJ597PPJBjOHJaTnPn26OYCBjvZPgbmYx+/4NFieCbdTILhxmFjaem8tNszGJKN2xjYkmfL4NPSkMYmwfDhduI86Ryz27z/DiS2MfAYM0vg09L/DKpF8ozZbR4GIrTIS4BsuXE7cbYED0IL4wc8WgwknjFbJJz5byzZkwPSAvQLM1syMx4dDPL9aYw3PhxLk5M4DnaYnez89ubDjD/w2XKAgUUiAUUIaAUzDz5bGhiYMR2O15ZRMApGwSgYcQAAaUxIM890lUcAAAAASUVORK5CYII=","orcid":"","institution":"Hackensack Meridian Health Center for Discovery and Innovation","correspondingAuthor":true,"prefix":"","firstName":"Gary","middleName":"","lastName":"Kwok","suffix":""},{"id":305356287,"identity":"bd4941a0-aa69-4efe-bc07-c5105c06df22","order_by":1,"name":"Alan Astrow","email":"","orcid":"","institution":"NewYork–Presbyterian Brooklyn Methodist Hospital","correspondingAuthor":false,"prefix":"","firstName":"Alan","middleName":"","lastName":"Astrow","suffix":""},{"id":305356290,"identity":"879c9bb1-9003-4d65-9c56-cd9073d643cb","order_by":2,"name":"Daniel Sulmasy","email":"","orcid":"","institution":"Georgetown University","correspondingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"","lastName":"Sulmasy","suffix":""},{"id":305356293,"identity":"95fa8000-ced5-4ba0-b0ad-4bab475c7135","order_by":3,"name":"Katie Devine","email":"","orcid":"","institution":"Rutgers Cancer Institute of New Jersey","correspondingAuthor":false,"prefix":"","firstName":"Katie","middleName":"","lastName":"Devine","suffix":""}],"badges":[],"createdAt":"2024-05-14 01:27:58","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4415737/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4415737/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00520-025-10105-8","type":"published","date":"2025-11-06T15:57:13+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":57874321,"identity":"9668c068-6dd0-4d34-8f88-d095fd41fffb","added_by":"auto","created_at":"2024-06-06 18:45:57","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":758502,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4415737/v1/ef6665fe047c4a3370401c78.png"},{"id":95564166,"identity":"758c13a0-1ab5-4499-9255-885bffd66a5a","added_by":"auto","created_at":"2025-11-10 16:08:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1578701,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4415737/v1/99ba55e4-ab79-4788-a7b4-82de7906b0ab.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Spiritual Needs and Satisfaction with Life: An Exploration of Mediating Pathways","fulltext":[{"header":"Background","content":"\u003cp\u003eSpiritual beliefs and concerns are essential components of high-quality cancer care [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] and quality of life [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] across all disease trajectories. Research has shown that unmet spiritual needs are prevalent among cancer patients regardless of religious affiliation and participation [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. For example, A study has shown nine out of ten cancer patients have one or more spiritual needs [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Many patients are interested in having their spiritual needs addressed by their physicians and healthcare providers [\u003cspan additionalcitationids=\"CR8 CR9 CR10\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Consequentially, unmet spiritual needs are associated with lower quality of care [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], patient satisfaction [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], and quality of life [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Improved spirituality can lead to higher satisfaction with life through lessening negative emotions (e.g., depression, anxiety, and anger) and increasing positive emotions such as hope, love, and happiness [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. It is also important to note the differences between spirituality and religiosity. While religiosity is the search for significance through beliefs and practices within the context of institutions [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], spirituality extends beyond meaning, purpose, and transcendence [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] and any individual can experience spirituality [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] through vocation, family, or nature [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eProviding care that enhances cancer patients' spiritual well-being and addresses their spiritual needs is an important aspect of holistic care. This has been highlighted by established associations between spirituality, quality of care, and well-being found in prior research. For example, a systematic review finds spiritual well-being is positively associated with the patient\u0026rsquo;s quality of life [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. On the other hand, a study has found that increased spiritual needs are associated with less satisfaction with patient care and lower perceived quality of care among cancer patients [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Studies have also shown that higher quality of care and patient satisfaction are associated with better quality of life [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Although studies have suggested preliminary associations, the pathways to which explaining how these factors are related to each other have not been fully understood. For example, there have been no direct tests of the potential effects of spiritual needs, quality of care, and satisfaction with care leading to satisfaction with life. These findings together suggest that further exploration of their relationships is needed.\u003c/p\u003e \u003cp\u003eThe present study aimed to investigate potential mediating factors linking spiritual needs to life satisfaction. Specifically, this study explores different potential exploratory pathways linking spiritual needs to satisfaction with life through the care they receive. Overall, we hypothesized that greater spiritual needs would be related to lesser satisfaction with life as supported by previous studies. Using a serial multiple mediation model, we hypothesized that this relationship would be mediated by the perception of quality of care and subsequent satisfaction with care.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eParticipants and procedure\u003c/h2\u003e\n \u003cp\u003eThe present study utilized data from a prior study that examined the spiritual, psychosocial, and religious needs among a racially and ethnically diverse hematology/medical oncology patient population [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]. Patients were recruited from four outpatient hematology/medical oncology sites in the New York Metropolitan area. Recruitment details are reported in Astrow et al. [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]. Briefly, participants were eligible if they were older than 18 years, spoke English, Spanish, Russian, or Chinese, and presented for a routine visit (i.e., not initial evaluation). After providing written consent, participants completed the questionnaire in their preferred language. The Institutional Review Board at the main study site approved this study (IRB# 12/04/XA06).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003eMeasures\u003c/h2\u003e\n \u003cp\u003e\u003cstrong\u003eSpiritual Needs\u003c/strong\u003e. Spiritual needs were assessed using the subscale from the Spiritual Needs Assessment for Patients (SNAP) scale [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e]. The Spiritual Needs subscale contains 13 measures of spiritual needs and Cronbach\u0026rsquo;s alpha was .94. Sample items include \u0026ldquo;How much would you like help with finding meaning in your experience of illness?\u0026rdquo; or \u0026ldquo;How much would you like to talk with someone about the meaning and purpose of human life?\u0026rdquo; All items were rated on a 4-point Likert scale (1 = \u0026ldquo;Not at All\u0026rdquo; to 4 = \u0026ldquo;Very Much\u0026rdquo;) and higher scores indicate greater needs.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSatisfaction with Life\u003c/strong\u003e. Satisfaction with Life was assessed using the 5-item Satisfaction with Life Scale [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]. Sample items include \u0026ldquo;In most ways my life is close to my ideal\u0026rdquo; and \u0026ldquo;The conditions of my life are excellent.\u0026rdquo; Participants rated the items on a 7-point Likert scale (1 = \u0026ldquo;Strongly Disagree\u0026rdquo; to 7 = \u0026ldquo;Strong Agree\u0026rdquo;) and higher scores indicate higher levels of satisfaction with life. The internal reliability in the present sample was adequate (Cronbach\u0026apos;s \u0026alpha;\u0026thinsp;=\u0026thinsp;0.89).\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSatisfaction with Care and Perception of Quality of Care\u003c/strong\u003e. Satisfaction with care and perception of quality of care were measured using the Quality of End-of-Life Care and Satisfaction with Treatment (QUEST) scale [\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e]. The Satisfaction with Care subscale has 6 items; internal reliability was adequate (Cronbach\u0026rsquo;s alpha\u0026thinsp;=\u0026thinsp;.93). Sample items include \u0026ldquo;How satisfied have you been with your doctor\u0026rsquo;s bedside manner or common courtesy?\u0026rdquo; Participants rated the items on a 5-point Likert scale (1 = \u0026ldquo;Very Dissatisfied\u0026rdquo; to 5 = \u0026ldquo;Very Satisfied\u0026rdquo;) and higher scores indicate higher levels of satisfaction with care. The Perception of Quality of Care subscale contains 9 items and the Cronbach\u0026rsquo;s alpha was 0.76. Sample items include \u0026ldquo;How often have the doctors spent enough time with you or arrived late when they promise to come see you.?\u0026rdquo; Participants rated the items on a 5-point Likert scale (1 = \u0026ldquo;Never\u0026rdquo; to 5 = \u0026ldquo;Always\u0026rdquo;). Five reversed items were recoded and higher scores indicate higher perceived levels of quality of care.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003eData analysis plan\u003c/h2\u003e\n \u003cp\u003ePath analysis was conducted using STATA 14 [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e]. We first tested the satisfaction with care as a mediator (i.e., spiritual needs ➔ satisfaction with care ➔ satisfaction with life; Model 1). In Model 2, we tested the perception of quality of care as a mediator (i.e., spiritual needs ➔ quality of care ➔ satisfaction with life). In Model 3, we tested the full mediation through the perception of quality of care and satisfaction with care (i.e., spiritual needs ➔ quality of care ➔ satisfaction with care ➔ satisfaction with life).\u003c/p\u003e\n \u003cp\u003eThe root mean square error of approximation (RMSEA) [\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e], standardized root mean residual (SRMR) [\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e], comparative fit index (CFI) [\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e], and the Tucker\u0026ndash;Lewis index (TLI) [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e] were used to assess model fit. Low values are desired for RSMEA and SRMR (\u0026lt;\u0026thinsp;.10 for moderate fit and \u0026lt;\u0026thinsp;.06 for good fit), while high values (\u0026gt;\u0026thinsp;.90 good; \u0026gt;.95 excellent) are desired for the CFI and TLI [\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e]. We excluded \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;123 patients with five or more missing items on the SNAP spiritual needs subscale from the analysis [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]. For those patients who failed to complete one to four items, we imputed their missing values using the Multivariate Imputation by Chained Equations (MICE) package from R [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]. Bootstrapping was used to obtain 95% confidence intervals to assess the significant indirect effects[1]\u003ca class=\"FNLink\" href=\"#Fn1\" id=\"#FNLinkFn1\"\u003e\u003c/a\u003e\u003csup\u003e1. The model tested included race, gender, and diagnosis as covariates\u003c/sup\u003e.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;727 patients participated in the study (\u003cem\u003eM\u003c/em\u003e\u003csub\u003e\u003cem\u003eAge\u003c/em\u003e\u003c/sub\u003e = 59.0, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;16.8; 67.8% female). The patient demographics breakdown was 49% non-Hispanic white, Black (25%), 14% Asian, and 13% Hispanic. 57% of participants reported English was the primary language spoken at home, followed by Russian (15%), Chinese (11%), and Spanish (9%). 23% of patients reported breast cancer, while 8% reported lung cancer and 7% reported colon cancer. Other diagnoses included: Ovarian cancer \u0026ndash; 3.2%, prostate cancer \u0026ndash; 2.9%, blood cancers \u0026ndash; 9.5%, low blood count \u0026ndash; 15.7%, bleeding or clotting problems \u0026ndash; 4.7%, and others \u0026ndash; 26.3%. Only 10.3% did not finish high school while about half (47%) were married. The complete description of the sample can be found in the parent study [20].\u003c/p\u003e\n\u003cp\u003e[Insert Table\u0026nbsp;1]\u003c/p\u003e\n\u003cp\u003eDescriptive statistics and bivariate correlations are presented in Table\u0026nbsp;1. While 23.7% reported high spiritual needs (scored above 39), 15.7% reported dissatisfied or extremely dissatisfied with life (score below 15) [32]. On the other hand, only 4% and 1.4% reported being dissatisfied or extremely dissatisfied with care and encountered poor or very poor care (scored below 16 and 23, respectively). Higher spiritual needs were associated with lower satisfaction with life (\u003cem\u003er\u003c/em\u003e = -0.11, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), lower satisfaction with care (\u003cem\u003er\u003c/em\u003e = -0.13, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and worse perception of quality of care (\u003cem\u003er\u003c/em\u003e = -0.13, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;2 shows the model fit statistics for each model: Model 1) satisfaction with care as mediator (i.e., spiritual needs ➔ satisfaction with care ➔ satisfaction with life); Model 2) perception of quality of care as mediator (i.e., spiritual needs ➔ quality of care ➔ satisfaction with life); and Model 3) full mediation through the perception of quality of care and satisfaction with care (i.e., spiritual needs ➔ quality of care ➔ satisfaction with care ➔ satisfaction with life). All models indicated good to moderate model fit with the exception of Model 2 (e.g., \u003cem\u003eCFI\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.68; \u003cem\u003eTLI\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.52).\u003c/p\u003e\n\u003cp\u003e[Insert Table\u0026nbsp;2]\u003c/p\u003e\n\u003cp\u003eThe model\u0026apos;s parameter estimates are shown in Fig.\u0026nbsp;1, and the corresponding coefficients for all the paths in the full model (Model 3) are presented in Table\u0026nbsp;3. First, Models 1 and 2 had similar significant indirect effects (estimate\u003csub\u003eModel 1\u003c/sub\u003e = -0.015, \u003cem\u003e95% CI\u003c/em\u003e = -0.029 to -0.003; estimate\u003csub\u003eModel 2\u003c/sub\u003e = -0.016, \u003cem\u003e95% CI\u003c/em\u003e = -0.025 to -0.004). For the full model, the total indirect effect of spiritual needs on satisfaction with life was significant (estimate\u003csub\u003eModel 3\u003c/sub\u003e = -0.020, \u003cem\u003e95% CI\u003c/em\u003e = -0.034 to -0.006; see Table 3 for standardized estimates). The specific indirect effect through satisfaction with care (i.e., spiritual needs ➔ satisfaction with care ➔ satisfaction with life) was not significant (estimate = -0.005, \u003cem\u003e95% CI\u003c/em\u003e = -0.014 to 0.003). Similarly, the indirect effects through the perception of quality of care (spiritual needs ➔ quality of care ➔ satisfaction with life) were not significant (estimate = -0.007, \u003cem\u003e95% CI\u003c/em\u003e = -0.016 to 0.002).\u003c/p\u003e\n\u003cp\u003e[Insert Fig. 1]\u003c/p\u003e\n\u003cp\u003eHowever, the relationship between spiritual needs and satisfaction with life was mediated through the perception of quality of care and satisfaction with care (i.e., spiritual needs ➔ quality of care ➔ satisfaction with care ➔ satisfaction with life). This specific indirect effect pathway was significant (estimate = -0.008; \u003cem\u003e95% CI\u003c/em\u003e = -0.014 to -0.002; see Table 3 for standardized estimates); greater spiritual needs were associated with a lower perception of quality of care (\u003cem\u003eb\u003c/em\u003e = -0.73, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), which, in turn, was associated with lower satisfaction with care (\u003cem\u003eb\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.26, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and consequently associated with lower satisfaction with life (\u003cem\u003eb\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.40, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In sum, the total effect of spiritual needs on satisfaction with life was significant (estimates = -0.068, \u003cem\u003e95% CI\u003c/em\u003e = -0.117 to -0.020; see Table 3). We also tested an alternate model with satisfaction with care preceding perception of quality of care (i.e., spiritual needs ➔ satisfaction with care ➔ quality of care ➔ satisfaction with life) and it was not significant (estimate = -0.003; \u003cem\u003e95% CI\u003c/em\u003e = -0.006 to 0.001).\u003c/p\u003e\n\u003cp\u003e[Insert Table 3]\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study examined the pathways through which spiritual needs, quality of care, and patient satisfaction influence patients\u0026rsquo; satisfaction with life. We explored the relationships between spiritual needs and patient care and found support for mediation hypotheses that spiritual needs were indirectly associated with patients\u0026rsquo; satisfaction with life through their perception of the quality of care that they had received which led to satisfaction with the care. Specifically, greater spiritual needs were associated with a lower perception of quality of care, which, in turn, was associated with lower satisfaction with care, resulting in lower satisfaction with life. The result aligned with the current literature suggesting that spiritual needs are negatively associated with satisfaction with care and perceived quality of care [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], while quality of care and patient satisfaction are positively associated with patient\u0026rsquo;s quality of life [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA cancer diagnosis can be a daunting experience and the role of spirituality is closely tied to patients\u0026rsquo; interpersonal relationships with providers and the psychosocial care available [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. The spiritual and interpersonal significance of patient-provider relationships has substantial implications on patients\u0026rsquo; satisfaction and quality of life. We also found that the perception of quality of care and satisfaction with care alone were not associated with satisfaction with life suggesting that rather than simple mediators, the impact of perception of quality of care and satisfaction with care are interconnected in impacting patient\u0026rsquo;s quality of life. Furthermore, when we tested satisfaction with care preceding quality of care (i.e., spiritual needs ➔ satisfaction with care ➔ quality of care ➔ satisfaction with life), we found no association suggesting a specific sequence in perception preceding their assessment of the care that they have received [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eClinical implications\u003c/h2\u003e \u003cp\u003eOur findings showed that increased spiritual needs have important associations with life satisfaction, specifically through the provision of care. Healthcare and psychosocial providers (e.g., oncologists, nurses, social workers, psychologists, etc.) working with racially and ethnically diverse cancer patients should pay attention to patients\u0026rsquo; spiritual needs because it impacts the way patients view and experience the care they are receiving. Patients with low levels of spiritual well-being often express hopelessness and may have more frequent follow-up visits [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Research has also shown that patients think it is appropriate for providers to inquire about their spiritual needs and other religious beliefs as part of their complete psychosocial history [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Patients welcome clinical practices related to spiritual care which embeds within the larger holistic care approach. Ultimately, providers can serve an important role in improving patients\u0026rsquo; lives through addressing spiritual needs.\u003c/p\u003e \u003cp\u003eClinical providers may encourage patients to disclose their cancer-related spiritual needs in a culturally sensitive way as part of the psychosocial history interview. The use of acronyms like \u0026ldquo;FICA\u0026rdquo; (F: faith and beliefs; I: importance of spirituality in your life; C: spiritual community of support; and A: how does the patient wish these addressed) can guide providers in asking about spiritual needs [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. There are also other general guidelines and open-ended questions to initiate discussions of the meaning of illness and spirituality with patients [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Providers can facilitate these inquiries through active listening, availability, understanding, and making referrals when necessary [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt is also important to distinguish the role of spirituality from religiosity because many clinical providers (e.g., physicians) may not understand what spiritual care is and subsequently believe it is outside their scope of practice. Similarly, patients do not want spiritual guidance from their doctors but rather facilitate access to this care [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Physicians and clinicians may make referrals to specialty practitioners such as chaplaincy to help patients process cancer-related distress [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Chaplains can assess and provide intervention to ameliorate distress, death anxiety, peace of mind, and issues of meaning [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Chaplains can also provide guidance that helps patients reconnect with their spiritual community [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. The clinical care team can work together to address patients\u0026rsquo; distress; for example, the chaplain can provide his/her findings and recommendations in the patient\u0026rsquo;s chart so that the rest of the team can better support the patient [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. For psychologists and social workers, spiritual needs can lead to distress that causes psychological and physical symptoms, such as depression, anxiety or acute pain [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Asking question patients about their spirituality is an important element in therapy because it gives the providers an understanding of their patients\u0026rsquo; presenting issues [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Psychosocial providers can use their skills and knowledge toward the patient\u0026rsquo;s spiritual needs and to work effectively with chaplains and other members of the team [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough addressing spiritual needs is important in clinical care, many staff reported having infrequent discussions of spiritual issues with patients and making infrequent referrals to chaplains [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Barriers to assessing and addressing spiritual needs include the lack of time, inadequate training in spiritual assessment, and the lack of spiritual inclination or awareness [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. In addition to tools such as FICA [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], we can create changes by incorporating spiritual care into recommended guidelines and offering additional training to healthcare and psychosocial providers.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStudy limitations\u003c/h2\u003e \u003cp\u003eThe current study has a few limitations. First, the cross-sectional nature of this study does not demonstrate a causal relationship between spiritual needs and satisfaction with life. Second, this is a secondary data analysis where constructs and measures were predetermined. For example, we could not control for cancer stages or prognoses because they were not captured in the parent study; for example, spirituality is an integral part of the end-of-life care [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e] and thus cancer stages could potentially confound the current findings. Moreover, spiritual need is a complex construct and our measure may not fully capture what spiritual needs entail. Although we used validated measures, our assessment precluded us from understanding if any culturally specific spiritual needs may impact one population more so than the others [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. For example, studies have shown that spirituality as a coping mechanism is culturally specific [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e], suggesting cross-cultural differences among racial/ethnic groups. Future research should utilize a mixed-methods design to address this gap using quantitative (e.g., self-reported questionnaires) and qualitative data (e.g., interviews or focus groups) to provide more robust context and meaning. Also, studies may benefit from using more advanced statistical methodologies such as Structural Equation Modeling (SEM) to account for measurement errors within these complex constructs.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe results from this study contribute to the literature by examining a unique indirect pathway from spiritual needs to satisfaction with life through the perception of quality of care and satisfaction with care. The current analyses added to the parent study [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] by introducing the extended impacts of unmet spiritual needs in clinical care settings; patients with unmet spiritual needs would often experience poorer care, leading to poor life outcomes. A better understanding of these relationships can shed light on the fact that the provision of care has impacts beyond the clinical setting. Lastly, as spirituality is a critical component of holistic and person-centered care, spiritual need assessments and interventions should be considered and incorporated into care plans for cancer patients [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. Healthcare and psychosocial providers are essential in implementing patient needs assessments and facilitating interventions (e.g., through FICA or referral to Chaplins) to give patient-centered high-quality care and a better quality of life beyond. Making chaplain referrals and having constant communications reflect the focus on holistic care among a vulnerable population.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments/Funding\u003c/strong\u003e: The study was supported by a grant from the Maimonides Research Fund and a generous gift from Ms. Dorothy Kryger.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinancial interests:\u0026nbsp;\u003c/strong\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003c/strong\u003e: The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval:\u0026nbsp;\u003c/strong\u003eThis article does not contain any studies with animals performed by any of the authors. All procedures performed in studies involving human participants were in accordance\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent:\u003c/strong\u003e Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Sharing\u003c/strong\u003e: The data that support the findings of this study are available from the corresponding author upon reasonable request. The data are not publicly available due to privacy or ethical restrictions.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePeteet JR, Balboni MJ (2013) Spirituality and religion in oncology CA Cancer J Clin 63: 280-289\u003c/li\u003e\n\u003cli\u003eWHOQOL SRPB Group (2006) A cross-cultural study of spirituality, religion, and personal beliefs as components of quality of life Soc Sci Med 62: 1486-1497\u003c/li\u003e\n\u003cli\u003eAstrow AB, Wexler A, Texeira K, He MK, Sulmasy DP (2007) Is failure to meet spiritual needs associated with cancer patients\u0026apos; perceptions of quality of care and their satisfaction with care? J Clin Oncol 25: 5753-5757\u003c/li\u003e\n\u003cli\u003eBalboni TA, Vanderwerker LC, Block SD, Paulk ME, Lathan CS, Peteet JR, Prigerson HG (2007) Religiousness and spiritual support among advanced cancer patients and associations with end-of-life treatment preferences and quality of life J Clin Oncol 25: 555-560\u003c/li\u003e\n\u003cli\u003eH\u0026ouml;cker A, Kr\u0026uuml;ll A, Koch U, Mehnert A (2014) Exploring spiritual needs and their associated factors in an urban sample of early and advanced cancer patients Eur J Cancer Care (Engl) 23: 786-794\u003c/li\u003e\n\u003cli\u003ePearce MJ, Coan AD, Herndon JE, 2nd, Koenig HG, Abernethy AP (2012) Unmet spiritual care needs impact emotional and spiritual well-being in advanced cancer patients Support Care Cancer 20: 2269-2276\u003c/li\u003e\n\u003cli\u003eMaugans TA, Wadland WC (1991) Religion and family medicine: a survey of physicians and patients J Fam Pract 32: 210-213\u003c/li\u003e\n\u003cli\u003eDaaleman TP, Nease DE, Jr. (1994) Patient attitudes regarding physician inquiry into spiritual and religious issues J Fam Pract 39: 564-568\u003c/li\u003e\n\u003cli\u003eAstrow AB, Sulmasy DP (2004) Spirituality and the Patient-Physician Relationship JAMA 291: 2884-2884\u003c/li\u003e\n\u003cli\u003eKing DE, Bushwick B (1994) Beliefs and attitudes of hospital inpatients about faith healing and prayer J Fam Pract 39: 349-352\u003c/li\u003e\n\u003cli\u003eHart A, Jr., Kohlwes RJ, Deyo R, Rhodes LA, Bowen DJ (2003) Hospice patients\u0026apos; attitudes regarding spiritual discussions with their doctors Am J Hosp Palliat Care 20: 135-139\u003c/li\u003e\n\u003cli\u003eClark PA, Drain M, Malone MP (2003) Addressing patients\u0026apos; emotional and spiritual needs Jt Comm J Qual Saf 29: 659-670\u003c/li\u003e\n\u003cli\u003eWilliams JA, Meltzer D, Arora V, Chung G, Curlin FA (2011) Attention to inpatients\u0026apos; religious and spiritual concerns: predictors and association with patient satisfaction J Gen Intern Med 26: 1265-1271\u003c/li\u003e\n\u003cli\u003eBalboni TA, Paulk ME, Balboni MJ, Phelps AC, Loggers ET, Wright AA, Block SD, Lewis EF, Peteet JR, Prigerson HG (2010) Provision of spiritual care to patients with advanced cancer: associations with medical care and quality of life near death J Clin Oncol 28: 445-452\u003c/li\u003e\n\u003cli\u003eShirkavand L, Abbaszadeh A, Borhani F, Momenyan S (2018) Correlation between spiritual well-being with satisfaction with life and death anxiety among elderlies suffering from cancer. In: Editor (ed)^(eds) Book Correlation between spiritual well-being with satisfaction with life and death anxiety among elderlies suffering from cancer, City.\u003c/li\u003e\n\u003cli\u003eHill PC, Pargament KI, Hood RW, McCullough J, Michael E., Swyers JP, Larson DB, Zinnbauer BJ (2000) Conceptualizing Religion and Spirituality: Points of Commonality, Points of Departure Journal for the Theory of Social Behaviour 30: 51-77\u003c/li\u003e\n\u003cli\u003eOman D (2013) Defining religion and spirituality. In: Paloutzian R, Park C (eds) Handbook of the Psychology of Religion and Spirituality. Guilford Press, pp. 23-47.\u003c/li\u003e\n\u003cli\u003eBalboni TA, VanderWeele TJ, Doan-Soares SD, Long KNG, Ferrell BR, Fitchett G, Koenig HG, Bain PA, Puchalski C, Steinhauser KE, Sulmasy DP, Koh HK (2022) Spirituality in Serious Illness and Health JAMA 328: 184-197\u003c/li\u003e\n\u003cli\u003eBai M, Lazenby M (2015) A systematic review of associations between spiritual well-being and quality of life at the scale and factor levels in studies among patients with cancer J Palliat Med 18: 286-298\u003c/li\u003e\n\u003cli\u003eAstrow AB, Kwok G, Sharma RK, Fromer N, Sulmasy DP (2018) Spiritual Needs and Perception of Quality of Care and Satisfaction With Care in Hematology/Medical Oncology Patients: A Multicultural Assessment J Pain Symptom Manage 55: 56-64.e51\u003c/li\u003e\n\u003cli\u003eEngel M, Brinkman-Stoppelenburg A, Nieboer D, van der Heide A (2018) Satisfaction with care of hospitalised patients with advanced cancer in the Netherlands Eur J Cancer Care (Engl) 27: e12874\u003c/li\u003e\n\u003cli\u003eSharifa Ezat WP, Fuad I, Hayati Y, Zafar A, Wanda Kiyah GA (2014) Observational study on patient\u0026apos;s satisfactions and quality of life (QoL) among cancer patients receiving treatment with palliative care intent in a tertiary hospital in Malaysia Asian Pac J Cancer Prev 15: 695-701\u003c/li\u003e\n\u003cli\u003eSharma RK, Astrow AB, Texeira K, Sulmasy DP (2012) The Spiritual Needs Assessment for Patients (SNAP): development and validation of a comprehensive instrument to assess unmet spiritual needs J Pain Symptom Manage 44: 44-51\u003c/li\u003e\n\u003cli\u003eDiener E, Emmons RA, Larsen RJ, Griffin S (1985) The Satisfaction With Life Scale Journal of Personality Assessment 49: 71-75\u003c/li\u003e\n\u003cli\u003eSulmasy DP, McIlvane JM, Pasley PM, Rahn M (2002) A Scale for Measuring Patient Perceptions of the Quality of End-of-Life Care and Satisfaction with Treatment: The Reliability and Validity of QUEST Journal of Pain and Symptom Management 23: 458-470\u003c/li\u003e\n\u003cli\u003eStataCorp (2015) Stata Statistical Software: Release 14. In: Editor (ed)^(eds) Book Stata Statistical Software: Release 14, City.\u003c/li\u003e\n\u003cli\u003eSteiger JH (1990) Structural Model Evaluation and Modification: An Interval Estimation Approach Multivariate Behavioral Research 25: 173--180\u003c/li\u003e\n\u003cli\u003eBentler PM (1990) Comparative fit indexes in structural models. Psychological Bulletin 107: 238--246\u003c/li\u003e\n\u003cli\u003eTucker LR, Lewis C (1973) A reliability coefficient for maximum likelihood factor analysis Psychometrika 38: 1--10\u003c/li\u003e\n\u003cli\u003eHu Lt, Bentler PM (1999) Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives Structural Equation Modeling: A Multidisciplinary Journal 6: 1--55\u003c/li\u003e\n\u003cli\u003eBuuren S, Groothuis-Oudshoorn C (2011) MICE: Multivariate Imputation by Chained Equations in R Journal of Statistical Software 45\u003c/li\u003e\n\u003cli\u003ePavot W, Diener E (2008) The Satisfaction With Life Scale and the emerging construct of life satisfaction The Journal of Positive Psychology 3: 137-152\u003c/li\u003e\n\u003cli\u003eHebert RS, Jenckes MW, Ford DE, O\u0026apos;Connor DR, Cooper LA (2001) Patient perspectives on spirituality and the patient-physician relationship Journal of general internal medicine 16: 685-692\u003c/li\u003e\n\u003cli\u003eBr\u0026eacute;dart A, Razavi D, Robertson C, Didier F, Scaffidi E, Fonzo D, Autier P, de Haes JCJM (2001) Assessment of Quality of Care in an Oncology Institute Using Information on Patients\u0026rsquo; Satisfaction Oncology 61: 120-128\u003c/li\u003e\n\u003cli\u003eDavidson R, Mills ME (2005) Cancer patients\u0026rsquo; satisfaction with communication, information and quality of care in a UK region European Journal of Cancer Care 14: 83-90\u003c/li\u003e\n\u003cli\u003eCannon AJ, Darrington DL, Reed EC, Loberiza FR, Jr. (2011) Spirituality, patients\u0026apos; worry, and follow-up health-care utilization among cancer survivors J Support Oncol 9: 141-148\u003c/li\u003e\n\u003cli\u003eAstrow AB, Puchalski CM, Sulmasy DP (2001) Religion, spirituality, and health care: social, ethical, and practical considerations Am J Med 110: 283-287\u003c/li\u003e\n\u003cli\u003ePost SG, Puchalski CM, Larson DB (2000) Physicians and patient spirituality: professional boundaries, competency, and ethics Ann Intern Med 132: 578-583\u003c/li\u003e\n\u003cli\u003eVachon MLS (2008) Meaning, Spirituality, and Wellness in Cancer Survivors Seminars in Oncology Nursing 24: 218-225\u003c/li\u003e\n\u003cli\u003eHamilton DG (1998) Believing in patients\u0026apos; beliefs: physician attunement to the spiritual dimension as a positive factor in patient healing and health Am J Hosp Palliat Care 15: 276-279\u003c/li\u003e\n\u003cli\u003eMandziuk PA (1994) The doctor-chaplain relationship West J Med 160: 376-377\u003c/li\u003e\n\u003cli\u003eBest M, Butow P, Olver I (2014) Spiritual support of cancer patients and the role of the doctor Supportive Care in Cancer 22: 1333-1339\u003c/li\u003e\n\u003cli\u003eCooper RS (2011) Case study of a chaplain\u0026apos;s spiritual care for a patient with advanced metastatic breast cancer J Health Care Chaplain 17: 19-37\u003c/li\u003e\n\u003cli\u003ePuchalski CM, King SDW, Ferrell BR (2018) Spiritual Considerations Hematol Oncol Clin North Am 32: 505-517\u003c/li\u003e\n\u003cli\u003ePuchalski C, Ferrell B, Virani R, Otis-Green S, Baird P, Bull J, Chochinov H, Handzo G, Nelson-Becker H, Prince-Paul M, Pugliese K, Sulmasy D (2009) Improving the quality of spiritual care as a dimension of palliative care: the report of the Consensus Conference J Palliat Med 12: 885-904\u003c/li\u003e\n\u003cli\u003eLomax JW, 2nd, Karff RS, McKenny GP (2002) Ethical considerations in the integration of religion and psychotherapy: three perspectives Psychiatr Clin North Am 25: 547-559\u003c/li\u003e\n\u003cli\u003eMoss EL, Dobson KS (2006) Psychology, spirituality, and end-of-life care: An ethical integration? Canadian Psychology / Psychologie canadienne 47: 284-299\u003c/li\u003e\n\u003cli\u003eKaut KP (2002) Religion, Spirituality, and Existentialism Near the End of Life: Implications for Assessment and Application American Behavioral Scientist 46: 220-234\u003c/li\u003e\n\u003cli\u003eEllis MR, Vinsor D, Ewigman B (1999) Addressing spiritual concerns of patients: family physicians\u0026apos; attitudes and practices Journal of Family Practice 48: 105-109\u003c/li\u003e\n\u003cli\u003eEllis MR, Campbell JD, Detwiler-Breidenbach A, Hubbard DK (2002) What do family physicians think about spirituality in clinical practice? Journal of Family Practice 51: 249-258\u003c/li\u003e\n\u003cli\u003eSteinhauser KE, Christakis NA, Clipp EC, McNeilly M, McIntyre L, Tulsky JA (2000) Factors considered important at the end of life by patients, family, physicians, and other care providers Jama 284: 2476-2482\u003c/li\u003e\n\u003cli\u003eCooley ME, Jennings-Dozier K (1998) Cultural assessment of black American men treated for prostate cancer: clinical case studies Oncology nursing forum 25: 1729-1736\u003c/li\u003e\n\u003cli\u003eJuarez G, Ferrell B, Borneman T (1998) Influence of Culture on Cancer Pain Management in Hispanic Patients Cancer Practice 6: 262-269\u003c/li\u003e\n\u003cli\u003ePuchalski CM (2012) Spirituality in the cancer trajectory Ann Oncol 23 Suppl 3: 49-55\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eThe absence of zero in the confidence intervals suggests a significant indirect effect.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/122228_c8a1650c59388082/122228_custom_files/img171742976616.png\"\u003e\u003c/p\u003e\n\u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/122228_c8a1650c59388082/122228_custom_files/img1717429766.png\"\u003e\u003c/p\u003e\n\u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/122228_c8a1650c59388082/122228_custom_files/img1717429765.png\"\u003e\u003cbr\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Supportive Care, Patient Satisfaction, Quality of Life, Quality of Health Care, Spirituality","lastPublishedDoi":"10.21203/rs.3.rs-4415737/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4415737/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eThis cross-sectional study seeks to understand how unmet spiritual needs are associated with lower satisfaction with life by investigating the mediating roles of perception of quality of care and satisfaction with care among a sample of racially/ethnically and religiously diverse hematology and oncology patients.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe constructed a path analysis relating spiritual needs, perception of quality of care, satisfaction with care, and satisfaction with life.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSeven hundred twenty-seven hematology and oncology patients (\u003cem\u003eM\u003c/em\u003e\u003csub\u003e\u003cem\u003eAge\u003c/em\u003e\u003c/sub\u003e = 59.0, 67.8% female) were recruited from four outpatient hematology/medical oncology sites. We found support for a serial multiple mediation hypothesis in which spiritual needs were indirectly associated with satisfaction with life through perception of quality of care and satisfaction with care. Specifically, higher spiritual needs were associated with a lower perception of quality of care (\u003cem\u003eb\u003c/em\u003e = -0.73, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), which, in turn, was associated with lower satisfaction with care (\u003cem\u003eb\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.26, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and subsequently resulted in lower satisfaction with life (\u003cem\u003eb\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.40, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe findings suggest that non-biomedical elements are important mechanisms through which spiritual needs are indirectly associated with satisfaction with life through the care cancer patients receive. In addition to addressing the quality of care, providers should pay attention to patients\u0026rsquo; spiritual needs (e.g., ask questions regarding spiritual needs as part of psychosocial history, refer to chaplains, etc.). Improving spiritual needs may lead patients to experience higher-quality care and, subsequently, a better quality of life.\u003c/p\u003e","manuscriptTitle":"Spiritual Needs and Satisfaction with Life: An Exploration of Mediating Pathways","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-06 18:45:53","doi":"10.21203/rs.3.rs-4415737/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-07T01:07:31+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-05T05:58:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"190189762364345680626522726042500922203","date":"2025-03-25T05:47:31+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-25T09:33:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"270710877884835324475371975468984496822","date":"2024-06-20T15:03:56+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-06-17T16:14:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-17T16:10:04+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-22T07:39:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"Supportive Care in Cancer","date":"2024-05-14T01:26:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"c76385e5-d26d-44e0-b8eb-87cff12a9858","owner":[],"postedDate":"June 6th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-10T16:05:04+00:00","versionOfRecord":{"articleIdentity":"rs-4415737","link":"https://doi.org/10.1007/s00520-025-10105-8","journal":{"identity":"supportive-care-in-cancer","isVorOnly":false,"title":"Supportive Care in Cancer"},"publishedOn":"2025-11-06 15:57:13","publishedOnDateReadable":"November 6th, 2025"},"versionCreatedAt":"2024-06-06 18:45:53","video":"","vorDoi":"10.1007/s00520-025-10105-8","vorDoiUrl":"https://doi.org/10.1007/s00520-025-10105-8","workflowStages":[]},"version":"v1","identity":"rs-4415737","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4415737","identity":"rs-4415737","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}