Psycho‐emotional recovery, the meaning of care in the process of providing palliative care to Iranian people with cancer: A grounded theory study

Abstract Aim Despite the significance of palliative care in treating people with cancer, the provision of this type of care in Iran is vague and unorganized. This research intends to explore the meaning of care in the process of providing palliative care to Iranian people with cancer and to develop a theory that would explain the phenomenon. Design This is a qualitative study in nature and Corbin and Strauss' Grounded Theory approach was used for data analysis. Methods Data was collected through semi structured interviews that were held with 21 participants who have had experiences in receiving and providing palliative care. The study was conducted in April to December 2019 in palliative care centres of Tehran. Sampling first started purposefully and moved to theoretical once concepts began to emerge from the data. Comparative and continuous data analysis was undertaken using Corbin and Strauss' (Basics of qualitative research: Techniques and procedures for developing grounded theory, Sage, 2015) approach. Results Main concerns of care providers in providing palliative care was to reduce the affliction and anxiety of patients by understanding the difficult state of patient and psycho‐emotional recovery was identified as the core category, which was performed via three critical strategies: building emotional connection, reinforcing positive mindset and having a core value in care.

effective approach and over the recent years, various countries have prioritized palliative care in their healthcare programs (Balducci & Dolan, 2016;Partridge et al., 2014;Salins et al., 2016). Analysis of current research has shown that several studies have recently concentrated on various aspects of delivering palliative care, which includes a list of the different roles that healthcare providers have in providing care, in particular nurses (Dahlin, 2015;Deitrick et al., 2011;Levit et al., 2013). Imhof et al. (2016) stated in their study that one of the most statistically significant roles of nurses is establishing and maintaining an interdisciplinary caring network, which also reflects on a nurse's leadership in the caring process (Imhof et al., 2016). To carry out this functional framework, nurses will be required to be trained and prepared, which based on the socio-cultural context of different communities, this will differ from one place to another. Sekse et al. (2018) have also pointed, in their meta-synthesis study, the role of nurses' availability in providing palliative care, and stated that this role may be determined based on the number of staff that a certain healthcare setting may have (Sekse et al., 2018).
Over the recent years in Iran, the palliative care approach has also gained recognition by healthcare policy-makers; yet, the use of this approach is nascent, and only a few centres actually offer this service but they lack a purposeful programme and do not really follow a certain care model (Mojen, 2017;. Therefore, it is not clear how the care is provided and the factors that affect it or its consequences are barely considered. Rassouli and Sajjadi (2016) have shown that although some measures have been taken to develop palliative care in Iran, there has been some obstacles and since there is no transparent functional framework to carry out the care, it has been suggested that some standard functional guidelines be designed addressed to physicians and nurses to effectively perform palliative care. Khoshnazar et al. (2016) have stated that the lack of rehabilitation programmes and care instructions is a fundamental challenge in providing palliative care.
Although some studies have addressed various aspects of providing palliative care, such as spiritual care (Rahnama et al., 2014) and have explored real-life experiences of palliative care (Seyedfatemi et al., 2014), it seems that because there is a lack of comprehensive local studies conducted on the process and methods of providing palliative care, no specific care framework has in turn been suggested. As a result, the patients who actually need these services can only receive limited palliative care since there is no clear guideline for the practice. Considering that frameworks and models can guide actions, it is necessary to develop a suitable functional model for providing palliative care in Iran. Therefore, it is necessary to develop a proper concept about the nature of palliative care and to reach a transparent understanding of the existing process of palliative care in the country. On the other hand, there are distinct and context-specific functional areas and functions of care providers that involve institutional variations in the health system and educational differences as well.
One of the main challenges in providing palliative care in Iran is the lack of a role profile for palliative care providers and the lack of serious training in the official curriculum of medical universities (Mojen, 2017). Delivering palliative care also relies on the cultural context, patients' character and socio-economic conditions (Stjernswärd et al., 2007). Therefore, it is hoped that this study will help to identify the factors and conditions that affect palliative care for people with cancer and the process of providing palliative care in Iran. The main purpose of this study was to explore the process of providing palliative care for people with cancer and to construct a grounded theory.

| Design
For this research, the qualitative Straussian Grounded Theory approach was used to explore the various methods of providing palliative care to people with cancer, to explore the current state of care in Iran, and to provide a substantive theory. Grounded Theory enables the exploration and interpretation of repeated behaviour patterns and the deduction of the underlying hypothesis to explain the under study phenomenon based on extracted data (Boeije, 2009).
Since palliative care is a dynamic process consisting of a number of interactions affected by various factors (Chamberlain-Salaun et al., 2013), Straussian Grounded Theory was considered an acceptable approach to this study.

| Participants and data collection
The study location was the healthcare centres and charitable institutions that offered palliative care to people with cancer in Tehran.
The main participants here were nurses who had experienced providing palliative care in palliative care wards and were also willing to participate in the study. Purposeful sampling was the first stage in selecting the participants. Next, participants were filtered based on the conceptual classifications that were achieved from data analysis. This allowed the collection of more accurate findings, which, in turn, allowed data saturation and the deduction of an underlying theory to define the phenomenon. Sampling and data collection continued until the saturation of all classifications were met and the underlying theory was completed. Finally, 21 individuals (9 nurses, 4 patients, 3 family members, 2 palliative care physicians, 1 psychologist, 1 spiritual counsellor, 1 social assistant) participated in this study (Table 1).
Data collection was undertaken by means of interviews. The unstructured interviews first started with open-ended questions such as "Please share your experience with providing palliative care to patients" and "Please share your experience in dealing with patients' problems and issues at your workplace," in order to collect the participants' relevant experience. Then, based on their answers, participants were asked exploratory questions, which were later followed by other questions that concerned their actions or the events, the reason for selecting certain treatments and way they had offered them. This was done by asking questions like "Could you please describe exactly how you perform your tasks?" and "Could you please elaborate." These questions made in-depth analysis possible. Then, by analysing all data collected from purposeful interviews, supplementary interviews were performed and theoretical sampling was used to determine the features of the phenomenon. All interviews were face-to-face and carried out at places of participant's choosing.
The interviews lasted for an average of 47 min and recorded upon the participant's consent.

| Data analysis
Data analysis was performed in parallel with data collection and constant comparative analysis were used. The researcher was involved in the data collection process and the transcribing of the audio files.
Then, the researcher read the transcriptions a number of times in order to reach a deep and general understanding of the collected data. These results influenced and guided subsequent interviews. In addition, the memoing was used to confirm data saturation, to confirm principles and to complete the underlying theory for building emotional connection, having a core value in care, reinforcing a positive mindset and tending psychological distress in care providers. Corbin and Strauss' (2015) approach was used for data processing, which consists of the following steps.

| Open coding to identify concepts
As soon as the first interview was over, open coding began. After studying the transcriptions of the interviews for several times and reaching a better understanding of the nature of the content, the text of the interview was divided and some parts were underlined.
A title was selected to define and later used to refer to that certain piece of information. The title was either extracted from the participant's own words used in the interview (in vivo codes) or in some other cases, the researcher selected a title to define the concept.

| Development of concepts based on their features and dimensions
The lower level of categories was defined by comparing the data collected between interviews that were in line with the concepts and by asking questions that allowed the concepts to be further established through theoretical sampling (memo writing). The categories where connected based on their conceptual, featural and dimensional characteristics. By considering the evolved concepts, the main concerns of care providers were identified. As an example, Table 2 demonstrates how the concept of Building Emotional Connection was developed through stages one and two.

| Analyse data for context
Here, based on data analysis, the researchers tried to reveal the situations that had affected the participants and caused them to respond in a certain way.

| Analyse data for process
To search for the process, the researchers read the notes of previous analyses. By identifying the context and condition of the palliative care process, the researchers sought to identify the strategies and behaviours that participants exhibit in response to problems resulting from the impact of contextual conditions. Therefore, by continuously analysis and comparing categories and subcategories, and by evaluating the memos and processes inferred from the interviews, an effort was made to obtain more abstract categories and to clarify the strategies used by the participants in dealing with the context.

| Integrating classifications
After carefully reviewing and categorizing all the memos, recording the narrations, and drawing a diagram, the researchers looked

| Rigour
In order to ensure the validity and accuracy of the study, the Lincoln and Guba's criteria of credibility, dependability, confirmability and transferability have been used (Polit & Beck, 2008). Based on the strategy of long-term interaction with data (which in fact increases the validity and accuracy of the data) the researcher spent as much time as required to collect enough data that would allow a deep understanding of the participants and ensure class saturation. Also, the member-checking technique was used for enhancing the credibility of the data and the findings through which we summarized and reviewed each interview content once holding it and asked the corresponding interviewee to confirm or revise our perceptions. Besides, a copy of each generated codes was provided to the corresponding interviewee and he/she was asked to revise or comment on our analyses. Accordingly, the findings were revised based on interviewees' comments.
The auditing technique was used to ensure the dependability of the findings. Accordingly, all the phases and the trends of the study were meticulously recorded and reported in order to provide others with the opportunity to trace our research-related activities.
To guarantee confirmability, we explained in detail all phases of the study including data collection, data analysis, conceptualization and categorization. This activity helps external reviewers assess and scrutinize our activities.
To increase transferability, attempts were made to enable others' judgement and evaluation of the transferability of the data through providing detailed descriptions. Additionally, applying maximum diversity in sampling, including gender, age and work experience, enhanced the transferability of the findings. Besides, comparing the findings of this study with the findings of previous studies helped enhance the transferability of the findings.

| Ethical considerations
First permission was obtained from the ethics committee of the In that situation what I could do was to accept the patient's condition as it was and to understand him/ her Encouraging the patient to express their emotions (P1. P5. P11*2. P14) I told him/her that I understood s/he is in pain and has many problems, and that s/he is afraid of what might happen in the future. As soon as I said that s/he opened his/her heart to me.
Putting oneself in patient's shoes (p11, p20) I understand how they feel, I try to put myself in their shoes and view the issue from their perspective consent forms were designed and given to participants to fill in and it was received. Prior to giving out the forms, the purpose of using a voice recorder during the interviews was explained to them and upon their consent the interview was taken. The time and place of the interviews were determined with the participants' consent and based on their choosing. Participants were assured that their statements were kept confidential; so that their data has been managed, analysed, and reported anonymously, using numbers. In addition; participants assured that they would be free to exit the study at any stage.

| FINDING S
By continuously comparing data through analysis, the following

| Reducing affliction and anxiety in patients (main concern)
The main concern of the study participants in terms of palliative care delivery was reducing their affiliation and anxiety. People with cancer normally encounter devastating conditions, which is the result of the mental, social, spiritual and physical turmoil that they experience. Care providers seek to reduce the agitations that have developed in the patient's mind to ease their condition. A Psychiatric Registered Nurse explained a relevant experience in the interview: When these patients undergo chemotherapy, when they wake up, they check their pillow to see how much hair they have lost, I mean, it's like they have drowned themselves in such an atmosphere. I spend time with them and explain the process so that their mind could be relieved from all the anxiety they're experiencing (p 6).
In the theoretical sampling, a psychologist mentioned how essential it was to reduce frustration and control all the emotions that may lead to depression in patients: We try to control patients' frustration to the point where they won't pull back anymore. This frustration is not something simple, there is a lot going on in the background, we try to understand the background that has built up to it. We try to reduce the emotions and affliction that cause frustration in them (p 11).

| Understanding the difficult state of patient (context analysis)
Analysis of data shows that care providers understanding of the challenging circumstances of patients with cancer, that means in terms of observing and understanding the lengthy tedious nature of their disease and treatment, patients drown in negative emotions, the patient's non-compliance because of their condition and patient's vague future and opporunity of death are formed. When care providers take underlying factors into consideration, they try to reduce the patients' affliction and anxiety in order to overcome this main concern. For instance, a Registered Nurse shared the following about observing and understanding the lengthy and tedious nature of the patient's disease: Some conditions are really hard for patients and they drown themselves in these atmospheres… When I see them in these conditions, I try to treat them in such way that would reduce their affliction and anxiety so at least they won't drown in all the emotional negativity (p 6).

| Analysing the process
Data analysis showed that the main strategies used by palliative care providers in treating people with cancer to reduce their affliction and anxiety, were recovering patients by building an emotional connection with them, having a core value in care providing, and reinforcing a positive mindset in them. These strategies induce inner peace in patients and they cause psychological distress in care providers.

| Having a core value in care
The having a core value in care strategy is the focus of the provided care, which is expected to be whatever the patient values. Here, care providers respect the patient's existential beliefs, try to meet the patient's spiritual needs as far as possible and provide caring services with dignity-all of which are efforts to reduce the patient's affliction. A Registered Nurse shares the following about respecting patients' beliefs: We don't try to impose our own beliefs on patients.
We let them talk and we just point them into a certain (p7).
About paying attention to the spiritual needs of patients in order to reduce their affliction and anxiety, another participant shared: We had a patient who felt hopeless and empty, and I had given the Quran to him many times and would tell him to recite one or two verses of it when he felt like that. In some way, I tried to build a spiritual atmosphere to help the patient overcome the empty feeling that he was experiencing (p 2).
About dignity-based care, care providers have tried to respect patients' privacy and decisions and have tried to consider each patient as a unique case. A social worker shared the following: The patient him/herself is important to us, and the way s/he thinks or feels. This is important to us as it determines how we get to address the patient's problem (p 15).

| Reinforcing patient's positive mindset
Data analysis showed that the affliction and anxiety, which patients' experience, makes their treatment a tedious process for them, which eventually may lead to mental and psychological distress. In

| Implications of strategies
Findings showed that the patients who had received palliative care by means of the strategies mentioned above, obtained a state of inner peace and this was realized through the development of the feelings of satisfaction, trust, sense of worth, hope and a sense of well-being.

| Integrating categories
Finally, in order to incorporate the findings and discuss the substantive theory, first the core category had to be determined as it played a key role in linking and incorporating the findings; then the underlying theory had to be explained. To find the core category, the memos have been reviewed and the main line of narration has been written. Based on the line of narration, the concepts explored and the relationship between concerns, strategies and consequences, psycho-emotional recovery was considered to be a core category.
All concepts related to different strategies, such as emotional connection, having a core value in care, and reinforcing positive mindset, alongside all the concerns and consequences explored, are interlinked at a higher level of psycho-emotional recovery. This is due to the fact that all concepts related to the provision of palliative care have been placed next to each other because care providers have focused their services on the recovery of the emotional mental state of patients. Finally, on the basis of the role held by each concept in relation to the core category and the other concepts, the manner in which they are prioritized, also on the basis of relational propositions and the type of relationship that occurs between concepts and psycho-emotional recovery, the categories have been related and incorporated on the basis of the core category. The substantive theory of the provision of palliative care in Iranian people with cancer was found after refining these categories, which is explained here under: In the treatment of people with cancer, palliative care providers understand and observe the lengthy tedious nature of their disease and treatment, patients drown in negative emotions, the patient's non-compliance because of their condition and patient's vague future and opportunity of death. In view of the above, the main concern of palliative care professionals is to "reducing the af-

| DISCUSS ION
In the present study, the qualitative research approach of grounded theory was used to explore how to provide palliative care and the care process. The grounded theory is an appropriate research method for examining processes in social interaction; because palliative care is a process of interactions, behaviours, and practices that can be explored with a grounded theory approach. The present study represents the process of providing palliative care as patients' psycho-emotional recovery. In line with the present study, Soanes and Gibson (2018) has interpreted the meaning of supportive care in people with cancer to be patient identity preservation by which care providers try to maintain patients' identities in a changed situation where the patient undergoes an exhausting condition. The changed situation in the above study indicates that patients have suffered under different conditions. Accordingly, the findings of the present study showed that care providers understand the difficult state of patient and their main concern is to reduce the patients' affliction.
This main concern is one of the most statistically significant ethical aspects in the process of providing patient-centred care. (Bélanger et al., 2016).
Nwozichi (2019)  Indirect support for nurses empowers them in the process of caring and rehabilitating people with cancer (Rahnama et al., 2015). The result of our study was contrary to this specific finding of Rahnama et al. Nurses in the present study suffered from psychological distress, which indicates that they were not receiving sufficient support in the process, which can also be due to managerial factors such as lack of human resources. In addition, in order to support nurses, the results of various studies have referred to the supportive role of management and leadership (Ferris et al., 2018;Klarare et al., 2020).
The psycho-emotional recovery of patients in the present study is done through three important strategies: building emotional connection, having a core value in care and reinforcing positive mindset. Seccareccia et al. (2015) found Another strategy for psycho-emotional recovery in the present study was setting a central value in care, which is characterized by spirituality and respect for different beliefs and dignified care. Other studies have also investigated the role of spirituality as being a factor that improves quality of life, cope with concerns and provide hope for patients (Bai & Lazenby, 2015;Ferrell et al., 2013;Fitch & Bartlett, 2019;Meireles et al., 2015;Puchalski, 2012 Reinforcing positive mentality was one of the salient strategies in psycho-emotional recovery as mentioned in the present study. This strategy involved inducing reality to the patient, providing care awareness, maintaining real hope and raising patient's spirit. Along with the concept of inducing reality and providing awareness, one of the psychological treatment techniques used for people with cancer is acceptance and commitment-based therapy. Being prepared to experience unpleasant feelings and not avoiding them lead to psychological flexibility in patients (Clarke et al., 2012;Kahl et al., 2012).
In other words, this treatment strategy is the process of reducing the patient's anxiety and psychological suffering. It also eliminates unwanted thoughts, emotions and unpleasant feelings, strengthens psychological flexibility and establishes the ability to change one's behaviour.
Reinforcing a positive mindset through giving real hope to patients helps them to cope with the pain of their illness and continue their treatment. It also prevents them from exhaustion and passivity. Soundy et al. (2014) found that in the process of providing raising the patient's morale and positive thinking protects them from these harmful effects and helps patients to overcome their suffering and achieve inner peace. Raising the morale of people with cancer is a part of positive psychology, in which an emphasis is equally placed on negative and positive experiences (Coyne & Tennen, 2010). Cancer has devastating effects with an inevitably exhaustive nature. However, palliative care providers focus on the positive consequences and experiences of patients to empower the patient. In other words, patients' achievement of inner peace or turmoil is influenced by focusing on the positive points and strengthening the morale, or through focusing on negative and exhausting experiences.

| Limitation of the study
The limitation of the present study was the lack of sufficient participants, especially in the professions of social worker, religious counsellor and psychologist; because in these professions there was not enough manpower in the palliative care centres. In the present study, in order to help diversify sampling, only one person from each of the mentioned professions was interviewed.

| CON CLUS ION
The underlying theory of psycho-emotional recovery provides a new perspective on why and how palliative care is provided in Iran.
In Iranian palliative care context, care providers use building emotional connection, reinforcing patient's positive mindset, having a core value in care strategies to have effective care of patients and the core of these strategies is the psycho-emotional recovery that is done to reduce the reduce the affection and anxiety of patients.

| RELE VAN CE TO CLINI C AL PR AC TI CE
Psycho-emotional recovery strategies can be used during the development and monitoring of palliative care in the care system. Given the fact that palliative care is a necessity in the management of people with cancer, the "psycho-emotional recovery" theory can be used as a guide for describing and expanding nurses' roles in palliative care delivery and clinical guidelines, and planning educational programs for nursing students and staff nurses. The present study showed that care providers were less supported in their workplace and some suffered from psychological distress. Traumatization of care providers could impair the quantity and quality of care.
Therefore, it is necessary to eliminate psychological trauma in care providers by recruiting more human resources into the program and also improving the work environment. Conducting action research studies in line with the present study can reveal the strengths and weaknesses of the present theory and facilitate its practical use in the context of care.

ACK N OWLED G EM ENTS
None declared.

CO N FLI C T O F I NTE R E S T
The authors have no conflicts of interest to declare that are relevant to the content of this article.

E TH I C A L A PPROVA L
Participants were assured that their statements were kept confidential; So that their data has been managed, analysed, and reported anonymously, using numbers.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request