Assessment of Spiritual Care Practices Among Nurses Caring for Cancer Patients in a Tertiary Hospital in Nigeria

Abstract

Introduction

The importance of spirituality in health and wellness has been documented in the literature. While the developed countries have reported robust evidence of spirituality in nursing practices, there is scant evidence in low- and middle-income countries like Nigeria.

Objectives

This study assessed the spiritual care practices of the nurses attending to cancer patients in a tertiary health institution in Ilorin. It further determined factors associated with spiritual caring practices among nurses.

Methods

A descriptive cross-sectional study was conducted between November 2021 and December 2021 to assess spiritual care practices among nurses caring for cancer patients. During the study period, 66 nurses were recruited randomly from the hospital's medical and surgical clinics, palliative care department, and Obstetrics and Gynecology department. Twelve items validated Nurses’ spiritual care practices questionnaire was adapted for this study. Data were analyzed using IBM SPSS version 23.

Results

The mean age of the respondents was 36.5 years ( + 10.1) while female respondents made up 83.3%. About 48% of the nurses had good spiritual caring practices while 52% had poor spiritual caring practices. Nurses with training in oncology (96%) with p = .001 and those with spirituality training (86.2%) with p = .017 showed significant association with spiritual care practices. This study concluded that spiritual care practices among nurses are sub-optimal with training as a significantly associated factor with spiritual care practices.

Conclusion

It is, therefore, suggested that spiritual care practices should be incorporated into all nursing training and curriculum. This will allow them to better support the spiritual needs of the patients, especially those with chronic diseases like cancer.

Keywords

nurses spirituality caring practices cancer patients

Introduction

Medicine and religion follow the common objective of prolonging life, improving quality of life, and improving health conditions (Wang et al., 2021). However, these two might adopt different tools in different cultures. Similarly, spiritual healing is one of the complementary and alternative treatments (Levin et al., 2020) that is used to reduce anxiety levels, achieve well-being, or improve the patient's condition (Carneiro et al., 2019). While spiritual healing is accepted in different cultures as a treatment (Bell, 2013), there is no clear and definite perception or definition of it available (Teut et al., 2014). Therefore, nurses need to be familiar with the spiritual life process and the aspects of health and healing in their culture (Olsen, 2003) and also need to have thorough knowledge about the dynamism of and the energy that constitutes the soul and inner healing to achieve the unity of the spirit and body.

The nursing profession is cardinal to the holistic care of patients from birth to death (Woolf & Fisher, 2015). This also includes other emotional, psychological, and spiritual support to the patients. Numerous types of spiritual care have been described as being crucial to nursing care (Breitbart et al., 2014).These ranged from engaging personally as nurses with patients or their families in exercising spiritual care practices such as reading a specific piece of scripture to calling in spiritual care providers from the respective faith community or denomination (Zumstein-Shaha et al., 2020). Many nursing procedural engagements have reported verbal or non-verbal strategies to indicate respect for the patient's connection with God or another higher power (Minton et al., 2018). Occasionally, nurses used the patients’ religious and spiritual connections and attitudes to promote coping during the period of infirmity. Several such spiritual care patient-oriented scenarios have been observed (Campbell, 2019). In some instances, patients have made requests for their religious rituals, beliefs, and injunctions to be observed or respected (Zumstein-Shaha et al., 2020). To achieve complete patient-oriented care, it is imperative for nurses to consciously plan for ways of implementing the exercise of faith-based practices with patients and to put these plans into action (Freeman et al., 2021).

Many spiritual care practices have been propounded in the literature (Asadzandi, 2017; Esibu, 2021). While some frameworks (Young & Koopsen, 2010) describe the patient-oriented spiritual care paradigm, others (Lloyd & O’Connor, 2007) describe profound spirituality as using compassion, hope, and the understanding that a person's life may be limited. Some frameworks delve deeper into human traditional practices and spiritual values (Allen 2012).

To offer spiritual care to patients, some competencies have been identified (Manitoba Corporate Competency Catalogue, 2008). These include: knowledge (academic), awareness, thinking skills, communication, interpersonal, leadership, accountability (managing for results), self-managing, information technology literacy, counseling and therapeutic skills, spiritual practice, and research skills. Schermerhorn et al., 2020 conducted a concept analysis of spiritual care by using the eight-step approach of Walker and Avant (2011) and identified the following attributes of spiritual care: healing presence, therapeutic use of self, intuitive sense, exploration of the spiritual perspective, patient-centeredness, meaning-centered therapeutic intervention, and creation of a spiritually nurturing environment. Possessing these competencies and skills will lead to positive outcomes such as healing, promotion of spiritual well-being, psychological adaptation, feelings of satisfaction for patients, promotion of spiritual awareness, and job satisfaction for nurses (Ramezani et al., 2014).

Some scales have been developed to evaluate the nurses’ competence, skills, and knowledge of spiritual care (Machul et al., 2022). Daghan et al. (2019) developed a scale for assessing the spiritual care competency of nurses with high reliability and validity. The Spiritual Care Practice Questionnaire (Vance, 2001) was developed to examine the spiritual care practices of nurses in the healthcare setting. It is divided into two parts: Part I which determines the percentage of acute care nurses who provide spiritual support to their patients and Part II which assesses the perceived barrier that inhibits providing spiritual care by nurses. The first part of responses is measured on a 5-point Likert-type scale with 1 being very seldom and 5 being very often. An established score of 32 (out of the possible score range of 9–45) is adjudged as an “ideal mean.” This score represents nurses who are involved in spiritual care activities somewhere between “occasionally” and “often” on the five Likert scales (Vance, 2001). Part II explores responses that determine the perceived barriers that inhibit providing spiritual care by nurses (Vance, 2001). These have two choices, agree or disagree.

Spiritual care will aid cancer patients in improving their quality of life. However, misinformation, poor integration, and a lack of full acceptance among Nigerian health professionals and institutions continue to affect spiritual caring practices (Silbermann, 2016). A review of Nigerian-based literature revealed that there has been little progress in the field of spiritual care in nursing in Nigeria. This is of concern because patients’ perceptions of illness and underpinning health beliefs in most Nigerians are that illness has a primary supernatural cause and requires spiritual solutions (Silbermann, 2016).

While the developed countries have reported robust evidence on spirituality in nursing care practices, there is a paucity of data in low- and middle-income countries like Nigeria. Whereas, nurses need to have thorough knowledge about the dynamism of and the energy that constitutes the soul and inner healing to achieve the unity of the spirit and body. Accordingly, we assessed the spiritual care practices of the nurses attending to cancer patients in a tertiary health institution in Ilorin, Kwara state.

Literature Review

According to Epstein-Peterson et al. (2015), the spiritual needs of persons receiving health care are being described globally by the patient's spiritual needs and nurse-provided spiritual care. Even though these spiritual needs were categorized, naming and classifying them always include needs that relate to finding meaning in an illness or life. This could involve finding a sense of direction or a resolve to life, or even finding inner peace and forgiving others. The salience of these spiritual needs and their potential impact on health and influence on responses to illness leads nurses and other health care providers to provide spiritual care.

Studies in the United States assessing patients with advanced cancer or in palliative care units reported spiritual needs that ranged between 44% and 91% (Astrow et al., 2007; Hui et al., 2011; Pearce et al., 2012). According to Mamier et al. (2019), given that spiritual needs or distress are prevalent, healthcare providers must ask whether their provision of spiritual care addresses patient needs.

Study findings provide evidence that spiritual care provided by a physician, a nurse, or a multi-disciplinary team is associated with greater patient satisfaction with health care, decreased cost, improved quality of life, increased use of hospice, and less depression and less stress (Küçük Alemdar et al., 2018; Astrow et al., 2007; Pearce et al., 2012; Steinhauser et al., 2017). Using meta-analysis to analyze the effects of spiritual interventions in cancer patients, it was discovered that nursing spiritual interventions with individual patients revealed significantly moderate effects on spiritual well-being, depression, and meaning of life (Oh & Kim, 2014).

Irrespective of the fact that patients’ spiritual needs are of great importance, the majority of nurses perceive barriers to providing spiritual care. Areas covering lack of education, lack of time, de-prioritization, confusion about the boundaries of spiritual care, and belief that spirituality is considered a private topic in which nurses are not allowed to intrude are stated as primary barriers (Gallison et al., 2013; Kalish, 2012; Selman et al., 2018; Vlasblom et al., 2015). Barriers like these are thought to significantly contribute to the infrequency of nurse-provided spiritual care.

In concert, study findings suggest that although spiritual needs are prevalent among persons experiencing serious health conditions, nurses often do not assess or attend to patients’ spiritual needs. Accordingly, we assessed spiritual care practices among nurses caring for cancer patients in a tertiary hospital in Nigeria. It further determined factors associated with spiritual caring practices among nurses.

Methods

Design

A descriptive cross-sectional study was conducted at the University of Ilorin Teaching Hospital (UITH), Kwara State, Nigeria. The stated design was selected because the study deals with a population-based survey. It is an over 400 bedded tertiary teaching hospital. They get referrals from public and private hospitals. They also get referrals from some of the state specialist hospitals. It has a catchment area covering the entire Kwara state. Over a quarter of the patients who attend UITH annually are from other parts of the country. Currently, the hospital has its main site in Oke-use on the outskirt of the Ilorin metropolis and its annex at the old wing in the center of the metropolis. It offers specialist care in oncology and palliative care.

Research Questions

What are the spiritual caring practices of nurses caring for cancer patients in UITH?

What factors influence nurses’ spiritual caring practices in UITH?

Sample

The target population of this study consisted of nurses caring for cancer patients receiving treatment at UITH. All the population includes those involved in the care of cancer patients in UITH and who were available during the period of the study. Between November 2021 and December 2021, 66 nurses from UITH's medical and surgical clinics, the palliative care department, and Obstetrics and Gynecology department were recruited into the study.

Inclusion Criteria

Nurses providing direct care to cancer patients.

Exclusion Criteria

Nurses who have not worked in the last 6 months in the care of cancer patients.

Study Instrument

For this study, we made use of the validated semi-structured questionnaire (Vance 2001) adapted from the survey tools by Gallison et al. (2013). It is a twelve (12) item, validated nurse's spiritual care practices questionnaire. This standardized supervised self-administered instrument was used to collect data from nurses in the study area on cancer patient care. The questionnaire was pretested among ten nurses from another State Specialist Hospital, Ilorin in Kwara State. The questionnaire was face validated and found to be reliable with Cronbach's alpha of 0.90. The questionnaire comprised two sections: Section A assessed the socio-demographic profile of respondents and section B assessed spiritual care practices among nurses caring for cancer patients.

There are a total of 12 items with a maximum score of 3 and a minimum score of 0. The mean scores for each practice item were presented. These scores were also re-categorized with a score of less or equal to 32 categorized as poor spiritual care practice and a score of above 32 as good spiritual care practice. This was informed by the sum of the mean of all the 12 practice items. Therefore, a score of 2 standard deviations (≤32) away from the mean was adjudged poor while a score above that (>32) was categorized as good practice.

Statistical Analysis

Data were analyzed using IBM SPSS version 23. Data were presented using frequency tables. The categorical data were summarized with percentages while the numeric variable was summarized with means and standard deviation. Chi-square analysis was used to determine the factors associated with the spiritual care practices of the nurses. The statistical significance level was set at a p-value of less than .05.

Results

Sample Characteristics

The mean age of the nurses was 36.5 (±10.1) years with females predominating. A little more than half (51.5%) had a BNSc qualification and a third (33.3%) had a diploma in nursing while about 8 (12.1%) also had a master's in nursing (Table 1). A third of the nurses (33.3%) are Nursing Officer II (NOII) cadre while the other proportion is shared by other senior cadres of the profession (Table 2). More than half (60.6%) of the nurses have practiced in the last 10 years with a mean duration of practice of 11.1 years (± 8.2). The majority (91.8%) of the nurses attend to between 1 and 20 patients per shift with a mean patient of 14.4 (± 6.4). Only a third (37.9%) of the nurses have had specialized training in oncology. General nursing (30.3%) and midwifery (57.5%) are the dominant specializations of the nurse respondents (Table 2). More than half of the nurses (57.6%) are of Islamic religion preference while Christianity constitutes 37.9% (Table 3). Less than half of the nurses (43.9%) have had training in spiritual care. The most notable of the route of acquiring the training was during the undergraduate program (19.7%), in-service (9.1%), graduate program (7.6%), and while reading (6.1%). Other routes varied widely (Table 3).

Table 1.

Socio-Demographic Characteristics of the Nurses Caring for Cancer Patients.

Items	Frequency (N = 66)	Percentage (%)
Age (years)
20–29	22	(33.3)
30–39	16	(24.2)
40–49	19	(28.8)
>/ = 50	9	(13.60)
Mean ± SD	36.5 ± 10.1 years
Gender
Male	11	(16.7)
Female	55	(83.3)
Educational background
Diploma in nursing	22	(33.3)
BNSC	34	(51.5)
No bachelor degree	2	(3.0)
Master in nursing	8	(12.1)

_{BNSC denotes Bachelor of Nursing Science degree.}

Table 2.

The Rank, Specialty, and Oncology Treatment Experiences of the Nurses.

Nurses’ variables	Frequency (N = 66)	Percentage (%)
Nurses rank
Nursing officer 11(NO11)	22	(33.3)
Senior nursing officer (SNO)	16	(24.2)
Principal nursing officer (PNO)	14	(21.2)
Chief nursing officer (CNO)	9	(13.6)
Assistant director of nursing services (ADNS)	5	(7.6)
Years as a registered nurse
1–10	40	(60.6)
11–20	16	(24.2)
21–30	9	(13.6)
31–40	1	(1.5)
Mean ± SD	11.1 ± 8.2 years
Number of patients cared for during shift
1–10	27	(40.9)
11–20	27	(40.9)
21–30	12	(18.2)
Mean ± SD	14.5 ± 6.4
Ward or unit of duty
Female medical ward	15	(22.7)
Male medical ward	15	(22.7)
Obstetrics & gynecology	14	(21.2)
Outpatient department	22	(33.3)
Specialized training in oncology
Yes	25	(37.9)
No	41	(62.1)
Areas of specialization
General nursing	20	(30.3)
Midwifery	38	(57.5)
Cardiothoracic nursing	1	(1.5)
Pediatrics	5	(7.6)
Others	2	(3.0)

Table 3.

Religion Preferences and Spiritual Training of the Nurses.

Spiritual training	Frequency (N = 66)	Percentage (%)
Religion preferences
Christianity	25	(37.9)
Catholic	3	(4.5)
Islam	38	(57.6)
Education on spiritual care
Yes	29	(43.9)
No	37	(56.1)
How the spiritual care training is acquired
Undergraduate program	13	(19.7)
Graduate program	5	(7.6)
In-service training	6	(9.1)
Education training unit in spiritual care	1	(1.5)
Reading about spiritual care	4	(6.1)
Respondents with no education in spiritual care	37	(56.1)

Research Questions Results

Table 4 shows the nursing care practice pattern. The results revealed that the majority of the items were “rarely” practiced, two items were “occasionally” practiced, and four items were often practiced. The items often practiced include: “listening to a patient talk about spiritual concerns (3.27),” “helping a patient to have quiet time or space for spiritual reflection or practices (3.23),” and “encouraging a patient to talk about how illness affects relating to God or whatever is his or her ultimate other or transcendent reality (3.18)” and “assessed a patient spiritual or religious beliefs or practices that are pertinent to health (3.11),” ranking 1st to 4th respectively. The average score of the nurses’ spiritual care was 35.6 ± 9.7. An aggregated categorization showed that about 48% of the nurses had good spiritual caring practices while 52% had poor spiritual caring practices. Only two factors were found to be associated with the good spiritual care practice of the nurses (Table 5). Nurses with training in oncology had adequate practices and had a higher percentage of 96% with p = .001, this was found to be statistically significant. Also, those with spirituality training had about 86.2% with p = .017 which was also found to be statistically significant (Table 5).

Table 4.

The Pattern of Spiritual Care Practices of Nurses.

S/N	Items	Mean	SD	Rank	Remark
1	Support patient spirituality	2.85	1.085	9th	Rarely
2	Quiet time for spiritual reflection	3.23	1.148	2nd	Often
3	Listened actively to spiritual themes	3.02	0.920	6th	Occasionally
4	Assessed a patient spiritual that are pertinent to health	3.11	1.152	4th	Often
5	Listened to a patient talk about spiritual concerns	3.27	1.103	1st	Often
6	Encourage the patient to talk about God	3.18	1.094	3rd	Often
7	Encourage the patient to talk about his or her spiritual coping	3.03	1.095	5th	Occasionally
8	Documented spiritual care	2.70	1.324	12th	Rarely
9	Discussed patient's spiritual care needs with colleagues	2.98	1.143	7th	Rarely
10	Arrange patients’ clergy to visit	2.79	1.295	10th	Rarely
11	Encourage the patient to talk about what gives his life meaning amidst illness	2.92	1.194	8th	Rarely
12	Offered to pray with a patient	2.77	1.368	11th	Rarely

Hint: Never (1–1.5); Rarely (1.6–2.9); Occasionally (3.0); Often (3.1–4.4); Very often (4.5–5.0); SD (Standard Deviation).

Table 5.

Factors Associated With Nurses’ Spiritual Care Practices.

Variable	Poor practice (%)	Good practice (%)	Statistics (X² test)	p-value
Age (years)
20–29	8 (36.4)	14 (63.6)	2,092	.554
30–39	5 (31.2)	11 (68.6)
40–49	5 (26.3)	14 (73.7)
≥ 50	1 (11.1)	8 (88.9)
Gender
Male	3 (27.3)	8 (72.7)	0.015	.903
Female	16 (29.1)	39 (70.9)
Training on oncology
Yes	1 (4.0)	24 (96.0)	12.062	.001*
No	18 (43.9)	23 (56,1)
Training on spirituality
Yes	4 (13.8)	25 (86.2)	5.674	.017*
No	15 (40.5)	22 (59.5)
Ward/unit currently work
Female ward	4 (26.7)	11 (73.3)	2.488	.478
Male ward	6 (40.0)	9 (60.0)
O&G	5 (35.7)	9 (64.3)
A&E	4 (18.2)	18 (81.8)
Religion preferences
Christianity	6 (24.0)	19 (76.0)	0.454	.797
Catholic	1 (33.3)	2 (66.7)
Islam	12 (31.6)	26 (68.4)

* p < .05.

Discussion

This study explored the nurse's care practice (as a major caregiver) to further understand the gaps in the spiritual care needs of cancer patients. The mean age of the nurses was 36.4 ( + 10.1) with females predominating. A little more than half had BNSc qualifications, a third was in the Nursing Officer II cadre. Spiritual education was obtained from various sources including, during academic and in-service training. It was found that those who had been trained in spiritual care were more confident to address spiritual needs without specialist support, for example, clergy; and had lower levels of discomfort around the provision of spiritual care. This was found to agree with other studies reported in the literature (O’Brien et al., 2019).

Nurses’ education, knowledge of spiritual care, and willingness to provide spiritual care by the nurses influenced nurses spiritual caring practices. This study is in agreement with other studies on spiritual care (Wu et al., 2016). Only a third of them have ever had oncology training. Those of Islam religion preference was a little above half and less than half have had education on spiritual training.

The average score of the nurses’ spiritual care was 35.6 + 9.7. When categorized almost half of the nurses had good spiritual care practices. This average figure is not in agreement with findings from some other studies (Folami & Onanuga, 2018; Gallison et al. 2013) and the response of the patients. The average practice observed in this study is possibly due to curriculum change in most schools as advocated and intervened in the outcome of a previous study (Afolayan & Frantz, 2019). These average findings imply that the nurses already have a good background to build on with a purposeful continuous education targeted at spiritual care practices. This also implied that the incorporation of spiritual care practice into the nursing school curriculum could have improved the average skills and practice of the nurses many years after school.

Only two factors were found to be significantly associated with nurses’ spiritual care practices. Having oncology training significantly increased the proportion of those with good spiritual care practices among the nurses. While past training on spirituality significantly increases the proportion of nurses with good spiritual care practices. These two factors re-emphasize the need for training for the nurses as suggested in the previous intervention (Afolayan & Frantz, 2019). The importance of training and capacity building in the nursing profession cannot be overemphasized and this has been reflected in the two significantly associated factors in this study. These factors represented both in-service training and continuous education. It implied the long-term impact of such interventions on the professional skills and competence of the nurses.

Strengths and Limitations of the Study

The original and primary data collection from a randomly selected nurse sub-population formed the strength of our study. The study was limited by the size of the specialized nurses studied. This could limit the generalizability of our findings. Further study is suggested on a larger scale among nurses caring for cancer patients.

The Implication of the Study

The recommendation includes the need for both in-service training and continuous education on spiritual care for nurses caring for cancer patients. This will have a long-term impact on the professional skills and competence of the nurses. The importance of training and capacity building in the nursing profession cannot be overemphasized and this has been reflected in the two significantly associated factors in this study.

Conclusion

This study shows that spiritual care practices among nurses are sub-optimal, with training as a significantly associated factor with spiritual care practices. It is, therefore, suggested spiritual care practices be incorporated into all nursing training and curriculum. Nurses should also be provided with continuing education as part of their professional practice. This will allow them to better support the spiritual needs of the patients, especially those with chronic diseases like cancer.

Footnotes

Acknowledgment

We appreciate all nurses who participated in this study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Statement

Ethical clearance was obtained from the Ethics Review Committee of the hospital (UITH ERC PROTOCOL: ERC PAN/2021/11/1024). Informed consent was obtained from the participants before the commencement of data collection. All methods were performed following relevant guidelines and regulations.

ORCID iD

Deborah Tolulope Esan

References

Afolayan

J. A.

Frantz

(2019). The view of key stakeholders on spirituality and spiritual care: Nigeria as a case study. Tropical Journal of Health Sciences, 26(3), 53–60.

Allen

J. G.

(2012). Restoring mentalizing in attachment relationships: Treating trauma with plain old therapy. American Psychiatric Pub.

Asadzandi

. (2017). Clients’ and patients’ spiritual nursing diagnosis of the sound heart model. Journal of Community Medicine & Health Education, 7(6), 2–6. https://doi.org/10.4172/2161-0711.1000581

Astrow

A. B.

Wexler

Texeira

M. K.

Sulmasy

D. P

. (2007). Is failure to meet spiritual needs associated with cancer patients’ perceptions of quality of care and their satisfaction with care? Journal of Clinical Oncology, 25(36), 5753–5757. https://doi.org/10.1200/JCO.2007.12.4362

Bell

(2013). Anishinaabe bimaadiziwin: Living spiritually with respect, relationship, reciprocity, and responsibility. In Contemporary studies in environmental and indigenous pedagogies (pp. 89–107). Brill Sense.

Breitbart

W. S.

Breitbart

Poppito

S. R.

(2014). Individual meaning-centered psychotherapy for patients with advanced cancer: A treatment manual. Oxford University Press.

Campbell

C. S.

(2019). Bearing witness: Religious meanings in bioethics. Wipf and Stock Publishers.

Carneiro

É. M.

Navinchandra

S. A.

Vento

Timóteo

R. P.

de Fátima Borges

(2019). Religiousness/spirituality, resilience and burnout in employees of a public hospital in Brazil. Journal of Religion and Health, 58(2), 677–685.

Daghan

Kalkim

Sağkal Midilli

(2019). Psychometric evaluation of the Turkish form of the spiritual care competence scale. Journal of Religion and Health, 58(1), 14–27.

10.

Epstein-Peterson

Z. D

., Sullivan

A. J

., Enzinger

A. C

., Trevino

K. M

., Zollfrank

A. A

., Balboni

M. J

., & Balboni

T. A

. (2015). Examining forms of spiritual care provided in the advanced cancer setting. American Journal of Hospice and Palliative Medicine®, 32(7), 750–757. https://doi.org/10.1177/1049909114540318

11.

Esibu

P. E

. (2021). Justice, Human Dignity and the Capabilities Approach: A Moral Assessment on Ghana’s Health Care Delivery System (Doctoral dissertation, Duquesne University).

12.

Folami

F. F.

Onanuga

K. A.

(2018). Perception of spirituality, spiritual care, and barriers to the provision of spiritual care among undergraduate nurses in the University of Lagos, Nigeria. Journal of Clinical Sciences, 15(1), 8.

13.

Freeman

Banner

Ward

. (2021). Hospice care providers experiences of grappling with medical assistance in dying in a hospice setting: A qualitative descriptive study. BMC Palliative Care, 20(1), 1–12. https://doi.org/10.1186/s12904-021-00740-3

14.

Gallison

B. S.

Jurgens

C. Y.

Boyle

S. M

. (2013). Acute care nurses’ spiritual care practices. Journal of Holistic Nursing, 31(2), 95–103. https://doi.org/10.1177/0898010112464121

15.

Hui

de la Cruz

Thorney

Parsons

H. A.

Delgado-Guay

Bruera

. (2011). The frequency and correlates of spiritual distress among patients with advanced cancer admitted to an acute palliative care unit. American Journal of Hospice and Palliative Medicine®, 28(4), 264 − 270. https://doi.org/10.1177/1049909110385917

16.

Kalish

. (2012). Evidence-based spiritual care: A literature review. Current Opinion in Supportive and Palliative Care, 6(2), 242 − 246. https://doi.org/10.1097/SPC.0b013e328353811c

17.

Küçük Alemdar

Kardaş Özdemir

Güdücü Tüfekci

(2018). The effect of spiritual care on stress levels of mothers in NICU. Western Journal of Nursing Research, 40(7), 997–1011.

18.

Levin

Hakala

T. A.

Schnaider

Bernardes

G. J.

Gazit

Knowles

T. P

. (2020). Biomimetic peptide self-assembly for functional materials. Nature Reviews Chemistry, 4(11), 615–634. https://doi.org/10.1038/s41570-020-0215-y

19.

Lloyd

O’Connor

(2007). Integrating spirituality into mental health rehabilitation. International Journal of Therapy and Rehabilitation, 14(4), 168–172.

20.

Machul

van Leeuwen

Ozga

Jurek

Boczkowska

Dobrowolska

(2022). The level of spiritual care competence of Polish nurses and the psychometric properties of the spiritual care competence scale (SCCS). BMC Nursing, 21(1), 1–10.

21.

Mamier

Taylor

E. J.

Winslow

B. W.

(2019). Nurse spiritual care: Prevalence and correlates. Western Journal of Nursing Research, 41(4), 537–554.

22.

Minton

M. E.

Isaacson

M. J.

Varilek

B. M.

Stadick

J. L.

O’Connell-Persaud

. (2018). A willingness to go there: Nurses and spiritual care. Journal of Clinical Nursing, 27(1–2), 173–181. https://doi.org/10.1111/jocn.13867

23.

O’Brien

M. R.

Kinloch

Groves

K. E.

Jack

B. A.

(2019). Meeting patients’ spiritual needs during end-of-life care: A qualitative study of nurses’ and healthcare professionals’ perceptions of spiritual care training. Journal of Clinical Nursing, 28(1-2), 182–189.

24.

P. J.

Kim

S. H.

(2014, September). The effects of spiritual interventions in patients with cancer: A meta-analysis. Oncology Nursing Forum, 43(5), E205–E217.

25.

Olsen

D. H

. (2003). Heritage, tourism, and the commodification of religion. Tourism Recreation Research, 28(3), 99–104. https://doi.org/10.1080/02508281.2003.11081422

26.

Pearce

M. J.

Coan

A. D.

Herndon

J. E.

Koenig

H. G.

Abernethy

A. P

. (2012). Unmet spiritual care needs impact emotional and spiritual well-being in advanced cancer patients. Supportive Care in Cancer, 20(10), 2269–2276. https://doi.org/10.1007/s00520-011-1335-1

27.

Ramezani

Ahmadi

Mohammadi

Kazemnejad

(2014). Spiritual care in nursing: A concept analysis. International Nursing Review, 61(2), 211–219.

28.

Schermerhorn

J. R.

Jr Bachrach

D. G.

& Wright

. (2020). Management. John Wiley & Sons.

29.

Selman

L. E.

Brighton

L. J.

Sinclair

Karvinen

Egan

Speck

, & InSpirit Collaborative. (2018). Patients’ and caregivers’ needs, experiences, preferences and research priorities in spiritual care: A focus group study across nine countries. Palliative Medicine, 32(1), 216–230.

30.

Silbermann

M. E

. (2016). Cancer care in countries and societies in transition. Springer.

31.

Steinhauser

K. E.

Fitchett

Handzo

G. F.

Johnson

K. S.

Koenig

H. G.

Pargament

K. I.

Balboni

T. A.

(2017). State of the science of spirituality and palliative care research part I: Definitions, measurement, and outcomes. Journal of Pain and Symptom Management, 54(3), 428–440.

32.

Teut

Stöckigt

Holmberg

Besch

Witt

C. M.

Jeserich

. (2014). Perceived outcomes of spiritual healing and explanations-a qualitative study on the perspectives of German healers and their clients. BMC Complementary and Alternative Medicine, 14(1), 1–10. https://doi.org/10.1186/1472-6882-14-240

33.

Vance

D. L

. (2001). Nurses’ attitudes towards spirituality and patient care. Medsurg Nursing, 10(5), 264.

34.

Vlasblom

J. P.

Van Der Steen

J. T.

Walton

M. N.

Jochemsen

. (2015). Effects of nurses’ screening of hospitalized patients’ spiritual needs on consultation and perceived nurses’ support and patients’ spiritual well-being. Holistic Nursing Practice, 29(6), 346 − 356. https://doi.org/10.1097/HNP.0000000000000111

35.

Walker

L.O.

Avant

K.C

. (2011) Strategies for Theory Construction in Nursing. 5th Edn. Prentice Hall.

36.

Wang, Z. Y., Wang, Z., Wang, Y., Han, G. H., & Pang, X. L (2021). Spiritual care perceptions, spiritual health and their relationships with spiritual care competence among clinical nurses in China: A cross-sectional quantitative study. TMR Integrative Nursing, 5(4), 145–159. https://doi.org/10.53388/TMRIN2021082505

37.

Woolf

Fisher

(2015). The role of dance movement psychotherapy for expression and integration of the self in palliative care. International Journal of Palliative Nursing, 21(7), 340–348.

38.

Tseng

Liao

. (2016). Nurse education and willingness to provide spiritual care. Nurse Education Today, 38, 36–41. https://doi.org/10.1016/j.nedt.2016.01.001

39.

Young

Koopsen

(2010). Spirituality, health, and healing: An integrative approach. Jones & Bartlett Publishers.

40.

Zumstein-Shaha

Ferrell

Economou

. (2020). Nurses’ response to spiritual needs of cancer patients. European Journal Of Oncology Nursing, 48, 101792. https://doi.org/10.1016/j.ejon.2020.101792