Introduction
The lives of individuals are affected physically, mentally,
and psychologically by chronic diseases, especially in cancer.[] These patients need not only medical treatment
but also quality holistic health care to survive and
recover.[,] The holistic health-care model suggests
that individuals should be handled in many dimensions conas
physically, psychologically, socially, and spiritually.
[] In this context, addressing the needs of oncology patients
with a holistic approach, with their physical, mental,
emotional, sociocultural, and spiritual dimensions
is important to increase patients" quality of care.[]
Spiritual care is an important part of holistic care
that is necessary to improve the patients" and their
caregivers" quality of life.[] The World Health Organization
defines spirituality as the fourth aspect of
health[,] and suggests it as an important element for
disease management.[,,] In the literature, it was
reported that spiritual care services positively affect
the mental health of patients, increase their coping resources,
improve pain management methods, and reduce
depression.[,,]
It is important to evaluate and care for the patients"
spiritual care needs by considering the spiritual care
that has positive effects on the improvement of the patient
outcomes by the oncology nurses and all other
health-care teams.[,,] Since spiritual care constitutes
the abstract part of nursing care, there is no
standardization for providing spiritual care yet.[] In
addition, it has been reported that there are differences
in the spiritual care perspectives and competencies of
nurses in determining the spiritual needs of patients
and providing care.[,-] In the literature, it is
stated that nurses with high spiritual care competencies
display a positive attitude toward spiritual care and
give more place to spirituality in nursing care.[,]
Oncology nurses should assess the spiritual care
needs of patients comprehensively and provide care in
areas that they find themselves competent or should
refer patients to spiritual care specialists.[,,] Spiritual
care is provided since 2015 in Turkey, by spiritual
care specialists in hospitals.[] In our country, spiritual
care services provide morale, motivation, and
spiritual support to patients, family caregivers, and
health-care providers in cooperation with the Presidency
of Religious Affairs and the Ministry of Health.
[] Considering spiritual care as one of the components
of nursing practices, oncology nurses should assess
patients" spiritual care needs, provide counseling
on spiritual care when patients need it, or refer patients
to spiritual care specialists. Although there are many
studies in the literature examining the spiritual care
competencies of oncology nurses, to the best of our
knowledge, no studies are evaluating the perspectives
and experiences of nurses about spiritual care services.
Therefore, it was aimed to determine the spiritual care
competence of oncology nurses and their perspectives
on spiritual care services.
Methods
Study Design and Samples
This descriptive study was conducted between August
2019 and March 2020 in Turkey. A total of 123 oncology
nurses who work in the hospitals with spiritual
care services in Turkey were enrolled in this study. We
reach out to the nurses through the Turkish Oncology
Nursing Society. The total number of members of the
Turkish Oncology Nursing Society was 744 at the time
we start to data collection. This number both consists
of nurses who work in hospitals and academia. The
number of the nurses who are the member of Turkish
Oncology Nursing Society and working in a hospital
with a spiritual care unit was 139.
The sample size was calculated based on the study
conducted by Hu et al.[] The sample size was calculated
as 128 using G*Power 3.1.9.4 program[] through
80% power, Type 1 error 0.05, effect size d=0.25 based on
the total score averages of nurses" "Spiritual Care Competence
Scale." One hundred and twenty-eight nurses were
achieved in the study, but the data of five nurses who did
not complete the questionnaires were not included in the
analysis. Therefore, the study completed with 123 nurses.
The post hoc test was performed after the study"s finding
with 123 nurses, Type 1 error 0.05, effect size d=0.25. The
power of the study was found as 86%.
Inclusion Criteria
The criteria for being included in this study are being
a nurse who works with cancer patients in hospitals
with spiritual care service units, being a volunteer to
participate in this study, being a member of the Turkish
Oncology Nursing Society, and being able to communicate
in Turkish.
Data Collection Tools
The data were collected using the "Information Form"
consist of questions related to the sociodemographic
characteristics of the nurses and the "Spiritual Care
Competence Scale' to assess the spiritual care competencies
of nurses.
Information Form
This form was developed by researchers in the line with
the literature.[,-] In this form, there are a total
of 17 questions, including five questions about nurses"
sociodemographic characteristics (age, gender, year of
work, and marital status) and 12 questions evaluating
their perspectives and experiences on spiritual care services
(the practices that spiritual care specialists conduct with patients and their relatives, the effectiveness
of spiritual care services, in which cases that the patients/
relatives applied to the spiritual care service, etc.)
Spiritual Care Competence Scale (SCCS)
The scale was developed by Van Leeuwen et al.,[]
Turkish validity and reliability studies were performed
by Daghan et al.[] The scale comprises 27 items and
3 subscales. The 5-point Likert-type scale is scored as
1 "Strongly Disagree" and 5 "Strongly Agree." The minimum
point that can be scored on the scale is 27 and
the maximum is 137. A high score indicates that the
nursing competence associated with spiritual care is
high. There are no reverse scored items on the scale.
The subscales of the scale are as follows:
? Improving the quality of professionalism and spiritual
care; 1, 2, 3, 4, 5, and 6. The subscale Cronbach"s
alpha value of the scale was 0.94 and was found as
0.96 in this study.
? Personal care and patient counseling; 7, 8, 9, 10, 11,
12, 13, 14, 15, 16, 17, 18, 19, 20, and 21. The subscale
Cronbach"s alpha value of the scale was 0.94
and was found as 0.98 in this study.
? Referring to an expert; 22, 23, 24, 25, 26, and 27.
The subscale Cronbach"s alpha value of the scale
was 0.97 and was found as 0.96 in this study.
Data Collection Process
The data were collected using a Google Forms survey.
After the approval of the ethics committee, we sent the
questionnaire through email to the nurses who members
of the Turkish Oncology Nursing Society.
Data Analysis
IBM SPSS Statistics for Windows (Version 23.0. Armonk,
NY: IBM Corp.) was used for data analysis.
The numbers, percentage distributions, the mean, and
standard deviation were used to analyses descriptive
data such as nurses" perspectives about spiritual care
services and nurses" sociodemographic characteristics.
Spearman"s correlation analysis, Mann?Whitney U,
Kruskal?Wallis, and Bonferroni adjusted Mann?Whitney
U-test were used to compare the mean scores of the
"Spiritual Care Competence Scale" by the characteristics
of the nurses. The results were considered within
the 95% confidence interval and the significance level
was considered as p<0.05.
Ethical Aspect of the Research
This study was approved by Scientific Research Ethics
Committee (TÜTF-BAEK 2019/297 no: 13/19). The written permission was obtained from the Turkish Oncology
Nursing Society to send data collection forms to
the members. Furthermore, the "Informed Volunteer
Consent Form" was sent to the participants with the
data collection forms and they were asked to fill in the
data collection forms after giving consent.
Results
The mean age of the nurses included in this study was
33.10±7.07, the mean working year was 11.25±7.23, and
85.4% were women. About 65.9% of the nurses were
graduated from a university and 56.1% were married.
The perspectives and experiences of oncology
nurses on spiritual care services are shown in Table 1.
In 28.5% of the hospitals where nurses work, spiritual
care services have been carried out for more than 36
months. About 26.0% of nurses stated that they assess
patients/caregivers spiritual care needs by interviewing
about their feelings and thoughts and 30.1% of nurses
stated that they provided patients/caregivers spiritually
care by themselves (preparation of the environment for
spiritual practices, therapeutic touch, relaxation exercises,
etc.), and 29.3% of nurses refer the patients/caregivers
to the spiritual care service. About 31.7% of the
nurses reported that they did not know about the activities
carried out by spiritual care specialists and 35.8%
of nurses performed therapeutic interviews for their
patients and caregivers. Most of the nurses (74.8%)
reported that spiritual care services" activities were effective,
and 62.6% of them reported that patients/caregivers
were satisfied with these activities. About 54.5%
of nurses stated that spiritual care specialists met the
needs of patients/caregivers, and 51.2% of them stated
that caregivers could benefit from spiritual care services
during the mourning period (Table 1).
Table 1: Applications and perspectives of oncology nurses about spiritual care services (n=123)
Results related to the total and subscales scores of
SCCS of nurses are shown in Table 2. The total mean
SCCS score of the nurses is 103.81±22.21. The results
regarding the relationship between the age and
working year of the nurses and mean scores of the total
scale and subscales are shown in Table 3. A positive
and weak correlation was found between the age
of the nurses and the total mean and subscale scores
(p<0.05). It was found that there is a weak and positive
correlation between nurses" working year and the total
mean score of the SCCS, and a positive moderate relationship
between nurses" working year and mean score
of the "Refer to a specialist" subscale (Table 3).
Table 2: Oncology nurses" mean scores of the SCCS and subscales
Table 3: Correlation coefficients and significance level between the age and working year of the oncology nurses and the
mean scores of SCCS (n=123)
The result of the comparison of the total and subscale
mean scores of SCCS by nurses" sociodemographic characteristics is shown in Table 4. The total
and subscales of SCCA were statistically significant
differences by the education levels of the nurses and
their perspectives about the effectiveness of spiritual
care services (p<0.05). There was no other statistically
significant difference by other characteristics of
nurses (p>0.05).
Table 4: Distribution of SCCS scores according to some characteristics of oncology nurses (n=123)
The nurses" mean scores of total scale and subscale
were found statistically significant differences by their
education levels (p<0.05). When the advanced analysis
was conducted, it was found that the mean of the total
scale and subscale of nurses who had doctor"s degrees
was higher than nurses who had high school and bachelor"s
degrees (Table 4).
Nurses" total and subscale mean scores were found
to be significantly different by their perspective on the effectiveness of spiritual care services (p<0.05). The
nurses who reported that spiritual care services were effective had a significantly higher mean of the total
scale and subscales score than other nurses (Table 4).
Discussion
Spiritual care is considered the major element of care for
oncology patients.[] It is reported that spiritual care is
an important element for the well-being of patients and
caregivers, and patient's quality of life and health outcomes
may be negatively affected if their spiritual needs
are not met.[,] Spiritual care, which is an important
aspect of holistic care, is an expected service in the hospital.
Therefore, nurses who spend the most time with
patients and caregivers should have enough knowledge
and experience to be able to provide spiritual care.
The International Nurses Association states that
assessing the spiritual needs of patients and providing
care based on these needs are an important part
of nursing intervention. The needs of individuals regarding
spiritual care are increasingly accepted by the
nurses day by day, and it is gaining importance for the
nurse to recognize the individual"s spiritual needs.[]
In this study, 26.0% of the nurses stated that they assess
patients/caregivers" spiritual care needs by interviewing
them and 30.1% of nurses stated that they care
about patient/caregiver spiritually, and 29.3% of them
refer the patient/caregiver to the spiritual care services.
In a study conducted with nursing students; it
was reported that the education level of the students,
their interest in the nursing profession, and their career
choices affect their perceptions of spirituality and spiritual
care.[,] As a result of this study, it was found
that the total and subscale mean score of spiritual care
competency scale of nurses who had doctor"s degree
was higher than others. In a study conducted by Kaddourah
et al.,[] while the work experience of nurses
affects positively their perception of spirituality, it was
found that the level of education did not affect their
perceptions of spirituality. In another study conducted
by Kavas and Kavas, it was reported that education
level was not associated with health-care professionals"
perception of spiritual care.[]
In the literature, it is reported that there is a positive
relationship between nurses" perception and competencies
on spiritual care.[,,] Similarly with literature,
it was found that nurses who think that spiritual
care services" activities were effective for patients had
high spiritual competencies. In the study conducted by
Aldaz et al.,[] oncology nurses reported that spiritual
care services were effective and important in meeting
the spiritual needs of patients and their relatives. It is reported that spiritual care helps patients for reducing
their difficulties, discovering their self-efficacy, hope,
belief, and confidence, and regain their inner peace.
[,-] In line with these results, it is thought that
with the high awareness of oncology nurses about the
effectiveness of spiritual care, their spiritual sensitivity
and ability to provide spiritual care will be high.
In this study, a positive relationship was found
between the age and working year(s) of the nurses
and their spiritual care competency scores. Similarly,
Moosavi et al.[] found that there was a relationship
between oncology nurses" professional readiness and
spiritual care competency.[] Kim et al.[] reported
that nurses who were younger and had less work experience
had high burnout levels and had low spiritual
competence. Ercan et al.[] found that as the working
year of nurses increased, their perceptions of spiritual
care increased. It can be said that the experience gained
with age and working improves the spiritual care competencies
of nurses and also increases their holistic attitude
skills to determine patient needs.
The role and importance of spirituality in cancer
care have received increasing attention from health-care
professionals in recent years.[-] In this study, we
determined that most of the hospitals, where oncology
nurses work, had spiritual care services for more than 2
years and 29.3% of the nurses refer patients/caregivers
to these services. According to the results of this study,
it can be said that oncology nurses are insufficient in
assessing the spiritual care needs of patients/caregivers
and making the necessary guidance. The result of this
study shows similarity to the literature. In a study conducted
by Van Meurs et al.[] with oncology nurses, it
was stated that nurses did not evaluate the spiritual care
needs of patients, because of lack of time and not giving
importance to spirituality. Similarly, in other studies, it
is stated that health care workers have performed intervention
in the treatment of cancer patients, but intervention
for spiritual care is insufficient.[,]
In this study, 39% of the oncology nurses were not
aware of the activities carried out by spiritual care specialists,
while approximately half of the nurses stated
that these specialists carried out activities such as therapeutic
interviews, prayers, and training with patients/
caregivers. Similarly, it is stated in other studies that
health professionals do not have sufficient knowledge
about the roles and activities of spiritual care specialists.[,] According to the results of this study, spiritual
care services are generally known as religious activities,
but spirituality is not only a paradigm related
to religion, the purpose of these services is carrying out to question the meaning of life, discover the sources of
morale and motivation, identify strengths and weaknesses,
and develop problem-solving skills.[,,,]
In this context, it is thought that by informing nurses
about the spiritual care services activities, more patients
and their caregivers can be referred to these services.
In this study, nurses stated that spiritual care specialists
met the needs of patients/caregivers, and patients/
caregivers were mostly satisfied with these services"
activities. Furthermore, nurses reported that
caregivers benefited from these services during bereavement.
Studies show that spiritual care services
increase patients" biopsychosocial well-being.[,] In
the study conducted by Donohue et al.[] with the
parents of children with cancer, 66% of parents stated
that the care provided by spiritual care specialists increased
their satisfaction, helped them strengthen their
hope, and reduced stress and facilitated their decisionmaking
process about care. Oncology nurses" being
sensitive and knowledgeable about the necessity of
spiritual care for cancer patients will enable them to
provide spiritual care and make holistic care possible.
In this way, it is predicted that spiritual care will increase
the efficiency of the care applied to the patients
and increase the patients" quality of life.
It was determined that 11.4% of the nurses in this
study did not evaluate the spiritual needs of the patients/
caregivers. The fact that nurses do not use any
method to evaluate the spiritual needs of patients/caregivers
may be due to their lack of training. In a study
by Moosavi et al.,[] it was stated that the education
level of oncology nurses affects attitudes and awareness
of spiritual care. The results of the studies show
that improving nurses" spiritual care competencies not
only increases nurses" satisfaction but also reduces their
burnout-related professional and helps them for providing
spiritual care to patients.[,] In the light of this
information, it is stated that to improve the knowledge
and competencies of nurses regarding spiritual care, the
subjects/courses related to spiritual care should be included
in the curriculum of nursing school.[,]
Limitations of the Research
One of the most important limitations of this study is
including only nurses who are members of the Turkish
Oncology Nursing Society. This issue limits the
generalization of the study results. Furthermore, the
duration of the presence of spiritual care services different
in hospitals where oncology nurses work. This
situation may affect the experiences and perspectives
of nurses about spiritual care services. In future studies, it is recommended to limit the duration of spiritual
care services to ensure homogeneity and to plan studies
with larger samples by reaching all oncology nurses.
Conclusion
The result of this study shows that oncology nurses"
spiritual care competencies are insufficient. It was found
that the spiritual care competencies of oncology nurses
were significantly different according to their education
levels, age, and professional experience. Most of the
nurses thought that spiritual care services were effective,
and they refer patients/caregivers to these services.
The most spiritual care practices provided by nurses
were environment preparation, therapeutic touching,
and teaching relaxation exercises. It is thought that
nurses need more competence and instructions for
practicing spiritual care and that necessary legal regulations
should be made in this regard. It is recommended
to include spirituality in nursing education programs
to increase nurses" knowledge and competence about
spirituality, facilitate the provision of spiritual care, and
increase the awareness about patients' spiritual needs.
Acknowledgments: The authors also thank all oncology
nurses who participated in this study for their valuable contributions.
Peer-review: Externally peer-reviewed.
Conflict of Interest: The authors declare that they have no
conflict of interest.
Ethics Committee Approval: The study was approved by
the Trakya University Faculty of Medicine Scientific Research
Ethics Committee (No: 13/19, Date: 19/08/2019).
Financial Support: The authors declared that this study has
received no financial support.
Authorship contributions: Concept - R.S., N.U., M.A.K.;
Design - R.S., N.U.; Supervision - R.S., N.U., G.B.; Funding
- None; Materials ? None; Data collection and/or processing
- R.S., F.Ç.Ş., N.K.; Data analysis and/or interpretation
- R.S., E.T.; Literature search - R.S., E.T., H.Ö.K., N.U., N.D.;
Writing - R.S., E.T., H.Ö.K., N.U., N.D.; Critical review -
N.U., G.B., M.A.K.
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