Introduction
Palliative care is an approach that seeks to prevent or at
least alleviate suffering by providing early assessment and
treatment of pain, psychological and other problems, as well as medical problems, to improve the quality of life
of patients and their families facing problems related to a
life-threatening illness.[,] In diseases with severe treatment
processes such as cancer, some patients may need
palliative care as their medical conditions may vary.
In the palliative approach, the well-being of the patient's
family members, a vital component of the process,
is also considered, in addition to that of the patient. The
World Health Organization (WHO) has identified as a
goal of palliative care, provision of support to the patient's
relatives throughout the progression of illness and
also during the grieving process that follows.[] During
the palliative period, caregiving duties often fall to the
patient"s relatives. The transition to the role of caregiver
holds significant importance for the relatives of the patient,
affecting them physically, mentally, and socially,
and caregivers have even been described as "hidden patients".[] As the patient relies on their relative, caregiving
tasks become increasingly difficult and time-consuming,
and at some point the carer realizes that they have devoted
their life to caring. As the demands increase, the
physical and mental health of the patient's relatives is
negatively affected due to constant pressure.[] As the
disease progresses and the patient enters the palliative
period, relatives may become more distressed and become
prone to psychiatric problems such as depression
and anxiety.[,] In a study conducted with caregivers of
cancer patients, it was found that 13% of caregivers met
the diagnostic criteria for psychiatric disorders according
to DSM-4 and only 46% of these individuals had access
to mental health services.[] Psychological and physical
strain on caregivers may lead to poor quality care and
adverse health outcomes, including neglect and abuse.[]
Psychological resilience is defined as the potential to
successfully maintain and restore mental health when
faced with risk factors.[,] Psychological resilience
has important effects on the ability of both survivors
and caregivers to overcome the difficulties they experience
during the cancer process. Negative experiences
such as inability to cope effectively with difficulties,
inadequacy in solving problems, and having chronic
stress levels are considered to be associated with low
levels of psychological resilience.[]
The physical, psychological, and social changes caused
by chronic diseases such as cancer in patients and their
relatives have brought the discussion of the quality of life
of these people to the agenda. In a study conducted with
200 family members caring for cancer patients receiving
health care services in Hematologic Oncology Service,
it was revealed that family members experienced high
levels of stress, their lives were negatively affected during
the process of caring for their patients and their quality
of life decreased.[] In another study, it was stated that
many needs of family members of cancer patients, most
of which were not adequately met, caused psychological
distress and decreased the quality of life.[]
In a study conducted on primary caregivers of
cancer patients, it was found that self-compassion,
which is a new concept, is a protective factor for the
mental health and quality of life of the caregiver.[]
Self-compassion has been shown to be associated
with concepts such as optimism, increased happiness,
individual initiative, and commitment; it has been
observed to reduce anxiety, depression, and rumination,
and there is a significant relationship between
understanding and psychopathology.[,] When
the studies conducted in foreign and domestic literature
were examined, no study was found to reveal the
predictive role of psychological resilience, quality of
life, depression, anxiety, and stress variables together
with self-comprehension levels. The aim of this study
was to identify problem areas encountered by caregivers
of palliative oncology patients during the care
process, as well as to determine the relationship between
psychological resilience, quality of life, depression,
anxiety, and stress levels, and self-compassion.
Methods
Study Population
This study was conducted with family caregivers of
palliative cancer patients who were hospitalized at Istanbul
University Oncology Institute. The study was
conducted with a total of 72 relatives of 72 patients, 39
of whom were female and 33 of whom were male. The
data collection phase of the study lasted for 5 months
between December 2018 and April 2019. Clinical Research
Ethics Committee approval dated 24.12.2018
and numbered 1735 was obtained for the research. The
data of 80 relatives of the patients included in the study
were invited, and the data of 8 relatives were not included
in the analysis because they did not accept to
participate in the study or the data collection process
was interrupted. It was conducted in adherence to the
principles outlined in the Declaration of Helsinki.
In the selection of the sample group, the following
criteria were sought: knowing how to read and write,
being older than 18 years of age, having the cognitive
competence to understand the statements in the scales,
not having any mental (developmental retardation,
psychosis, mania, dementia, delirium, alcohol-substance
addiction) or physical health impairment that
would prevent them from continuing the study, and
being willing to participate in the study. The interview
was interrupted when the patient's relative did not feel
well during the application. Participants were included
in the study through random sampling.
Sociodemographic and Caregiving Data Collection
Form
The form consists of two parts. The first part aims to
collect basic demographic information such as age,
gender, marital status, and socio-economic status of the
participants. The second part, which was developed by
the researchers based on the literature[,,,] to collect
information about the care process, includes questions
such as the degree of closeness of the caregiver
to the patient, the duration of care for the patient, how
many hours per day he/she devotes to himself/herself,
whether he/she receives support during the care process,
and whether he/she finds the support given to
him/her sufficient. In addition, the relatives were asked
about a number of items that the patient's relatives
found difficult in caring for the patient, and they were
asked to respond by choosing one of the following options:
not at all/a little, moderately, and very much. The
form consists of two parts. The first part aims to collect
basic demographic information such as age, gender,
marital status, and socio-economic status of the participants.
The second part, which was developed by the
researchers based on the literature[,,,] to collect
information about the care process, includes questions
such as the degree of closeness of the caregiver to the
patient, the duration of care for the patient, how many
hours per day he/she devotes to himself/herself, whether
he/she receives support during the care process, and
whether he/she finds the support given to him/her
sufficient. In addition, the relatives were asked about
a number of items that the patient's relatives found difficult
in caring for the patient, and they were asked to
respond by choosing one of the following options: not
at all/a little, moderately, and very much.
Self-Compassion Scale (SCS)
SCS was developed by Neff and the Turkish reliability
and validity study of the scale was conducted by Deniz,
Kesici, and Sümer on a sample of university students.[,] The scale consists of 6 sub-dimensions
and 26 items. In the scale, respondents are asked to
rate how often they act in a given situation on a fivepoint
Likert-type scale ranging from "Almost never=
1" to "Almost always=5". The internal consistency
coefficient of the scale was 0.89 and the test-retest
correlation was 0.83. The criterion-related validity
of the self-compassion scale showed that there were
correlations of r=0.62 between the self-compassion
scale and self-esteem scale, r=0.45 between self-compassion
and life satisfaction, r=0.41 between positive
emotion and r=-0.48 between negative emotion.[]
The Resilience Scale for Adults (RSA)
The RSA was developed by Friborg et al.[] and
adapted into Turkish by Basım and Çetin[]. The subdimensions
of the scale, which has a total of 33 items,
are self-perception, future anxiety, structural style, social
competence, family cohesion, and social resources.
The Cronbach alpha values of the sub-dimensions calculated
for the reliability of the scale are between 0.66
and 0.81 (student sample) and between 0.68 and 0.79
(employee sample). The overall Cronbach's alpha coefficient
was 0.86 for both samples. In addition, the testretest
reliability was between 0.68 and 0.81.[]
The Caregiver Quality of Life Index Cancer Scale
(CQOLC)
The CQOLC was developed by Weitzner et al.[]
to measure the quality of life of cancer caregivers,
including the dimensions of emotional functioning,
family functioning, physical functioning, and social
functioning. The total score obtained from the scale
and its sub-dimensions ranges from 0 to 140. The
higher the score on the scale, the better the quality of
life. In the Turkish adaptation study, the Cronbach's
alpha coefficient was found to be 0.88 for the total
scale; the test-retest correlation coefficient was found
to be between 0.84?0.95 for the sub-dimensions of
the scale and 0.96 for the total scale.[]
The Short-Form Version of the Depression Anxiety
Stress Scales (DASS-21)
The 42-item scale developed by Lovibond and Lovibond
[] was later converted into a 21-item short
form.[] In this scale, depression, stress, and anxiety
sub-dimensions consist of 7 items each. In the Turkish
validity study, Cronbach's alpha internal consistency
reliability coefficient was found to be α=0.87 for
the depression subscale, α=0.85 for the anxiety subscale,
and α=0.81 for the stress subscale in the clinical
sample, while the test-retest correlation coefficients
were found to be r=0.68 for the depression subscale,
r=0.66 for the anxiety subscale, and r=0.61 for the
stress subscale in the healthy sample.[]
Statistical Analysis
Quantitative analysis methods were used in the
analysis of the data by using SPSS 25.0 program. In
this context, frequency and percentage analyses and
descriptive analyses such as mean, standard deviation,
etc. were used to determine descriptive findings
about the participants and scales. Chi-square analysis
was used to determine the effect of sociodemo graphic characteristics on dependent and independent
variables. The effects of psychological resilience,
depression, anxiety, stress, and quality of life on selfunderstanding
were determined by multiple linear
stepwise regression. In the multiple correlation analyses,
it was determined that there was no multicollinearity
problem between the independent variables
by examining the correlation and VIF values. In all
of the analyses, the significance level was accepted as
p<0.05 and the confidence interval as 95%.
Results
Sociodemographic and Caregiving Characteristics
The mean age of the participants was 43.64±13.10
years (19-69), 54.2% were female and 45.8% were
male. The time elapsed since the diagnosis of the relatives
of the participants varied between 1-120 months,
with a mean and standard deviation of 20.44±24.25
months. Approximately 40% of the participants included
in the study have been caring for the patient
for more than 6 months. Two-thirds of them were
children or spouses of the patient, and approximately
70% of them lived with the patient. While 54.3% of
the participants stated that they shared the responsibility
of caregiving equally with other relatives of the
patient, approximately 38% stated that they were the
main caregivers who took all the responsibility and
did not find the support they received sufficient. As a
matter of fact, although the rate of receiving care support
was approximately 80%, the rate of receiving information
support, psychological/emotional support,
and financial assistance remained below 40%. The sociodemographic
and caregiving characteristics of the
participants are shown in detail in Table 1.
Table 1 Sociodemographic and caregiving characteristics of the participants
In addition, the most difficult situations in the caregiving
process for relatives of oncology patients were,
respectively, feeling sorry for the patient's condition
(94.5% moderate or above) and trying to cope with
changes in the patient's psychology or behavior (84.7%
moderate or above), physical fatigue (77.8% moderate
and above), financial issues (70.9% moderate and
above), not having time for oneself (66.7% moderate
and above), coping with treatment side effects (65.3%
moderate and above), and making decisions about
treatment (54.1% moderate and above) (Table 2).
Table 2 Situations in which the participants experienced difficulties in the care-giving process
Correlation Between Scale Points
The mean scale scores obtained from the participants
and the correlation coefficients between the scale scores are presented in Table 3. A negative correlation
was determined between SCS scores and RSA (r=-
0.629, p<0.001), CQOLC (r=-0.608, p<0.001), depression
(r=-0.521, p<0.001), anxiety (r=-0.508, p<0.001),
and stress (r=-0.502, p<0.001) scores.
Table 3 Descriptive statistics and pearson correlation coefficients for the relationships between variables
The Predictive Role of Psychological Resilience,
Quality of Life, Depression, Anxiety, and Stress
in Respect of Self-Compassion
Multiple linear stepwise regression analysis showed
that "Psychological Resilience" and "Quality of Life"
variables explained 47% of the total variance in "Selfcompassion"
levels in the relatives of palliative period
oncology patients (R=0.69, R2=0.47, F=30.751,
p<0.001). The predictive role of the scores obtained
from the "Depression Anxiety Stress Scale-21" form
could not be determined. The stepwise multiple linear
regression analysis was completed in two stages.
Firstly, the psychological resilience variable entered the
analysis. It is seen that psychological resilience, which
is the independent variable of the study, predicts selfcompassion,
which is the dependent variable, significantly
and positively and explains approximately 40%
of the variance in self-compassion by itself. The first
model with a single independent variable was found
statistically significant. The second model with two independent
variables was found statistically significant
(R=0.63, R2=0.39, F=45.870, p=0.000) (Table 4).
Table 4 R and R2 change regarding the effect of psychological resilience and quality of life
on self-compassion
In the first stage of the analysis, the standardised regression
coefficient (β) of the psychological resilience
variable was found to be 0.63. In the second stage of the
analysis, the quality of life variable was included in the
model in which the psychological resilience variable
was included. The quality of life variable contributed
to the total variance and increased the R2 variance ratio
to 47% (R=0.68, R2=0.47, F=30.751, p=0.000). The
standardised regression coefficient (β) of the quality of
life variable at this stage was 0.35 (Table 5).
Table 5 Multiple stepwise linear regression results related to self-compassion
Psychological resilience and quality of life explain
the change in the total variance of "self-compassion"
scores at a good level. The regression equation model
is as follows: "SELF-COMPASSION=13.975+0.46 x
PSYCHOLOGICAL RESILIENCE+0.35 x QUALITY
OF LIFE". When the regression equation is examined,
when "Quality of Life" scores are kept constant,
a 1 (one) unit increase in "Psychological Resilience"
scores causes a 0.46 unit increase in "Self-Compassion"
scores. Similarly, when "Psychological Resilience"
scores are kept constant, a 1 (one) unit increase
in "Quality of Life" level causes a 0.35 unit
increase in "Self-compassion" scores.
Discussion
Cancer can cause many negative changes not only in the
patient, but also in the life of the patient's family and especially
in the life of the patient's relatives, who play a primary
role in the patient's care. Difficulties increase over
time and can lead to serious psychological problems. The patient's relatives experience many complex emotions
such as fear, anger, helplessness, denial, and guilt
in the face of the illness. They have to try to cope with
these complex emotions and provide support and care
to the patient.[] This study addressed the problems
experienced by palliative oncology caregivers during the
care process and aimed to determine the relationship between psychological resilience, quality of life, depression,
anxiety, and stress levels, and self-compassion.
The study identified physical fatigue, lack of personal
time, financial issues, coping with treatment side
effects, and loneliness as the most challenging situations
faced by relatives caring for cancer patients in the
palliative period. The high percentage of participants
(70%) living with the patient may contribute to the physical fatigue and lack of personal time. It is important
to address these issues to support the well-being
of both the patient and their caregivers. The literature
reports that caregivers who live with the patient experience
a higher care burden compared to those who do
not. Constantly being with the patient results in the neglect
of the caregiver's self-care and social life. This can
lead to an inability to spare time for themselves.[] It has been revealed that caregivers of patients often experience
problems such as fatigue, neglect of personal
care, lack of interest in previously enjoyed activities,
sleep problems, and loss of appetite.[] These difficulties
are expected due to the continuous care required
for the patient. Similar results have been reported in
the literature regarding the employment status of caregivers.
In their study, Çivi et al.[] also found a 60%
decrease in work and 58.2% decrease in daily functioning
among cancer caregivers. Caregivers may also experience
emotional effects in addition to the time they
need to allocate for the patient's care.
The study found a strong positive correlation between
the stress levels of patients" relatives and their depression
and anxiety levels. Additionally, a negative correlation
was observed between quality of life and depression.
These findings are consistent with existing literature. Depression
and anxiety are prevalent psychiatric disorders
that are often comorbid. Posluszny et al.[] observed
that caregivers had higher anxiety rates and were more
emotionally fragile than cancer patients. The literature
has shown a strong relationship between the quality of
life and depression in the relatives of cancer patients.[]
The research results suggest that psychological resilience
levels primarily explain the levels of self-compassion, followed
by quality of life levels. The results of our study
align with previous research that highlights the correlation
between self-compassion and psychological resilience,[] as well as quality of life.[,]
A multiple regression analysis was conducted to determine
the extent to which psychological resilience,
depression, anxiety, stress, and quality of life predicted
levels of self-understanding. The results showed that
psychological resilience and quality of life significantly
predicted self-understanding levels, explaining 47% of
the variance. Upon analysis of the results, it was found
that changes in psychological resilience and quality of
life scores were associated with changes in self-compassion
levels. However, changes in depression, anxiety, and
stress levels did not significantly affect self-compassion
levels. The regression analysis results suggest that selfcompassion
levels in caregivers of cancer patients in palliative
care are explained by their psychological resilience
levels and quality of life levels. Increasing the resilience
levels of patients" relatives against challenging life events
can play an important role in increasing their self-compassion
levels. It is expected that psychological resilience
levels have a positive predictive power in this regard.
When considering the positive predictive power of quality
of life on self-compassion levels, it was found that increasing
the quality of life levels of patients" relatives may
have a low-level effect on self-compassion scores.
Numerous studies have revealed the relationship
between psychological resilience and self-compassion.
[,,] Self-compassion is based on establishing a
better relationship with oneself, particularly during difficult
life events and feelings of inadequacy.[] Therefore,
it is expected that psychological resilience would predict self-compassion. The use of participants" quality of life as
a predictor of self-compassion levels is consistent with
the literature. A study conducted on primary caregivers
of cancer patients" relatives found that self-compassion
was a protective factor for caregiver mental health and
quality of life. Low self-compassion was associated with
increased depression and stress symptoms, as well as low
quality of life scores in cancer patients.[,] The current
study found that depression, anxiety, and stress levels
of palliative period oncology patient relatives were not
significant predictors of self-compassion levels. However,
there was a moderate and negative relationship between
the participants" depression, anxiety, and stress levels and
their self-compassion levels. Although this finding cannot
predict self-compassion, it suggests that caregivers of
palliative period oncology patients with low levels of depression,
stress, and anxiety may have high levels of selfcompassion.
Previous studies have linked higher levels of
self-compassion with lower levels of depression, anxiety,
and stress.[,,] In a study with 72 lung cancer patients
and their caregivers, Hsieh et al.[] demonstrated
that self-compassionate action can mitigate the impact
of caregiving stress on depressive symptoms. This was
shown after controlling for patients" factors such as treatment
status, symptom distress, and depressive symptoms,
as well as caregivers" health status.
Conclusion
The depression, anxiety, and stress levels of the patient's
relatives, who are responsible for the care of the cancer
patient and are an important and integral part of the
treatment, are among the important factors influencing
the patient care process. This highlights the importance
of investigating the relationship between psychological
problems such as depression, anxiety, and stress, and
self-compassion in the relatives of palliative period oncology
patients. The results suggest that caregivers of palliative
period oncology patients may experience a decrease
in their quality of life and psychological resilience, which
could have a negative impact on their self-compassion
levels. Therefore, during the palliative period, when the
quality of life and psychological resilience of both caregivers
and patients are crucial, intervention programmes
can be developed to increase individuals" self-compassion
levels while also aiming to improve their psychological
resilience. For instance, in these supportive approaches,
the aim may be to equip the patient's relatives with
skills that enhance their psychological resilience, such as
self-efficacy, problem-solving ability, optimism, and autoregulation,
to help them develop greater self-compassion.
Ethics Committee Approval: The study was approved by
the İstanbul Faculty of Medicine Clinical Research Ethics
Committee (no: 1735, date: 24/12/2018).
Authorship contributions: Concept - S.A., D.A., M.Ö.;
Design - S.A., D.A., M.Ö.; Supervision - S.A., D.A., M.Ö.;
Funding - S.A., D.A., M.Ö.; Materials - S.A., D.A., M.Ö.;
Data collection and/or processing - S.A., D.A., M.Ö.; Data
analysis and/or interpretation - S.A., D.A., M.Ö.; Literature
search - S.A., D.A., M.Ö.; Writing - S.A., D.A., M.Ö.; Critical
review - S.A., D.A., M.Ö.
Conflict of Interest: All authors declared no conflict of interest.
Use of AI for Writing Assistance: Not declared.
Financial Support: None declared.
Peer-review: Externally peer-reviewed.
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