Perceptions of professional nurses towards the inclusion of spiritual activities in oncology practice in the uMgungundlovu and eThekwini Health Districts, KwaZulu-Natal, South Africa: A quantitative descriptive study.

Ethical considerations

The study was approved by the KwaZulu-Natal Department of Health (KZN-DoH), National Health Research Ethics Committee on 3^rd December 2021 (NHRD Ref: KZ _ 202111_ 020). An application for full ethical approval was made to the Biomedical Research Ethics Committee (BREC) at the University of KwaZulu-Natal, and approval was received on 08^th December 2021 (BREC/00003395/2021). Information regarding the research study was fully explained in an information letter, which was given to the respondents and was explained by the researcher. Written informed consent was obtained and anonymity was maintained as respondents did not have to reveal their names. During data capturing no personal details of respondents were captured instead each questionnaire was coded. This study was conducted in conformance with the Helsinki Declaration.

Study design and setting

A quantitative descriptive survey was used to analyse the perceptions of professional nurses towards the inclusion of spiritual activities in oncology practice.

The South Africa health care system has a two tier health care system which has a large subsidized public sector and a small private sector. About 80%of the population use the public healthcare, while 20 % use private healthcare.⁹ Funding in the public sector comes from point-of-care spending from those using the services and the government. Private health care can be accessed through private heath insurances. The NGO relies on donations from the public or they may claim from a medical aid that includes Hospice care as a part of the plan.

This study was conducted in two health districts in KwaZulu-Natal. The reason for choosing the selected two health districts is that oncology patients from other health districts are referred to the eThekwini and uMgungundlovu health district for further management. The selected districts have health care institutions that offer different levels of oncology care from diagnosis, into survivorship, and during death and dying. Both districts have public and private health care institutions.

The study was conducted in four sites offering oncology care in the uMgungundlovu and eThekwini Health Districts, KwaZulu-Natal. The sites were purposively selected based on their levels of care: a private hospital, offering specialized oncology care; a public-private partnership hospital, offering central and tertiary care; a public hospital, offering tertiary care, and a non-government organisation (NGOs) offering oncology and palliative care.

Sample and sampling method

Simple random sampling was best suited, as the researcher went to the oncology units and sampled all participants from the abovementioned hospitals and NGOs. This ensured that every professional nurse had an equal opportunity of being selected. Professional nurses who had a minimum of six months working experience, were directly involved in oncology nursing care, and who agreed to participate were eligible to take part in this study. Professional nurses included in the pilot study; those working in other departments and in the oncology units for less than six months and were unwilling to participate in this study were excluded.

A total of 89 participants that were included in this study were the only participants eligible. More so there was no hypothesis tested in this study which demanded to meet sample size calculations. As such the study was purely descriptive in nature.

Study instrument

The researcher requested and received permission from the author, Professor Mc Sherry to use original ‘The Spirituality and Spiritual Care Rating Scale’ (SSCRS) hence allowing the researcher to modify and adapt the scale to the current study. The scale is easily available and can be copied. The SSCRS was developed by Mc Sherry (2002) to assess nurse’s perception of spiritual care.¹⁰

This five-point Likert scale includes 17 items and explored four factors viz. (i) spirituality, (ii) spiritual care (iii) religiosity and (iv) personal care. According to Mc Sherry et al¹¹ the SSCRS tool assess the beliefs and values of nurses viz, beliefs about spirituality; beliefs about the way nurses can provide spiritual care; beliefs about religiosity and the expression of religiosity and values around personalized care. Factor I includes matters pertaining to life and existence, specifically the necessity of giving life meaning and purpose and the necessity of finding these things during periods of illness or hospitalization. Secondly, factor II focuses on aspects of spiritual care. In addition to maintaining religious customs and listening attentively, the nurse must also respect privacy and dignity, spend time with patients, and provide care by acting with kindness and concern. Factor III supports the idea that spirituality is a much broader phenomenon than just attributing it to formal religious expressions by recognizing that domains like creativity, art, and self-expression are part of the concept. This seems to highlight the universal nature of spirituality and its uniqueness to all people. Lastly factor iv acknowledges that spirituality is based ones is values, morals, beliefs and existential background.

For the current study, how professional nurses, conceptualized spirituality personally and in a nursing, context was measured by the SSCRS and were in line with the research objective. The questionnaire was designed along the subsection headings and part of the original questions used by McSherry; and together with the researchers own questions gave rise to a new survey questionnaire (see Extended data).³⁰

The questionnaire was pre-tested for validity and reliability among four professional nurses, one from each institution. According to Viechtbauer, Smits, Kotz, Bude, Spigt, Serroyen & Crutzen (2015),¹² a pilot study including at least 4 participants will almost certainly identify data collection tool problems with a prevalence of 60% with 95% confidence level and that was the approach that we used to arrive at the 4 nurses.

The questionnaire was in English and only the content was adapted to ensure that relevant questions were included in order to determine professional nurse’s perceptions towards the inclusion of spiritual activities in oncology practice.

The final questionnaire (see Extended data³⁰) consisted of two sections as follows:

Section A is related to the demographic characteristics of the participants: gender, ethnic group, working experience in nursing, and religious affiliation.

Section B is related to the SSCRS; focusing on the professional nurse’s perceptions about spirituality and spiritual activities in oncology nursing practice.

The Likert scale required the participants to answer the questions with a response (Agree) or (Disagree). The researcher submitted the questionnaire to her supervisor to check if all the questions reflected all the concepts being studied.

Data collection process

Gatekeeper permission was obtained from the relevant heads of institutions and units to conduct the study. The researcher arranged with the manager of each unit regarding a convenient day and time to meet with the professional nurses. The researcher met with the participants and explained the process to be followed, and time was given to ask questions. A package including an information letter, questionnaire, and consent form was handed to the participants and collected after three weeks for the two hospitals in the eThekwini Health District due to the distance, nature of the participants’ work, and their availability. Data collection was done over a period of five days at the hospital and NGO in the uMgungundlovu Health District with the same package delivered. Data collection was done over a period of four weeks from 3^rd January 2022 to 9^th February 2022. The researcher arranged a date and time at their convenience to pick up the completed questionnaires and consent forms from both districts. The completed questionnaires and consent forms were placed into a sealed envelope that was kept in a locked cupboard only accessible to the researcher.

Data analysis

All questionnaires collected were checked for completeness; were numbered and each question was given a code and then entered onto an excel spreadsheet (see Underlying data).²⁹ Out of the 89 questionnaires distributed, all 89 were completed correctly and included in the final analysis.

The data collected was analysed using the Statistical Package for Social Science (SPSS) version 27, with the assistance of a statistician. The descriptive statistics results were reported as frequencies and percentages to summarize the categorical variables.

Validity and reliability

The questionnaire was tested for validity and reliability.

Face validity is what it appears to measure and someone is not an expert in the field can just read through as they have face value knowledge. In this case we sought the services of professional editors who were not part of the participants and also did not have enough knowledge about the content and terminology of the questionnaire.

On the other hand, content validity measures the appropriateness of the content. In contrast to face validity, this requires an expert in the area of research who also understands the technical content as the researcher. The supervisor for the study was used to review the contents of the instrument.

Construct validity ensures that the questionnaire measures accurately what it is supposed to measure.¹³ The questionnaire was adapted to ensure that relevant questions were included to determine the perceptions of professional nurses towards inclusion of spiritual activities in oncology practice.

The items used were that on a dichotomous scale (only agree and disagree), which is by nature bound to give low values of Cronbach’s values. Hence obtaining the Cronbach’s alpha for the reliability was not considered appropriate.

Professional nurse’s perceptions about spirituality and spiritual activities in oncology nursing practice

A large portion of participants agreed that spirituality is to do with the way one conducts one’s life here and now, which signifies that spirituality is relevant at the time of a patient’s illness in terms of how they manage their illness. These results corroborate with Ebenau et al., and Rego et al.,^17,18 who noted that spirituality is a dynamic dimension of human life as it encourages one to find meaning and purpose in life during suffering and death.

Having faith and a relationship with God is universal. Believing that it is God’s power, love, and existence that allows us to find peace and contentment in daily living cannot be over-emphasized. This was evident by the statistics which revealed that only a few professional nurses agreed that spirituality is not concerned with a belief and faith in a God, however, the majority disagreed on this point. This discrepancy is in line with Hu, Jiao, and Li and Siqueria et al.,^19,20 who argues that in diseases like cancer, spirituality allows patients to form interrelationships with God, nature, and oneself and this is seen as their coping strategy during their journey.

The findings of the study highlight that there is a high acceptance of spirituality among professional nurses. This is supported by the fact that almost all the participants agreed that spirituality is a unifying force that enables one to be at peace with oneself and the world thereafter. This signifies that when facing an illness or a life crisis, spirituality allows individuals to find peace within themselves, and with family and not blame others for the situation that they are in.

Forming relationships with a higher being during times of ill health allows individuals to gain strength and create hope so that they can cope better.²¹ Hope is a part of everyone’s life that arises in both good and bad situations. It is associated with resilience and can change the perception of a stressful experience into a comforting and manageable experience.²² This was evident in the statistics revealed, that the majority of the participants reported that spirituality is about having a sense of hope in life during drastic oncology care.

It was interesting to note that only a small percentage of participants were in agreement that spirituality does not include areas such as art and creativity, but Corry, Tracey, and Lewis²² emphasizes that creativity is an aspect of spirituality that alleviates anxiety, creates joy, and provides self-esteem. The reason for this may be related to the fact that some professional nurses experience heavy workloads and do not have the time to explore these creative avenues or they may be unaware that this could take the patient’s mind off their negative emotions and allow them to express their feelings healthily.

It was encouraging to note that the majority of professional nurses were in agreement that spirituality is concerned with counselling, and a need to forgive and be forgiven. This issue is very close to the researcher’s ideology because nurses as human beings need to forgive each other to work harmoniously together. This is in line with Siler et al.,²³ who concurs that patients who are suffering from a terminal illness, like cancer, begin to question their lives and feel like they have not been forgiven and are now punished by God for all the wrongdoings in their lives. But then again when someone feels that they have been forgiven for their wrongdoings in life, suffering and death become more acceptable.²⁴

It is recommended that if spiritual practices are integrated into nursing practice, then nurses will become mindful of the patient’s spiritual needs and implement spiritual activities like meditation, prayer, art therapy, and other rituals into nursing practice.⁶ Nursing literature reveals that these activities are common in nursing care and contribute to the realm of holistic nursing care.^7,17 This is in line with the findings of this study as almost all professional nurses agreed that spiritual care can be provided by implementing various spiritual activities into nursing care.

Hospitals always aim to provide the best care for their patients, but the care provided by nurses might not always meet the emotional and spiritual needs of their patients. This is in line with Siler et al.,²³ who emphasizes that spiritual care is not the sole responsibility of one health care discipline, but it should be a team approach including an oncology nurse, oncologist, psychologist, social worker, and religious leaders who are trained in spiritual care,²³ This can be accomplished as majority of the professional nurses stated that spiritual care can be provided by arranging a religious leader to meet the spiritual needs of the patient. Our clients come from different social and spiritual backgrounds, so the availability of a chaplain could not be over-emphasized.

Cancer patients might feel lonely, isolated, hopeless, and abandoned by God as reported by Siler et al.,²³ whereas almost all the professional nurses stated that oncology nurses can provide spiritual care by showing kindness, concern, and cheerfulness when giving care. During the nurse’s daily routine, an act of kindness such as helping patients take a bath, administering their medication, instilling hope, and creating a positive outlook on life can reduce their stress, anxiety, and depression, which can make their situation and experience more pleasant.

It was encouraging to note that all professional nurses agreed that spiritual care can be provided by spending time with their patients, providing support and reassurance. Similar findings were made by Starc, Karnjus, and Babnik and Forshaw et al.,^2,26 who concur that when patients are reassured and informed about their condition and their treatment modalities, they may feel more prepared to deal with their illness. Nurses can offer support to the patient, visitors, and family during visiting hours by explaining the patient’s condition just to allay any fears and anxieties.

A large percentage of participants agreed that spirituality can be provided by listening to patients and providing them with radio, magazines, and extended visiting hours. The hospitalized patient can benefit from listening to the radio and having an in-house saloon or beauty therapist to improve their physical image. In the case of children, the importance of play cannot be over- emphasized; therefore, a playroom is ideal where children can participate in a variety of activities simultaneously. This notion is supported by Herlianita et al.,²⁷ who stated that Islamic patients cope better with their illness when reading or listening to their Holy Quran. Although, providing such spiritual activities is ideal, financial or structural barriers could prevent such provisions.

Another interesting finding was that all professional nurses stated that oncology nurses can provide spiritual care by having respect for the privacy, dignity, and religious and cultural beliefs of a patient. For nurses, the important thing is to respect the patient’s rights and beliefs even if you disagree with them. Siler et al.,²³ supports this idea that a patient’s belief and view of God or higher power must be respected. Nurses need to accommodate those spiritual needs that do not interfere with the safety of the patients or health care. To handle the situation, nurses need to apply nursing activities that secure the patient’s dignity by addressing them properly and respecting their personal space and possessions. In fact, Bagherian et al.,²⁸ confirms that cancer patients are more vulnerable to the loss of their dignity, hence they need to be handled with care.

These activities fall in the realm of caring and nurses should be equipped with how to integrate these activities into nursing care to ensure the well-being and recovery of oncology patients. The current study has some limits that should be addressed in future research. The study exclusively addressed the perceptions of professional nurses towards inclusion of spiritual activities in oncology practice. Future research should include other categories of nursing personnel and patients in different hospitals and settings.