Abstract
Background
Patient empowerment is central to high-quality palliative care, yet the factors influencing a patient’s sense of control remain poorly understood. While clinical practice often focuses on physical symptoms, the impact of spiritual well-being and prior illness experience on empowerment requires further exploration. This study examined how symptom burden and spiritual well-being relate to patient empowerment in individuals receiving palliative care.
Methods
A descriptive, cross-sectional, and correlational design was employed. The study included 140 patients followed in a palliative care unit of a public hospital in Turkiye. Data were collected using the Edmonton Symptom Assessment Scale-Revised, the Functional Assessment of Chronic Illness Therapy–Spiritual Well-Being Scale, and the Patient Empowerment Scale. Data analysis included descriptive statistics, Pearson correlation, and multiple linear regression analysis.
Results
The mean total symptom burden score was 50.95 ± 11.41, with pain, fatigue, anxiety, and depression being the most severe symptoms. Despite high symptom intensity, patients maintained moderate levels of spiritual well-being (24.25 ± 4.93) and empowerment (3.05 ± 0.48). Correlation analysis revealed a significant positive relationship between spiritual well-being and empowerment (r = 0.520, p < 0.01). Regression analysis showed that the model explained 42.8% of the total variance in patient empowerment. Spiritual well-being (β = 0.484, p < 0.001) and the presence of other chronic diseases (β = 0.372, p < 0.001) were identified as the strongest significant predictors of empowerment, whereas symptom burden did not have a significant predictive effect (p > 0.05).
Conclusion
Spiritual resources are significantly associated with patient empowerment, even in the presence of a high symptom load. Nursing care can be enhanced by complementing physical symptom management with a holistic approach that incorporates spiritual support and acknowledges the experiential expertise of patients.
Keywords: Palliative care, Patient empowerment, Spiritual well-being, Symptom burden, Nursing
Introduction
The increasing global prevalence of chronic and terminal illnesses has heightened the necessity for palliative care as an interdisciplinary approach that prioritizes quality of life over curative treatments [1, 2]. Given the progressive nature of these diseases, palliative care aims to alleviate symptom burden, support patient functionality and autonomy, and maintain the quality of life for both the individual and their family [3, 4]. This approach encompasses holistic interventions addressing psychosocial and spiritual needs alongside physical symptoms [4].
Identifying the prevalence and distribution of symptoms in palliative care patients is fundamental for clinical decision-making and the development of personalized care plans [3]. Early and comprehensive symptom assessment not only supports clinical management but also facilitates patient adaptation to the disease process and enhances the involvement of caregivers [5, 6]. While pain remains the most prevalent and well-defined symptom in the literature, patients frequently experience a concurrent cluster of physical and psychosocial symptoms, including fatigue, anorexia, dyspnea, gastrointestinal issues, sleep disturbances, and anxiety or depression [2, 3, 5]. Despite etiological differences, the high symptom burden in these patients often leads to a progressive decline in physical and cognitive functioning [3, 7, 8]. However, addressing high symptom burden solely as a physical parameter is insufficient to explain an individual’s capacity for existential coping and making sense of the illness experience [9]. This highlights the critical role of spiritual well-being in contextualizing the symptom experience within palliative care.
Spiritual well-being is a vital health component that enables individuals to structure their relationship with the meaning and purpose of life and transcendence. It is shaped through dynamic connections with oneself, others, and the sacred [4, 10]. In the literature, spiritual well-being is defined not merely as religious practice, but as a functional resource encompassing inner peace, the search for meaning, and the capacity to cope with life challenges [11]. Individuals who maintain inner balance can develop more adaptive responses to the disease process and cope more effectively with feelings of uncertainty, fear, and anxiety. The achievement of psychological tranquility contributes to reduced emotional distress, positively impacting sleep patterns and nutritional behaviors, thereby mediating physical comfort [12, 13]. High levels of spiritual well-being in palliative care patients are reported to reduce emotional and physical symptoms while enhancing overall quality of life [10, 14, 15]. Consequently, integrating spiritual needs into palliative care is a fundamental strategy. Spiritual well-being, encompassing meaning, peace, and faith, acts as an essential internal resource. In this context, these spiritual assets can directly feed patient empowerment across core domains like personal control, identity, and decision-making, while ultimately helping to bolster resilience for patients and caregivers [4, 12].
Patient empowerment in palliative care is a multidimensional and dynamic concept. It represents an individual’s capacity to make informed decisions regarding the disease process, actively participate in care, and maintain a sense of self-efficacy [16, 17]. An empowered patient acts as a stakeholder who determines their own care goals and utilizes coping resources effectively. However, due to high symptom burden and the complexity of treatment, palliative care patients often struggle to demonstrate these self-management skills [16, 18]. Conversely, proactive symptom management and spiritual well-being add meaning to the illness experience, enabling patients to assume an active role in the care process beyond mere physical and psychological relief [12, 19]. Determining the cumulative effect of symptom burden and spiritual resources on patient empowerment is essential for structuring care models that center on patient autonomy and holistic outcomes. This study was planned to examine the predictive effect of spiritual well-being and symptom burden on patient empowerment among palliative care patients.
Methods
Study design
This study was conducted using a descriptive, cross-sectional, and correlational design.
Participants and setting
The study population consisted of patients followed in the palliative care unit of Batman Training and Research Hospital. The inclusion criteria were: (1) being aged 18 years or older, (2) having a confirmed diagnosis for at least three months and receiving palliative care services, and (3) being conscious, oriented, and able to communicate effectively.
The sample size was calculated a priori using G*Power (version 3.1) software. Based on a 95% confidence interval, a 5% margin of error, and a medium effect size (r = 0.30), the minimum required sample was determined to be 138 patients. Due to the clinical recruitment challenges inherent in a palliative care setting, such as high patient vulnerability, rapid clinical deterioration, severe fatigue, and cognitive fluctuations, participants were selected via convenience sampling. A total of 140 patients who met all inclusion criteria and completed the data collection forms in full were included in the final analysis. While convenience sampling was clinically necessary under these recruitment challenges, it is explicitly recognized that non-probability sampling may compromise the statistical representativeness assumed by formal sample size calculations.
Instruments
Demographic information form
This form included questions regarding age, gender, educational status, marital status, employment status, diagnosis group, duration of diagnosis, duration of palliative care, and comorbid chronic diseases.
Edmonton symptom assessment scale-revised (ESAS-R)
Originally developed by Bruera et al. (1991) to assess symptom intensity in cancer patients, this is a multidimensional self-report tool [20]. It consists of nine items- pain, tiredness, drowsiness, nausea, lack of appetite, shortness of breath, anxiety, depression, and best well-being- rated on a scale from 0 (none) to 10 (worst possible). The Turkish validity and reliability study was conducted by Usta Yesilbalkan et al. (2008) with a reported Cronbach’s α of 0.77 [21]. In this study, the total ESAS-R score was calculated by summing the nine items, with higher scores indicating a greater symptom burden. The Cronbach’s α for the present study was 0.74.
Functional assessment of chronic illness therapy–spiritual well-being scale (FACIT-Sp-12)
This scale assesses spiritual well-being in individuals with cancer or chronic illnesses. The FACIT-Sp-12 operationalizes spiritual well-being through a comprehensive, multidimensional framework that defines spirituality as an individual’s ongoing pursuit of meaning, purpose, and inner faith, sustained through deep connections with oneself, others, nature, or a transcendent dimension. The scale comprises 12 items across three subscales: meaning, peace, and faith. In the context of palliative care, these subscales represent core spiritual determinants that function as internal resources to support patient empowerment and psychological resilience. The Turkish validity and reliability study was performed by Aktürk et al. (2017). Items are rated on a 5-point Likert scale (0 = not at all to 4 = very much), and total scores range from 0 to 48, with higher scores indicating better spiritual well-being. The Cronbach’s α was reported as 0.87 [22] and was 0.73 in the present study.
Patient empowerment scale (PES)
Developed by Small (2012) and adapted into Turkish by Kaya and Işık (2018), this scale evaluates empowerment across five subscales: identity, personal control, decision-making, knowing and understanding, and interaction with others [23]. It consists of 37 items on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Higher average scores (approaching 5) reflect higher levels of empowerment. The scale’s Cronbach’s α was reported as 0.92 [24]. The scale’s Cronbach’s α in this study was calculated as 0.95.
Data collection
Data were collected face-to-face between August and December 2025. The researcher explained the study purpose and emphasized voluntary participation. For those who consented, the researcher administered the forms, a process lasting approximately 15–20 min per participant.
Data analysis
Data were analyzed using SPSS version 26.0. Normal distribution was confirmed through skewness and kurtosis coefficients (± 3). Descriptive statistics were presented as frequencies, percentages, means, and standard deviations. Independent samples t-test and one-way ANOVA (with Tukey post-hoc test) were used for group comparisons. Pearson correlation analysis determined relationships between scales. Simple and multiple linear regression (Enter method) were performed to identify the predictive effects of spiritual well-being and symptom burden on patient empowerment. Correlation strengths were interpreted as: 0.00–0.10 (negligible), 0.10–0.30 (weak), 0.30–0.50 (moderate), 0.50–0.70 (strong), and 0.70–1.00 (very strong) [25]. Statistical significance was set at p < 0.05.
Results
Participant characteristics
The descriptive and clinical characteristics of the participants are summarized in Table 1. The mean age of the patients was 51.42 ± 13.36 years, and 77.1% were receiving palliative care with a diagnosis of cancer. Male patients had significantly higher spiritual well-being and patient empowerment scores compared to female patients. Empowerment scores of married and single patients were significantly higher than those of widowed or divorced patients (p < 0.05).
Table 1.
Comparison of scale scores according to demographic characteristics (n = 140)
| Variables Age (years): Mean ± SD (51.42 ± 13.36) Min-Max. (19–74) |
n | % | FACIT-Sp-12 | ESAS-R | PES | |
|---|---|---|---|---|---|---|
| Mean ± SD | Mean ± SD | Mean ± SD | ||||
| Gender | Female | 66 | 47.1 | 30.59 ± 6.26 | 50.75 ± 11.76 | 2.96 ± 0.49 |
| Male | 74 | 52.9 | 33.56 ± 7.62 | 51.12 ± 11.17 | 3.13 ± 0.46 | |
| t / p | -2.506 / 0.013 | -0.188 / 0.811 | -2.091 / 0.038 | |||
| Marital status | Single1 | 20 | 14.3 | 33.00 ± 8.62 | 49.35 ± 11.41 | 3.20 ± 0.40 |
| Married 2 | 110 | 78.6 | 32.14 ± 6.81 | 51.11 ± 11.62 | 3.07 ± 0.46 | |
| Divorced/ widowed3 | 10 | 7.1 | 30.70 ± 8.06 | 52.30 ± 9.59 | 2.52 ± 0.51 | |
| F / p | 0.344 / 0.710 | 0.275 / 0.760 |
7.665 / 0.001 1, 2 > 3 |
|||
|
Education status |
Illiterate 1 | 35 | 25.0 | 28.22 ± 5.05 | 49.37 ± 12.76 | 2.62 ± 0.39 |
| Primary/secondary school 2 | 38 | 27.1 | 29.86 ± 4.87 | 50.71 ± 11.96 | 2.88 ± 0.31 | |
| High school 3 | 47 | 33.6 | 33.59 ± 7.08 | 51.48 ± 11.33 | 3.26 ± 0.35 | |
| Bachelor’s degree and above 4 | 20 | 14.3 | 40.05 ± 7.11 | 52.90 ± 7.92 | 3.62 ± 0.33 | |
| F / p |
18.810 / 0.000 4 > 1, 2, 3; 3 > 1 |
0.562 / 0.642 |
43.346 / 0.000 4 > 1, 2, 3; 3 > 1, 2; 2 > 1 |
|||
| Employment status | Employed 1 | 21 | 15.0 | 26.14 ± 6.79 | 48.80 ± 9.17 | 3.28 ± 0.51 |
| Unemployed | 77 | 55.0 | 23.72 ± 4.64 | 51.46 ± 11.76 | 3.06 ± 0.48 | |
| Retired 2 | 42 | 30.0 | 24.26 ± 4.19 | 51.07 ± 11.89 | 2.92 ± 0.44 | |
| F / p | 1.210 / 0.307 | 0.447 / 0.640 |
3.950 / 0.021 1 > 2 |
|||
| Diagnosis | Cancers | 108 | 77.1 | 23.79 ± 5.00 | 50.95 ± 11.79 | 3.06 ± 0.46 |
| Respiratory system diseases | 22 | 15.7 | 25.45 ± 4.13 | 52.04 ± 10.60 | 2.94 ± 0.61 | |
| Other | 10 | 7.1 | 26.50 ± 5.10 | 48.50 ± 9.30 | 3.16 ± 0.38 | |
| F / p | 2.189 / 0.116 | 0.328 / 0.721 | 0.758 / 0.481 | |||
| Time since diagnosis | 3 months to 1 year | 12 | 8.6 | 25.75 ± 4.63 | 45.66 ± 10.92 | 2.91 ± 0.60 |
| > 1 year to 3 years 1 | 51 | 36.4 | 24.13 ± 5.44 | 51.88 ± 13.09 | 3.15 ± 0.46 | |
| > 3 years to 5 years | 35 | 25.0 | 24.40 ± 4.88 | 50.48 ± 8.10 | 3.14 ± 0.47 | |
| More than 5 years 2 | 42 | 30.0 | 2383 ± 4.46 | 51.71 ± 11.66 | 2.89 ± 0.44 | |
| F / p | 0.484 / 0.694 | 1.069 / 0.372 |
3.061 / 0.030 1 > 2 |
|||
| Duration of palliative care/treatment | 3 months to 1 year | 101 | 72.1 | 24.45 ± 5.09 | 51.39 ± 11.35 | 3.11 ± 0.49 |
| > 1 year to 3 years | 35 | 25.0 | 23.20 ± 4.42 | 50.71 ± 11.44 | 2.89 ± 0.41 | |
| More than 3 years | 4 | 2.9 | 28.25 ± 2.06 | 41.75 ± 11.44 | 2.94 ± 0.48 | |
| F / p | 2.233 / 0.111 | 1.391 / 0.252 | 2.796 / 0.065 | |||
| Presence of other chronic diseases | Yes | 77 | 55.0 | 23.97 ± 4.31 | 53.09 ± 11.18 | 2.87 ± 0.43 |
| No | 63 | 45.0 | 24.58 ± 5.62 | 48.33 ± 11.23 | 3.28 ± 0.44 | |
| t / p | -0.712 / 0.478 | 2.499 / 0.014 | -5.437 / 0.000 | |||
SD standard deviation, FACIT-Sp-12 Functional Assessment of Chronic Illness Therapy–Spiritual Well-Being Scale, ESAS-R Edmonton Symptom Assessment Scale-Revised, PES Patient Empowerment Scale
A significant positive correlation was found between educational level and both spiritual well-being and patient empowerment scores (p < 0.001). Patients without comorbid chronic diseases had higher empowerment scores than those with comorbidities (p < 0.001). Furthermore, patients with chronic diseases exhibited a significantly higher symptom burden (p = 0.014). Other descriptive characteristics did not show a statistically significant difference in symptom burden (p > 0.05).
Levels of study variables
The distribution of total and subscale scores for the scales is presented in Table 2. The mean total symptom burden score was 50.95 ± 11.41. Among the subscales, the symptoms with the highest intensity were pain (6.95 ± 1.88), fatigue (6.80 ± 1.72), anxiety (6.32 ± 1.86), and depression (6.02 ± 1.89) (Fig. 1). The mean total score for patient empowerment was 3.05 ± 0.48. Within the empowerment subscales, the highest mean was observed in “decision-making” (3.41 ± 0.49), while the lowest was in “identity” (2.68 ± 0.61). The mean total score for spiritual well-being was 24.25 ± 4.93, with the highest scores reported in the “faith” subscale (9.89 ± 2.65).
Table 2.
Mean scores of ESAS-R, FACIT-Sp-12, and PES scales and subscales (n = 140)
| Mean | SD | Min | Max | Cronbach’s α | |
|---|---|---|---|---|---|
| ESAS-R | 50.95 | 11.41 | 23.00 | 78.00 | 0.745 |
| Pain | 6.95 | 1.88 | 2 | 10 | |
| Fatigue /Loss of energy | 6.80 | 1.72 | 2 | 10 | |
| Drowsiness | 5.88 | 2.31 | 0 | 10 | |
| Nausea | 3.82 | 2.84 | 0 | 10 | |
| Loss of appetite | 5.61 | 2.25 | 0 | 10 | |
| Shortness of breath | 3.18 | 3.09 | 0 | 10 | |
| Depression | 6.02 | 1.89 | 1 | 10 | |
| Anxiety | 6.32 | 1.86 | 2 | 10 | |
| Overall well-being | 6.32 | 1.50 | 3 | 9 | |
| PES | 3.05 | 0.48 | 1.90 | 4.00 | 0.952 |
| Identity | 2.68 | 0.61 | 1.33 | 4.11 | |
| Personal control | 2.91 | 0.49 | 1.57 | 4.00 | |
| Decision-making | 3.41 | 0.49 | 2.00 | 4.25 | |
| Knowledge and understanding | 3.24 | 0.63 | 1.75 | 4.63 | |
| Enabling other | 3.01 | 0.61 | 1.60 | 4.40 | |
| FACIT-Sp-12 | 24.25 | 4.93 | 11.00 | 36.00 | 0.736 |
| Meaning | 7.27 | 1.90 | 2.00 | 11.00 | |
| Peace | 7.08 | 1.93 | 0 | 11.00 | |
| Faith | 9.89 | 2.65 | 4.00 | 16.00 |
Fig. 1.
Mean symptom severity scores assessed by the ESAS-R (0–10 scale)
Correlations among study variables
Correlation analyses between variables are presented in Table 3. A significant moderate positive correlation was found between spiritual well-being and patient empowerment (r = 0.520, p < 0.01). A significant weak negative correlation was observed between symptom burden and patient empowerment (r = -0.238, p < 0.01). No statistically significant relationship was found between spiritual well-being and symptom burden (r = -0.156, p > 0.05).
Table 3.
Correlations between symptom burden, spiritual well-being, and patient empowerment (n = 140)
| Variables | 1 | 2 | 3 |
|---|---|---|---|
| 1. FACIT-Sp-12 | 1 | ||
| 2. ESAS-R | -0.156 | 1 | |
| 3. PES | 0.520** | -0.238** | 1 |
r, pearson correlation coefficients; **p < 0.01
Predictors of patient empowerment
The results of the multiple linear regression analysis conducted to determine the predictors affecting patient empowerment are presented in Table 4. The model was found to be statistically significant (F = 33.934, p < 0.001). The model, including spiritual well-being, presence of comorbid chronic disease, and symptom burden, explained 42.8% of the total variance in patient empowerment (Adjusted R2 = 0.415). Analysis of the regression coefficients revealed that spiritual well-being (β = 0.484, p < 0.001) and the presence of an additional chronic disease (β = 0.372, p < 0.001) were the strongest and most significant predictors of patient empowerment.
Table 4.
Multiple linear regression analysis for predictors of patient empowerment (n = 140)
| Predictors | B | SE | β | t | P | 95% CI |
|---|---|---|---|---|---|---|
| Lower- Upper | ||||||
| Constant | 1.562 | 0.258 | 6.060 | 0.000 | 1.052–2.072 | |
| FACIT-Sp-12 | 0.048 | 0.006 | 0.484 | 7.364 | 0.000 | 0.035–0.060 |
| ESAS-R | -0.004 | 0.003 | -0.085 | -1.263 | 0.209 | -0.009-0.002 |
| Presence of other chronic diseases | 0.362 | 0.064 | 0.372 | 5.614 | 0.000 | 0.234–0.489 |
| R = 0.654, R2 = 0.428, Adjusted R2 = 0.415, F = 33.934, P < 0.001, Durbin-Watson = 1.746 | ||||||
B unstandardized regression coefficients, SE standard error, β standardized regression coefficients, R2 determination coeffient
Discussion
This study is among the limited number of investigations examining the relationship between symptom burden, spiritual well-being, and patient empowerment among palliative care patients. The findings reveal that despite facing a high symptom burden, the individuals in the sample maintained moderate levels of spiritual well-being and empowerment capacity. Specifically, the high intensity of multifactorial symptoms, such as pain, fatigue, anxiety, depression, and poor perceived general well-being, aligns with the literature indicating that these patients face significant holistic physical and psychosocial pressures [2, 3]. Although literature typically reports that increased symptom severity is associated with impaired functional performance and lower spiritual perception [12, 26, 27], the observed co-occurrence of preserved empowerment capacity alongside a high symptom burden in our sample is noteworthy. This observation suggests an association wherein patients may continue to seek self-management and maintain adaptive mechanisms despite clinical limitations.
Regression analysis indicates that spiritual well-being is strongly associated with patient empowerment in this population. This observed association with patient empowerment supports theoretical frameworks suggesting that faith and the search for meaning may nurture an individual’s sense of internal control [28, 29]. Similarly, cross-sectional studies indicate that patients receiving interdisciplinary palliative care show higher scores in the dimensions of spiritual peace and meaning, with these internal resources being linked to adaptive coping with illness [11, 30]. As noted by Pakenham and Martin (2024) [31], individualizing psychosocial interventions and integrating spiritual priorities into care are considered essential strategies for supporting dignity and quality of life in the final stages of life. Supporting spiritual well-being may thus serve as a valuable avenue to encourage active participation in the care process.
The palliative care process represents a dynamic phase where patients encounter complex, fluctuating symptom clusters, which are frequently associated with reduced physical function and social withdrawal [26, 27]. In the literature, symptom burden is often defined as a primary barrier that suppresses self-management capacity and forces the patient into a passive role [12, 32]. However, the findings of this study did not demonstrate a direct deterministic link between symptom severity and the level of patient empowerment. This suggests that the perception of empowerment in palliative care may share a closer relationship with spiritual well-being than with biophysical comfort alone. Qualitative insights provided by Yang et al. (2024) suggest that active coping, manifested through information seeking, strategy development, and family support, may reflect higher empowerment despite symptom burden [27]. Our findings suggest an association between spiritual well-being and adaptive coping when patients face symptom-related existential distress. Patients with higher spiritual well-being despite physical limitations may view symptoms not merely as absolute barriers, but as clinical parameters to be managed [26, 27]. While the presence of comorbid chronic diseases was initially expected to be negatively correlated with self-management [33, 34], our analysis revealed a positive association with empowerment. This finding may align with the concept of “experiential knowledge” in the literature, where long-term illness experience is associated with greater familiarity and active involvement in care management [35]. In this context, living with multiple chronic conditions, when coupled with spiritual meaning-making, may be associated with a more proactive orientation toward self-management [36, 37]. Consequently, empowerment in palliative care is best viewed as an associative, multidimensional process linked to both spiritual well-being and prior illness experience.
Implications for nursing practice and research
The study findings offer useful perspectives for nursing approaches in palliative care. Clinical nursing practice can benefit from integrating spiritual and experiential resources alongside physical symptom management. In clinical settings, recognizing the potential association between spiritual well-being and patient empowerment underscores the value of incorporating spiritual support into holistic routine care. Furthermore, individuals with multiple chronic conditions may be recognized for their experiential knowledge within the care process, which can be leveraged to foster active engagement. Symptom burden should not automatically be viewed as an absolute barrier to empowerment; therefore, proactive nursing strategies to encourage self-management capacity should be considered even for patients experiencing high symptom intensity.
Limitations
While providing valuable insights into palliative care, several methodological limitations warrant cautious interpretation of these findings. First, the cross-sectional design precludes establishing causal pathways or temporal directionality; thus, spiritual well-being may either support empowerment, be enhanced by baseline empowerment, or share a bidirectional relationship. Second, relying on self-reported instruments introduces potential response bias and shared method variance. Unmeasured confounders, such as psychological disposition, optimism, or external social support, could simultaneously influence both spiritual perception and perceived empowerment. Third, single-center convenience sampling (N = 140) limits generalizability. Although meeting the G*Power threshold (N = 138), non-probability sampling amidst severe clinical challenges (patient vulnerability, fatigue, and cognitive fluctuations) may increase Type II error risks in secondary analyses. Furthermore, excluding patients with severe cognitive impairment or active end-stage illness restricts findings to a relatively stable palliative subgroup. To address these limitations, future research should employ longitudinal designs to clarify temporal trajectories. Additionally, randomized controlled trials testing targeted spiritual interventions and qualitative studies investigating adaptive coping are essential to clarify the therapeutic mechanisms and experiential dynamics underlying these relationships.
Conclusion
This study identified that despite a high symptom burden, characterized primarily by pain, fatigue, anxiety, and depression, palliative care patients maintain moderate levels of spiritual well-being and empowerment. Regression analysis demonstrated that symptom burden was not significantly associated with empowerment; instead, spiritual well-being emerged as the strongest independent factor correlated with patient empowerment. Moreover, the presence of comorbid chronic diseases was positively associated with empowerment capacity. Spiritual resources appear to be significantly associated with the preservation of self-management capacity, even amidst heavy symptom loads. It is recommended that nursing care be structured through a holistic approach that moves beyond physical symptom management to support spiritual well-being and center on the patient’s experiential expertise.
Authors’ contributions
Z.G: Conceptualization, methodology, ınvestigation, formal analysis, writing – original draft preparation, supervision, writing–reviewing and editing. U.Ö: Conceptualization, methodology, data curation, writing – original draft. All authors had full access to all the data in the study, and all authors had final responsibility for the decision to submit for publication. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.
Funding
This work was supported by the Scientific Research Projects Coordination Unit of İnönü University (Project Number: TSA-2026-4511). The funders played no role in the design of the study, nor in the decision-making process regarding data collection, analysis, interpretation, report writing, or submission of the article for publication.
Data availability
Data available on request from the authors.
Declarations
Ethics approval and consent to participate
Institutional permission was obtained from the Batman Provincial Health Directorate, and ethical approval was granted by the İnönü University Health Sciences Scientific Research Ethics Committee (Approval number: 2025/8157). The study was conducted in accordance with the principles of the Declaration of Helsinki. Prior to data collection, all participants were fully informed about the study’s purpose, procedures, and the voluntary nature of participation. As approved by the Ethics Committee, verbal informed and written informed consent were obtained from all participants prior to administering the questionnaires.
Consent for publication
Participants provided informed consent for their personal and clinical data to be used for research purposes and for the resulting manuscript to be published. Authors have read and agreed to the published version of the manuscript.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Uhlig S, Doberschütz F, Hallmann F, Salm H, Sigle JM, Pink D. Exploring the integration of dentistry within a multidisciplinary palliative care team: does bedside dental care improve quality of life and symptom burden in inpatient palliative care patients? Support Care Cancer. 2024;32(8):491. 10.1007/s00520-024-08671-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Salm H, Doberschütz F, Hallmann F, Munzert P, Rahm J, Uhlig S, et al. How do quality of life (qol) and symptom burden evolve in inpatient palliative care (pc) patients following one week of care in a specialized palliative care unit (pcu)? A comparison of two groups, with one receiving specialized outpatient palliative care prior to admission. Cancers. 2024;16(8):1612. 10.3390/cancers16081612. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Cotogni P, Costantini E, Macchi G, Scarmozzino A. Symptom prevalence in palliative care patients admitted to the emergency department: are there differences between patients with cancer and non-cancer illness? Ann Palliat Med. 2025;14(6):558–69. 10.21037/apm-25-93. [DOI] [PubMed] [Google Scholar]
- 4.Wulandari BT, Rochmawati E. Effectiveness of dignity therapy on well-being among patients under palliative care: A systematic review and meta-analysis. Int J Nurs Stud. 2024;149:104624. 10.1016/j.ijnurstu.2023.104624. [DOI] [PubMed] [Google Scholar]
- 5.Rafaqat W, Syed AR, Ahmed IM, Hashmi S, Jabeen I, Rajwani S, et al. Impact of an outpatient palliative care consultation and symptom clusters in terminal patients at a tertiary care center in Pakistan. BMC Palliat Care. 2023;22(1):75. 10.1186/s12904-023-01195-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Bozkurt C, Yildirim Y. The effectiveness of reminiscence therapy on the symptom management, the life satisfaction, and the self-transcendence in palliative care patients: a randomized controlled trial. Support Care Cancer. 2024;32(7):431. 10.1007/s00520-024-08626-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Gestsdottir B, Hjaltadottir I, Gudmannsdottir GD, Jonsson PV, Gunnarsdottir S, Sigurðardottir V. Symptoms and functional status of palliative care patients in Iceland. Br J Nurs. 2015;24(9):478–83. 10.12968/bjon.2015.24.9.478. [DOI] [PubMed] [Google Scholar]
- 8.Rottländer D, Schmitz MT, Grabenhorst U, Weckbecker K, Just JM. Comparison of specialised outpatient palliative care in heart failure and cancer patients: a German cross-sectional study. BMJ Open. 2025;15(7):e096223. 10.1136/bmjopen-2024-096223. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Corvin J, Hoskinson Z, Mozolic-Staunton B, Hattingh L, Plumbridge-Jones R. The effects of virtual reality interventions on occupational participation and distress from symptoms in palliative care patients: A pilot study. Palliat Support Care. 2024;22(6):1865–72. 10.1017/S1478951524000245. [DOI] [PubMed] [Google Scholar]
- 10.Piamjariyakul U, Young S, Shafique S, Palmer N, Wang K. Spiritual well-being in appalachian family caregivers. Online J Rural Nurs Health Care. 2024;24(1):103–30. 10.14574/ojrnhc.v24i1.757. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Yoon SJ, Suh S-Y, Kim SH, Park J, Kim YJ, Kang B, et al. Spiritual well-being among palliative care patients with different religious affiliations: A multicenter korean study. J Pain Symptom Manage. 2018;56(6):893–901. 10.1016/j.jpainsymman.2018.09.001. [DOI] [PubMed] [Google Scholar]
- 12.Mendes BV, Donato SCT, Silva TLD, Penha RM, Jaman-Mewes P, Salvetti MG. Spiritual well-being, symptoms and performance of patients under palliative care. Rev Bras Enferm. 2023;76(2):e20220007. 10.1590/0034-7167-2022-0007. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Fang T, Zeng X, Zhang Y, Li P, Li Q, Zhong X, et al. The relationship between palliative care needs and spiritual well-being of maintenance hemodialysis individuals in China: A cross-sectional study. J Relig Health. 2025;64(3):2321–36. 10.1007/s10943-025-02326-2. [DOI] [PubMed] [Google Scholar]
- 14.Austin PD, Lee W, Keall R, Lovell MR. Efficacy of spiritual interventions in palliative care: An umbrella review of systematic reviews. Palliat Med. 2024;39(1):70–85. 10.1177/02692163241287650. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Hsueh EJ, Tsai SC, Lai JH, Lu CY, Huang TW, Gautama MSN. Spiritual well-being of terminally ill patients and next-of-kin caregivers in hospice care: A quantitative and qualitative approach. Palliat Support Care. 2025;23:e95. 10.1017/s1478951525000409. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Ziegler E, Hill J, Lieske B, Klein J, dem Knesebeck O, Kofahl C. Empowerment in cancer patients: Does peer support make a difference? A systematic review. Psycho-oncology. 2022;31(5):683–704. 10.1002/pon.5869. [DOI] [PubMed] [Google Scholar]
- 17.Gürdap Z, Cengiz Z. Patient empowerment in health care system: Opportunities and challenges. Artuklu Int J Health Sci. 2023;3(1):74–81. 10.58252/artukluder.1209933. [DOI] [Google Scholar]
- 18.Rabben J, Vivat B, Fossum M, Rohde GE. Shared decision-making in palliative cancer care: A systematic review and metasynthesis. Palliat Med. 2024;38(4):406–22. 10.1177/02692163241238384. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Smith CS, Henderson NL, Hendrix EK, Padalkar T, Huang CS, Dent DN, et al. Patient-Perceived benefits and limitations of standard of care remote symptom monitoring during cancer treatment. Cancer Control. 2024;31:10732748241297368. 10.1177/10732748241297368. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. The Edmonton Symptom Assessment System (ESAS): A simple method for the assessment of palliative care patients. J Palliat Care. 1991;7(2):6–9. 10.1177/08258597910070. [DOI] [PubMed] [Google Scholar]
- 21.Usta Yesilbalkan Ö, Ozkutuk N, Karadakovan A, Turgut T, Kazgan B. Validity and reliability of the Edmonton Symptom Assessment Scale in Turkish cancer patients. Turk J Cancer. 2008;38(2):62–7. [Google Scholar]
- 22.Aktürk Ü, Erci B, Araz M. Functional evaluation of treatment of chronic disease: Validity and reliability of the Turkish version of the Spiritual Well-Being Scale. Palliat Support Care. 2017;15(6):684–92. 10.1017/S1478951517000013. [DOI] [PubMed] [Google Scholar]
- 23.Small NL. Patient empowerment in long-term conditions: development and validation of a new measure. The University of Manchester (United Kingdom); 2012.
- 24.Kaya N, Işık O. Validity and reliability of the patient empowerment scale in Turkish. J Bus Sci. 2018;6(1):27–42. [Google Scholar]
- 25.Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed. Routledge; 2013.
- 26.Lai Q, Lu W, Xiao L, Luo Y, Yang Z, Miao J, et al. Experiences of the fatigue-pain-sleep disturbance symptom cluster among patients with lung cancer: A descriptive qualitative study. Asia Pac J Oncol Nurs. 2025;12:100823. 10.1016/j.apjon.2025.100823. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Yang H, Wu B, Hu R, Wang Y. Symptom experiences and self-management strategies of patients with haematological malignancy undergoing chemotherapy: A qualitative study. Asia Pac J Oncol Nurs. 2024;11(9):100563. 10.1016/j.apjon.2024.100563. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Redondo Elvira T, del Ibáñez C, Cruzado JA. Psychological well-being in palliative care: A systematic review. OMEGA - J Death Dying. 2021;87(2):377–400. 10.1177/00302228211019203. [DOI] [PubMed] [Google Scholar]
- 29.Wisesrith W, Sukcharoen P, Sripinkaew K. Spiritual Care Needs of Terminal Ill Cancer Patients. Asian Pac J Cancer Prev. 2021;22(12):3773–9. 10.31557/apjcp.2021.22.12.3773. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Sun V, Kim JY, Irish TL, Borneman T, Sidhu RK, Klein L, et al. Palliative care and spiritual well-being in lung cancer patients and family caregivers. Psycho-oncology. 2016;25(12):1448–55. 10.1002/pon.3987. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Pakenham K, Martin CL. Psychosocial palliative care: Patients’ preferred intervention medium, target domains, and well-being priorities. Palliat Support Care. 2024;22(4):742–50. 10.1017/S1478951522001535. [DOI] [PubMed] [Google Scholar]
- 32.Ping Z, He C, Liu S, Tan R, Hu D. Social support and demoralization among patients with lung cancer in China: A moderated mediation model of self-efficacy and symptom distress. Asia Pac J Oncol Nurs. 2025;12:100749. 10.1016/j.apjon.2025.100749. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Kowalczys A, Bohdan M, Wilkowska A, Pawłowska I, Pawłowski L, Janowiak P, et al. Comprehensive care for people living with heart failure and chronic obstructive pulmonary disease-Integration of palliative care with disease-specific care: From guidelines to practice. Front Cardiovasc Med. 2022;9:895495. 10.3389/fcvm.2022.895495. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Storey S, Luo X, Ren J, Huang K, Von Ah D. Symptom clusters in breast cancer survivors with and without type 2 diabetes over the cancer trajectory. Asia Pac J Oncol Nurs. 2024;11(1):100343. 10.1016/j.apjon.2023.100343. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Pomey MP, Schaad B, Lasserre-Moutet A, Böhme P, Jackson M. Towards a new integrated model for taking into account the experiential knowledge of people with chronic diseases, integrating mediation, therapeutic education and partnership: The expanded chronic care patient-professional partnership model. Health Expect. 2024;27(5):e70054. 10.1111/hex.70054. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Cardoso Barbosa H, de Queiroz Oliveira JA, Moreira da Costa J, de Melo Santos RP, Gonçalves Miranda L, de Carvalho Torres H, et al. Empowerment-oriented strategies to identify behavior change in patients with chronic diseases: An integrative review of the literature. Patient Educ Couns. 2021;104(4):689–702. 10.1016/j.pec.2021.01.011. [DOI] [PubMed] [Google Scholar]
- 37.Wang R, Zhou C, Wu Y, Sun M, Yang L, Ye X, et al. Patient empowerment and self-management behaviour of chronic disease patients: A moderated mediation model of self-efficacy and health locus of control. J Adv Nurs. 2022;78(4):1055–65. 10.1111/jan.15077. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data available on request from the authors.