Introduction

COVID-19, which emerged in China and has affected the whole world since its emergence, is a highly contagious epidemic disease that has caused panic and anxiety all over the world (Li et al., 2020). Due to its rapid spread and severe clinical courses, the virus has become a crisis all over the world in a short time (Bany Hamdan et al., 2020). COVID-19 has been reported to kill more than six million people and to make 530 million people sick since it emerged (World Health Organization (WHO), 2021). During this period, COVID-19 has shaken the basic sense of trust of individuals and not only has negatively affected the mental health of individuals but also has damaged their physical health (Bany Hamdan et al., 2020; Huang & Zhao, 2020).

Patients hospitalized during this period have experienced stress, anxiety, intense feelings of guilt, fear of death, loneliness, and helplessness due to uncertainty and obscurity resulting from the COVID-19 pandemic (Zandifar et al., 2020). In studies conducted on this issue, it has been determined that patients with COVID-19 suffer from post-traumatic stress disorder (PTSD), sleep disturbance, stress, anxiety and depression and that they have intense suicidal thoughts (Argüder et al., 2020; Bonazza et al., 2020; Brooks et al., 2020; Roth et al., 2020; Xiong et al., 2020). Coronavirus disease makes it difficult for individuals to feel psychologically good due to such problems it has created (Li et al., 2020). According to the definition of the concept of psychological well-being having emerged at this point, an individual has positive emotions rather than negative emotions, and his/her thoughts and expectations about his/her life are positive (Bulut & Dilmaç, 2018; Zümbül, 2019). In the literature, it is known that psychological well-being is negatively related to mental disorders (Ryff & Singer, 2008; Telef, 2013). That is why, the psychological well-being levels of inpatients diagnosed with COVID-19 are thought to have a negative effect.

A human being has a holistic structure with his or her physical, spiritual, social, cultural and spiritual aspects (Boztilki & Ardıç, 2017). For this reason, it is stated in the literature that the individual should be evaluated holistically in nursing care and nursing interventions should be planned considering all areas of nursing. In addition, it is reported that spirituality is an area that is overlooked in nursing care compared to other areas and that the spiritual needs of patients are not adequately met (Boztilki & Ardıç, 2017; Gönenç et al., 2016; Hawthorne & Gordon, 2020). Spirituality is defined as searching the meaning and purpose of life, inner peace and well-being (Güner, 2020). Spirituality and religion are two concepts confused with each other, but spirituality is a broader concept beyond religious beliefs. Although spirituality includes religious elements, it is considered as all actions that serve well-being of an individual (Çınar & Eti Aslan, 2017). Thanks to his or her spiritual values, an individual has the feelings of belief, hope, tolerance, optimism, inner peace, life satisfaction and is aware of the meaning and purpose of life (Güner, 2020). In studies conducted on this issue with patients diagnosed with cancer, it was determined that patients with a high level of spirituality had higher levels of life satisfaction, happiness and hope and lower levels of helplessness and depression, that rituals such as prayer and meditation were an important tool in coping with stress and difficulties, and that the high level of spirituality increased their quality of life (Albayrak & Kurt, 2016; Ata, 2018; Levine et al., 2009; Zamanian et al., 2015). It is reported that individuals' emotional reactions, behaviors and even disease prognosis are positively affected by their spirituality (Bany Hamdan et al., 2020).

Patients with COVID-19 can cope with the stress by taking strength from their spiritual values they have, and thus, they can protect their physical and mental health (Bany Hamdan et al., 2020; Boztilki & Ardıç, 2017). In light of this information, it is important to reveal the relationship between the spirituality orientation and psychological well-being of COVID-19 patients and to determine the factors affecting the psychological well-being of the patients. In the literature review, while there are many studies conducted with the general population during the pandemic (Kasapoğlu, 2020; Luo et al., 2020; Marotta et al., 2020), it is seen that the number of studies conducted with inpatients with a diagnosis of COVID-19 is limited (Argüder et al., 2020). Our search for studies conducted to investigate the spiritual orientation of inpatients with a diagnosis of COVID-19 in our country, Turkey, revealed a gap in Turkish literature. It is thought that this study will provide important and up-to-date data to the literature and will shed light on the nursing care and mental health interventions to be given to patients with COVID-19.

The primary aim in this study was to investigate the relationship between the spiritual orientation and psychological well-being levels of inpatients with a diagnosis of COVID-19. The secondary aim was to investigate the relationship between the sociodemographic characteristics of patients with COVID-19 and their spiritual orientation and psychological well-being levels.

Methods

Design

This descriptive, cross-sectional and correlational study was conducted between May 1, 2021, and July 15, 2021. It was reported using the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines (Vandenbrouche et al., 2007).

Participants

The study population consisted of patients with a diagnosis of COVID-19 who were hospitalized in the COVID-19 clinics of a hospital between May 1, 2021, and July 15, 2021, in Bayburt, a city located in the Eastern Black Sea Region of Turkey. It is known that the people in the eastern Anatolia region where the research was conducted have a high level of moral values, extended family structure and strong family ties. The study followed a convenience sampling approach. Of the inpatients in the population, 136 who volunteered to participate in the study were included in the study sample.

Inclusion criteria were as follows: having no serious mental health disorders, having a cellular phone next to her or him so she or he can participate in the survey online, being ≥ 18 years old, and volunteering to participate in study.

Data Collection

The study data were collected by the researcher between May and July 2021. In order to minimize face-to-face interaction and contact with patients, a link address was shared with the patients and the data were collected via an online questionnaire (Google Forms). The survey link was shared with the social media of the patients diagnosed with COVID-19, and the data were collected through this online survey. Before starting to fill out the forms, all participants were informed about the study, and an explanation was given that their personal information would be kept confidential and that their privacy would be taken care of. Afterward, verbal and written consents were obtained from the patients who volunteered to participate in the study. Because the scales were completed online and it was compulsory to answer each question, there were no missing data. In the online forms, settings were arranged so that each patient answered the questions only once.

Data Measurement

To collect the study data, the Personal Information Form, Spiritual Orientation Scale (SOS), and Psychological Well-Being Scale (PWBS) were used.

Personal Information Form

In the present study, a personal information form developed by the researchers in line with the literature was used to collect the data on the sociodemographic characteristics and health status of the participants. The form consists of two parts: the sociodemographic data section comprises eight items questioning the participants’ characteristics such as age, sex, educational status, marital status and place of residence. In the health status section, there are 12 items questioning the number of the days a patient is hospitalized, whether the patient has been diagnosed with COVID-19 before, or whether he or she has been hospitalized with the diagnosis of COVID-19 before.

Spiritual Orientation Scale (SOS)

There are 16 items in the scale developed by Kasapoğlu (2016) to evaluate the spirituality of individuals. The scale, which consists of items such as 'Prayer/meditation is an important part of my spiritual life', is in a seven-point Likert type ranging from 1 (strongly disagree) to 7 (strongly agree). The minimum and maximum possible scores to be obtained from the overall scale are 16 and 112, respectively. The higher the score obtained from the scale is the higher the level of spiritual orientation is. The Cronbach's alpha value of the scale was 0.87 in Kasapoğlu’s study and 0.93 in the present study.

Psychological Well-Being Scale (PWBS)

There are 8 items in the scale developed by Diener et al. (2009) to assess the psychological well-being of individuals. The scale, which consists of items such as 'I lead a purposeful and meaningful life', is in a seven-point Likert type scale ranging from 1 (strongly disagree) to 7 (strongly agree). The minimum and maximum possible scores to be obtained from the overall scale are 8 and 56, respectively. The higher the score obtained from the scale is, the higher the level psychological well-being of the patient is. The scale was adapted into Turkish by Telef (2013). The Cronbach’s alpha coefficient of the scale was 0.80 in the reliability study of the scale and 0.84 in the present study.

Ethical Considerations

Before the study was conducted, ethics committee approval was obtained from the Scientific Research and Publication Ethics Committee of a university (dated April 27, 2021: numbered 10,761). Institutional permission was obtained from the management of the hospital where the study was to be conducted. The patients were informed about the study verbally and in writing, and their written informed consent was obtained online.

Data Analyses

The data were analyzed using the IBM SPSS Statistics version 22.0 (IBM Corp, Armonk, NY). Data are accepted to have normal distribution if the skewness and kurtosis values are between -2 and + 2 (George & Mallery, 2010). The data have normal distribution except for economic status, person supporting during illness, perception of disease status. Descriptive data were analyzed using numbers, percentages, arithmetic mean, and standard deviation. Mann–Whitney U test, Kruskal–Wallis test, independent t test, ANOVA were used in the comparison of the scale items; Pearson correlation analysis and regression analysis were used to determine the relationship between the scales. In the simple linear regression analysis, a model was created in line with the primary aim, and the effect of spirituality on psychological well-being was examined. Therefore, psychological well-being was taken as the dependent variable. Correlation coefficient ranging between 0.00 and 0.25 was considered as very weak, between 0.26 and 0.49 as weak, between 0.50 and 0.69 as moderate, between 0.70 and 0.89 as severe, between 0.90 and 1.00 as very severe (Coşansu, 2014). The Cronbach's alpha coefficient was used to calculate the reliability coefficients of the scales. P values less than 0.05 were considered statistically significant.

Findings

The mean age of the participating patients was 56.7 ± 6.84 years. Of them, 55.1% were female, 50.7% were > 65 years old, 78.7% were married, 49.3% were primary/secondary school graduates, 39% did not work at any paid job and 85.3% perceived their economic status as moderate (Table 1).

Table 1 Sociodemographic Characteristics of the Patients (n = 136)
Full size table

The participating patients 69.9% were hospitalized for 0–7 days, 54.4% had a chronic disease, none had been diagnosed with COVID-19 before, and none smoked or drank alcohol. Of them, 82.4% had not lost a loved one due to COVID-19, 89% were supported by their spouse and child, 92.6% perceived their illness as a disease requiring long-term treatment (Table 2).

Table 2 Distribution of the Patients Health-Related Characteristics (n = 136)
Full size table

The mean scores the participants obtained from the Spiritual Orientation Scale and Psychological Well-Being Scale were 101.33 ± 9.28 and 46.87 ± 4.05, respectively (Table 3). The comparison of their mean scores for the Spiritual Orientation Scale and Psychological Well-Being Scale revealed a weak positive correlation between them (r = 0.335, p < 0.001). In the regression analysis, it was determined that spirituality had a positive and 11.2% effect on the level of psychological well-being, which was included in the model as a dependent variable (R2 = 0.112, B = 0.175, p < 0.001) (Table 4).

Table 3 Mean Spiritual Orientation Scale and Psychological Well-Being Scale Scores of the Patients (n = 136)
Full size table
Table 4 Regression analysis of and correlation between Spiritual Orientation Scale and Psychological Well-Being Scale
Full size table

The comparison of the mean scores the participants obtained from Spiritual Orientation Scale in terms of their gender demonstrated a statistically significant difference between the groups (p < 0.05). Women spirituality levels were higher than men. According to the comparison of the mean scores obtained from the Psychological Well-Being Scale in terms of the variables such as gender, age range, the number of hospitalization days, presence of a chronic disease there was a statistically significant difference between the groups (p < 0.05). Psychological well-being levels of male patients were higher than female patients; it was determined that the psychological well-being levels of the patients between the ages of 35–50 were higher than the patients over the age of 65. Psychological well-being levels of patients hospitalized for 0–7 days were higher than those hospitalized for 8–14 days; it was found that patients who do not have chronic diseases have higher levels of psychological well-being than those with chronic diseases (Table 5).

Table 5 Comparison of the mean scores the patients obtained from the Spiritual Orientation Scale and Psychological Well-Being Scale in terms of their sociodemographic characteristics
Full size table

Discussion

Discussing the Levels of Spiritual Orientation and Psychological Well-Being and the Relationship Between Them

In the present study, conducted to determine the relationship between the spiritual orientation and psychological well-being levels of inpatients with COVID-19, it was found that the participants had high levels of spirituality. While the participants’ mean score for the spirituality was moderate in Prieto-Ursua and Jodar’s study (2020) conducted with the general population during the pandemic, it was high in Lucchetti et al.’s study (2020) conducted with quarantined individuals. In Gürsu and Bayındır’s study (2021), conducted with healthcare workers who had the COVID-19 disease in our country, Turkey, it was determined that the participants’ spirituality levels were high and that their spirituality levels increased even more after they were diagnosed with the disease. This is probably due to the fact that individuals who went through a traumatic process such as COVID-19 turn to their spiritual values in order to cope with this difficult process. It has been reported that individuals experience some changes in their philosophy of life after traumatic processes, and they turn toward spirituality and religion more and determine their priorities in life (Prieto-Ursúa & Jódar, 2020; Stallard et al., 2021). In addition, since the studies are carried out in different cultures and regions, this difference is thought to lead to differences in spirituality levels of individuals. In the present study, the spirituality levels of the participants were high. Our country is a Muslim country, and it is thought that this has a great share in the high level of spirituality of individuals.

In this study, it was observed that the patients’ psychological well-being levels were high. In their study conducted with the general population in Italy during the pandemic, Marotta et al. (2020) reported that the psychological well-being levels of the participants were low, which suggests that their levels were negatively affected by the pandemic. In Wang et al.’s study (2020), conducted with the general population in China the psychological well-being levels of the individuals were moderate and they highly suffered from symptoms of depression, anxiety and stress. In their meta-analysis, Luo et al. (2020) determined that the psychological well-being levels of individuals were negatively affected by the pandemic and that they moderately experienced depression and anxiety. In the aforementioned studies conducted in different cultures and regions, the findings related to psychological well-being levels yielded different results, which may be due to the fact that these countries were affected by the COVID-19 pandemic at different levels. While the number of cases and deaths in some countries is very high, it is low in some countries. Policies and restrictions implemented by countries during the pandemic have changed from one country to another, and accordingly negative effects of pandemic on the mental states of societies have been different (Bany Hamdan et al., 2020; Li et al., 2020). In addition, individual factors (psychological resilience, coping skills, social support, etc.) can also be said to have affected the findings.

The comparison of the relationship between the mean scores the participants obtained from the SOS and PWBS demonstrated a weak positive correlation between them. According to this finding, as the spirituality levels of the participants with COVID-19 increased so did their psychological well-being levels. In their study conducted with the general population in Turkey during the pandemic, Kasapoğlu (2020) determined that spirituality increased the psychological resilience level and reduced the anxiety level. In their study conducted in Spain, Prieto-Ursua and Jodar (2020) determined that individuals with high levels of spirituality during the pandemic had higher traumatic growth levels. In their study, Coppola et al. (2021) investigated the factors affecting the psychological well-being of individuals during the pandemic and found that individuals with strong spirituality had higher psychological well-being levels. Coppola et al. (2021) also reported that individuals with strong spirituality were in better condition not only spiritually, but also physically and socially. In his systematic review, Fardin (2020) stated that spirituality was a protective factor for the mental health of individuals in crisis and improved their psychological well-being. In several studies, it has been indicated that spirituality is an effective coping tool for individuals in a traumatic process such as the pandemic. Accordingly, individuals with a high level of spirituality are less affected psychologically, and they maintain their psychological well-being in crisis. The results of the present study suggest that individuals diagnosed with the disease can protect their physical and mental health by taking strength from spiritual methods in order to cope with the stress they suffer. At this point, it is important for nurses not only to provide care for physiological symptoms, but also to support their patients spiritually and to plan nursing interventions from a holistic perspective (Bahramnezhad & Asgari, 2021).

Discussing the Relationship Between the Sociodemographic Characteristics of Patients with COVID-19 and Their Spiritual Orientation and Psychological Well-Being Levels

The female patients who participated in the present study had higher spiritual orientation levels but lower psychological well-being levels than did the male patients. In Rababa et al.’s (2021) study, the female participants had higher spirituality levels but lower psychological well-being levels than did the male participants. In their study (2020), Wang et al. determined that the mental health of women was affected more negatively than was that of the men during the pandemic. According to the findings of the present study, the female patients’ mental states were affected more than were those of the male patients, and they used spirituality as a coping tool in this regard. In the family structure in Turkey, women assume more responsibilities and because they cannot fulfill these roles and responsibilities during the disease process, they may have been affected psychologically negatively more. It is also known that women are in the risk group for mental illnesses (Dovbysh & Kiseleva, 2020). It was also found in the present study that the women's mental health was affected more negatively than was that of the men when they were faced with a serious disease like COVID-19 affecting the individual physically and mentally.

In the present study, psychological well-being levels of the participants aged 35–50 were higher than were those of the participants over the age of 65. In their systematic review, Xiong et al. (2020) reported that among the risk factors making a person more vulnerable to mental illnesses during the COVID-19 period was the person’s being under the age of 40. These findings in the literature are not consistent with the finding of the present study because in the present study, the participants over the age of 65 were affected by the pandemic psychologically adversely. This result is thought to stem from the fact that individuals over the age of 65 were the group isolated first during the pandemic in Turkey, that they were isolated for a long time and that they were more exposed to ageism during this period (Ekici, 2020). In addition, the knowledge that older individuals are more affected by the COVID-19 and that they were affected by the disease more severely may have affected mental health of older individuals in our country negatively. Therefore, this finding suggests that the mental states of the older participants diagnosed with COVID-19 should be evaluated more carefully and that they should be supported while they are given nursing care.

In the present study, psychological well-being levels of the participants hospitalized for 0–7 days were higher than were those of the participants hospitalized for 8–14 days. In their study, Argüder et al. (2020) determined that as the length of hospitalization of the patients hospitalized with the diagnosis of COVID-19 increased so did their depression and anxiety levels. In the present study, as in the literature, psychological well-being levels of the participants hospitalized for a long time were negatively affected. When the study data were collected, the third wave of the pandemic was reigning in our country, Turkey. The high severity of the disease in this period may have caused patients to be hospitalized for longer periods. Therefore, the mental health of the patients may have been negatively affected. Evaluation of the patients hospitalized for a long time due to COVID-19 in terms of mental disorders, and performing screenings as early as possible are gaining importance.

It was determined that the participants without a chronic disease had higher levels of psychological well-being than did those with chronic disease. In several studies (Luo et al., 2020; Xiong et al., 2020), it was determined that individuals with chronic diseases such as hypertension, diabetes, cancer experienced higher levels of stress, anxiety and depression during the pandemic. In the present study, the mental states of patients with COVID-19 having chronic diseases were adversely affected. Having a chronic disease was stated as a risk factor for COVID-19, which may have affected the mental status of the patients more adversely. At this point, trainings on the process and treatment of the disease can be planned in order to reduce the stress and anxiety levels of the patients. In addition, in this process, patients can be encouraged to gain effective coping skills. With the holistic nursing approach, the mental problems experienced by patients with COVID-19 during this period can be prevented, and the treatment process and disease prognosis can be changed for the better.

Strength and Limitations

In this process, inpatients diagnosed with COVID-19 make up the group difficult to work with. It is difficult to reach this group and collect data due to the symptoms of the patients and the contagious nature of the disease. In the literature, the number of studies conducted with this patient group is limited. Therefore, the present study is of importance because it was conducted with hospitalized patients with a diagnosis of COVID-19. The results of the study show that spirituality affects psychological well-being and draw attention to both spiritual care overlooked in the provision of care and the care of patients' physical and mental symptoms.

One of the limitations of the study is that the patients were selected from the population using the non-probability accidental sampling method. Thus, the results of the study are applicable only to the patients surveyed, and they cannot be generalized to all patients with COVID-19. This is a cross-sectional study, and the cross-sectional nature of this study prohibits any speculations about causation or direction of effect. In addition, the fact that the sample is mostly in the age range of 65 and over and there is no pilot study can be added to the limitations. Another limitation of this study is that since the study was conducted online, the patients who did not use social media tools could not be contacted. The measurements obtained from the study were limited to the scales used and the participants’ self-reports.

Conclusion and Recommendations

In the present study, a positive and significant relationship was determined between the spiritual orientation and psychological well-being levels of the inpatients diagnosed with COVID-19. Risk factors for psychological well-being during the pandemic were determined as follows: female gender, being over 65 years of age, having a chronic disease and being hospitalized for a long time. While providing nursing care to people in these at-risk groups, their mental status should be evaluated at certain intervals, and screenings should be carried out as early as possible. It may also be recommended that COVID-19 clinics should be included in consultation–liaison psychiatry services and that psychiatric interventions should be made early. It is understood that nurses should provide care in accordance with the individual needs of the patients without judging their religion, beliefs and spiritual values. Nurses should take patients’ spiritual values into account and encourage them to engage in activities such as meeting their families and friends online, performing activities appropriate to their religious beliefs, praying, writing down their beliefs, carrying auspicious objects (evil eye charm, etc.), and meditation. It is thought that the holistic nursing care given to the patients by considering the spiritual dimension will positively affect their hopes in life and mental health and that even their physical health will be better. It is also recommended that the spirituality, which is ignored in nursing care, should be emphasized during basic nursing education and in-service trainings in hospitals.