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Oncology Nurses’ Spiritual Care Competence and Perspective About Spiritual Care Services

1Department of Child Health and Disease Nursing, Trakya University Faculty of Health Sciences, Edirne-Turkey 2Department of Nursing, Amasya University Faculty of Health Sciences, Amasya-Turkey 3Koç University Faculty of Nursing, İstanbul-Turkey 4Department of Nursing, Ankara Yıldırım Beyazıt University Faculty of Health Sciences, Ankara-Turkey 5Department of Nursing, Selçuk University Faculty of Nursing, Konya-Turkey 6Hacettepe University, Oncology Hospital, Ankara-Turkey


Introduction
The lives of individuals are affected physically, mentally, and psychologically by chronic diseases, especially in cancer. [1] These patients need not only medical treatment but also quality holistic health care to survive and recover. [2,3] The holistic health-care model suggests that individuals should be handled in many dimensions

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. [19] The sample size was calculated as 128 using G*Power 3.1.9.4 program [20] 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. [2,[21][22][23] 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 con-as physically, psychologically, socially, and spiritually. [4] 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. [5] Spiritual care is an important part of holistic care that is necessary to improve the patients' and their caregivers' quality of life. [6] The World Health Organization defines spirituality as the fourth aspect of health [7,8] and suggests it as an important element for disease management. [1,9,10] 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. [6,11,12] 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. [3,10,13] Since spiritual care constitutes the abstract part of nursing care, there is no standardization for providing spiritual care yet. [3] 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. [6,[14][15][16] 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. [10,13] 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. [6,15,16] Spiritual care is provided since 2015 in Turkey, by spiritual care specialists in hospitals. [17] 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. [18] 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. duct 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., [24] Turkish validity and reliability studies were performed by Daghan et al. [25] 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 0.97 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).
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).
The result of the comparison of the total and subscale mean scores of SCCS by nurses' sociodemo-Oncology Nurses' Perspective About Spiritual Care 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). graphic 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). Nurses' total and subscale mean scores were found to be significantly different by their perspective on the   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. [26] 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. [2,7] 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. [27] 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. [10,28] 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., [29] 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. [5] In the literature, it is reported that there is a positive relationship between nurses' perception and competencies on spiritual care. [10,30,31] 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., [32] 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. [19,[33][34][35][36] 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. [37] found that there was a relationship between oncology nurses' professional readiness and spiritual care competency. [37] Kim et al. [38] reported that nurses who were younger and had less work experience had high burnout levels and had low spiritual competence. Ercan et al. [13] 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. [39][40][41] 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. [15] 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. [19,37] 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. [13,42] 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. [7,9,17,42] 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. [2,43] In the study conducted by Donohue et al. [44] 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., [37] 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. [38,45] 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. [22,46] 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 stud-ies, 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.