Relationships Among Spiritual Well-being, Adjustment, and Quality of Life in Patients With a Stoma: A Cross-sectional, Descriptive Study

Individual spiritual preferences and adjustment to a stoma may affect quality of life. Purpose: This study aimed to investigate the relationship among and the factors that influence spiritual well-being, adjustment to a stoma, and quality of life in patients with a stoma. Methods: A cross-sectional, descriptive study was conducted over 6 months among outpatients with a stoma recruited from general surgery and enterostomal therapy clinics of a university hospital in Turkey. Turkish-speaking patients who were at least 18 years of age and had a colostomy or ileostomy for at least 2 months were eligible to participate. Participants independently (or with researcher help if necessary) completed the Sociodemographic Characteristics Form; the 12-item Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-Sp) that utilized 5-point, Likert-style responses to items regarding meaning, peace, and faith (score range 0–48; higher scores indicate more spiritual well-being); the 23-item Ostomy Adjustment Scale that utilized 5-point, Likert-style responses to items regarding acceptance worry, social adjustment, and anger (score range 0–92; higher scores indicate better adjustment); and the 21-item Stoma Quality of Life Scale that used a combination of scoring methods (score range 0–100; higher scores imply better quality of life) and Likert-style questions. Data were transferred without patient names from the questionnaires directly into a software program for analysis. Descriptive statistics, correlation, and hierarchical regression analyses were applied. Results: Of the 95 participants (52 [54.7%] men; mean participant age 56.54 ± 13.74 years), mean scores were 31.66 ± 7.39 for spiritual well-being, 51.73 ± 12.28 for adjustment to a stoma, and 55.27 ± 16.45 for quality of life. A statistically significant difference was found between the mean spiritual well-being and quality-of-life (r = 0.525, P <.001) and adjustment to a stoma (r = .549, P <.001) scores, and a significant relationship was noted between the mean quality-of-life and adjustment scores (r = 0.698, P <.001). Stoma adjustment and quality of life significantly correlated with the meaning and peace subscales of FACIT-Sp (P <.001). No correlation was found between faith or stoma adjustment and quality of life. Hierarchical regression analysis showed the most significant factors affecting quality of life were adjustment to a stoma (β = .541) and spiritual well-being (β = .190). Conclusion: Adjustment and spirituality are important quality-of-life factors in patients with a stoma. Clinical assessments and practices should include the meaning and peace aspects of spiritual well-being and how well the patient is adjusting to the stoma. Well-designed randomized controlled studies that evaluate the impact of the spiritual dimension of nursing care on patient outcomes as well as the effect of spiritual well-being on adjustment to stoma are suggested.

The most common indications for creating a colostomy or ileostomy are colorectal cancer, inflammatory bowel disease, or trauma.¹ Approximately 100 000 people have been reported to undergo stoma surgery every year, and ~1 million people in the United States have fecal or urinary diversions.²

Qualitative³ and phenomenological⁴ studies and a systematic review of the literature⁵ have shown individuals with a stoma can experience many physiological, psychological, and social problems after the surgery. A systematic review of the literature⁵ and multisite cross-sectional⁶ and prospective⁷ studies have found changes in the physical appearance and functions of the individual with a stoma may affect self-esteem and body image and cause psychological and social problems, making it difficult for individuals to adapt to their stomas, preventing them from engaging in daily life activities and reducing their quality of life. Hu et al⁸ conducted a cross-sectional study among Chinese patients with a colostomy from 5 hospitals (N = 129) and reported 63.6% of individuals with a stoma had moderate and 33.3% had low levels of adjustment to the stoma. These authors further reported that poor stoma care self-efficacy, lack of social support, poor acceptance of the stoma by the partner, antipathy for the stoma, and fear of bad smells affect adjustment to the stoma. 

About one quarter of the world’s population is Muslim⁹; in Turkey, 99.2% of the population is Muslim.¹⁰ According to a systematic review of 12 relevant publications,¹¹ Muslims are one of the groups most affected by having a stoma. Muslim communities place high value on secrecy regarding intestinal and bladder emptying. Thus, gas and waste matter released involuntarily from a stoma can contribute to the belief that a stoma makes certain acts of worship invalid. This may affect religious practices. In addition, this perspective makes stoma acceptance and adjustment difficult and decreases quality of life.^11,12 Quality of life among Muslims with a stoma has been found to be lower than that of Muslims who do not have a stoma.¹¹ 

Adjustment to a stoma and quality of life are affected not only by religion, but also by spirituality, which has a broader meaning and includes the concept of religion.^13-15 Spirituality has been described in a qualitative-quantitative (mixed) study,¹³ a descriptive exploratory¹⁶ study, and an investigation of cancer survivorship¹⁷ as the effort of individuals to understand and accept their relationships with themselves and other people, their places in the world, and the value of life. Spiritual well-being is another aspect that must be taken into consideration and can be conceptualized as a measurement of spirituality or the state of spiritual health. In addition, in the context of cancer, spiritual well-being also is defined as “the ability to keep hopes alive and making sense of the cancer experience.”¹⁶ 

 Spiritual well-being is comprised of 2 dimensions: horizontal (existential) and vertical (religious). Existential, spiritual well-being includes the feelings of hope, inner peace, and meaning in life, whereas the religious dimension contains a feeling of comfort originating from being connected to a divine and eternal higher power.^14,17 Research^13,17 has revealed the existential dimension is more influential than the religious dimension in terms of decreasing uncertainty and increasing positive mood, social adaptation, and quality of life. The descriptive, cross-sectional study on Taiwanese patients with colorectal cancer and a colostomy (N = 45) by Li et al¹⁴ reported existential spiritual well-being is an important factor in psychosocial adjustment after colostomy surgery. Reviews of the literature^18,19 found the religious dimension may be a factor in coping and adapting to diseases and in increasing quality of life. 

Living with and adjusting to a stoma is time-consuming.⁷ Spiritual well-being has been shown in qualitative-quantitative (mixed)^13,20 and descriptive exploratory¹⁴ studies to have a long-lasting effect from diagnosis to the weeks or months after surgery. Therefore, evaluating spiritual well-being, quality of life, and adjustment to a stoma and understanding the relationships among these factors are important to understanding the experiences of the individuals who have undergone permanent physical changes because of a stoma.^14,21 

A patient’s spiritual preferences are an important part of the holistic nursing approach. No study examining the effect of a stoma on spirituality in Turkey was found in the literature, although such studies conducted abroad have evaluated the spiritual well-being of individuals with colorectal cancer.^14,16,22 No studies addressing the relationship among or the factors affecting spiritual well-being, adjustment to a stoma, and quality of life of individuals with stomas were found in the literature. The aim of this study was to examine the relationship among and to identify the factors that influence spiritual well-being, adjustment to stoma, and quality of life in individuals with stomas. 

Participants. This cross-sectional, descriptive study comprised patients recruited from general surgery and enterostomal therapy clinics of a university hospital in Turkey who received care between December 15, 2017, and June 25, 2018. Persons at least 18 years of age who had a colostomy or ileostomy for at least 2 months and who could read and/or speak Turkish were included in the study. Patients with mental disorders, no ability to communicate orally, and who did not want to participate in the study were excluded. 

Sample size. The sample size of the present study was determined by conducting a power analysis. Type 1 error of 0.05 and Type 2 error of 0.20 (80%) were based on the G-Power statistical program (Franz Faul; University Kiel, Germany). Regression analysis results from the study conducted by Li et al¹⁴ were used. The necessary sample size was determined to be 16; however, the study researcher and analyst decided the sample group should include at least 95 individuals, because a higher number of participants would more clearly facilitate determining the relationship between the correlation and regression analyses. For the post power analysis, the power obtained by using the correlation coefficients in the G-Power 3.0.10 statistical program was determined to be 99%. 

Data collection tools. Data were collected using the Sociodemographic Characteristics Form, the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-Sp), the Ostomy Adjustment Scale (OAS), and the Stoma Quality of Life Scale (SQOL). 

Sociodemographic Characteristics Information Form. This form was developed by the researchers in agreement with the literature^{7,13,14,23-25} and included items on age, gender, marital status, education level, chronic disease, time of stoma placement, reason for stoma placement, whether the stoma site was marked preoperatively, type of stoma (colostomy/ileostomy), any problem hindering the care of the stoma (eg, visual impairment, comorbidity- and age-related poor dexterity), provision of radiotherapy or chemotherapy, stomal or peristomal complications, the frequency of performing religious practices, and self-rated disease severity (how participants perceived the severity of their disease). All questions were closed-ended with the exception of the perception of illness severity, which was rated on a Likert-type scale, where 1 = a little severe, 2 = severe, and 3 = very severe.

 FACIT-Sp. The FACIT-Sp was developed by Peterman et al²⁶ in 2002 to assess the spiritual well-being of individuals with cancer and chronic illness. The scale consists of 12 items with 3 subscales (meaning, peace, and faith). Participants responded to questions using a 5-point Likert-type scale, where 0 = never and 4 = always. The total score for each subscale ranges from 0 to 16, with a total score between 0 and 48. A validity and reliability study of the Turkish version of the scale was conducted by Aktürk et al²⁷ in 2017; the Cronbach α value was 0.87. The Cronbach α value of the present study was 0.817. 

OAS. The OAS is a 23-item self-assessment tool developed by Simmons et al²⁵ to determine individual adjustment levels to a stoma. The scale consists of 4 subscales on acceptance, anxiety/worry, social adjustment, and anger; participants respond using a 5-item Likert-type scale, where 4 = strongly agree, 3 = agree, 2 = neutral, 1 = disagree, and 0 = strongly disagree. Higher scores indicate better adjustment. A validity and reliability study of the Turkish version by Karadag et al²⁸ reported a Cronbach α value of 0.87. The Cronbach α value in the present study was 0.845.

SQOL. The SQOL is a 21-item scale developed by Baxter et al²⁹ to measure the quality of life of individuals with stomas. The Turkish version of the scale comprises 19 items. The first 2 items are related to the individual’s general satisfaction with life rated on a scale of 0 (dissatisfaction) to 100 (absolute satisfaction); the remaining 17 items involve 5-point, Likert-type responses, where 1 = never, 2 = seldom, 3 = occasionally, 4 = frequently, and 5 = always within 3 subscales: work/social function, sexuality/body image, and stoma function. A validity and reliability study of the Turkish version performed by Karadag et al³⁰ found the Cronbach α value was 0.87. The Cronbach α value in the present study was 0.808. 

Study procedure. Data were collected during face-to-face interviews using paper/pencil instruments. Potential participants who met the criteria for inclusion were provided information about the study when they visited their physician in clinic. After their written and verbal consent was obtained, participants were asked to complete the forms related to the research. The researcher was available during data collection to answer any questions regarding the forms. If patients were unable to read the instruments, the researcher read the questions. Form completion took approximately 20 to 30 minutes. Data collection procedures were conceived to preserve participant confidentiality. The interviews were conducted in a quiet and private room. Confidentiality was protected; only the researchers had access to the data.

Ethical considerations. Written consent of the authors who prepared the scales to be used in the study was obtained. After researchers informed participants about the aim and details of the study, participants completed a form stating that they agreed to participate. The administration of the hospital where the study would be carried out and the Ethics Committee for Non-Interventional Investigations approved the study (Date: September 28, 2017, Protocol no: 3677-GOA). 

Data collection and analysis. Data were entered from the questionnaires without names directly into SPSS, version 22.0 (IBM Corp, Armonk, NY); the databases and analyses were checked by the investigators and quality analysts. Data were analyzed using Kolmogorov Smirnov, orthographic skew images, and histograms to examine whether continuous numerical variables had normal distributions. Descriptive statistics involving mean and standard deviation were used for normally distributed variables. 

Percentages and descriptive statistics were used to evaluate the sociodemographic characteristics of the participants and information about their stomas. The relationships among the scales were assessed using bivariate Pearson and Spearman correlation analyses. Student’s t test and Mann-Whitney U and Kruskal-Wallis analyses were used in independent groups to examine the relationship between the sociodemographic characteristics and descriptive information about patients’ stomas and their quality of life as well as to compare their stoma adjustment scores and mean scores of well-being. Hierarchical regression analysis was performed during the assessment of patient sociodemographic characteristics and stoma information to determine whether the patient adjustment to stoma and spiritual well-being had an effect on quality of life. Demographic variables to be taken into the model were decided in accordance with the literature^7,14,23-25 and by considering univariate analyses. When a linear relationship was found to exist only between age, gender, and problems hindering stoma care and quality of life, these variables also were analyzed. The analysis was performed in 3 steps: the information about individuals’ sociodemographic characteristics and stomas was included in the model, then adjustment to stoma and spiritual well-being were included, and finally the hierarchical regression analysis was conducted. 

Of the 95 individuals with stomas who participated in the study (52 [54.7%] men, mean age of all participants 56.54 ± 13.74 years), 71 (74.7%) were married, 26 (27.4%) were graduates of a university, and 55 (57.9%) had no chronic disease. Participants had stomas for a mean of 14.87 ± 22.39 months, and 73 (76.8%) underwent stoma placement because of colorectal cancer. The majority of the participants (73, 76.8%) had undergone planned surgery, 43 (45.3%) had their stoma site marked preoperatively, and 50 (52.6%) had received radiotherapy or chemotherapy. Among the participants, 57 (60%) had colostomies and 38 (40%) had permanent stomas. Most (77, 81.1%) did not describe any obstacle to ostomy care. Twenty-four (24, 27.9%) practiced their religious rituals regularly (eg, salat, an act of religious worship that is accompanied with special bodily movements and prayers,¹² is practiced 5 times daily and/or individuals pray and read the Quran every day). Thirty-eight (38, 41.3%) and 34 (37%) perceived their diseases as severe or very severe, respectively (see Table 1).

The mean scores for spiritual well-being, adjustment to the stoma, and quality of life were 31.66 ± 7.39, 51.73 ± 12.28, and 55.27 ± 16.45, respectively, representing moderate levels of spiritual well-being, adjustment to stoma, and quality of life (see Table 2). 

No statistically significant relationships were found among age and adjustment to stoma, quality of life, spiritual well-being, or its subscales (P >.05) (see Table 3). A moderate, positive, statistically significant difference was noted between the mean scores of adjustment to stoma and spiritual well-being (r = 0.549; P <.001) and between spiritual well-being and quality-of-life scores (r = .525; P <.001); a high, positive, statistically significant relationship was noted between adjustment to stoma and quality-of-life scores (r = 0.698; P <.001) (see Table 3). 

Using the FACIT-Sp, a moderate, positive, statistically significant relationship was found between meaning and stoma adjustment (r = 0.602; P <.001), between meaning and quality of life (r = 0.566; P <.001), between peace and stoma adjustment (r = 0.611; P <.001), and between peace and quality of life (r = 0.584; P <.001). No statistically significant relationship was found between faith and stoma adjustment (r = 0.081; P >.05) or between faith and quality of life (r = 0.138; P >.05) (see Table 3).

A hierarchical linear regression analysis was performed to investigate the effects of age, gender, and obstacles to stoma care on quality of life. When age, gender, and obstacles to stoma care were included, they significantly predicted quality of life (F [3.91] = 5.380; P = .002; adjusted R² = 0.123). However, as indicated by the R² value, only 12% of the variance in quality of life could be predicted by gender and obstacles to stoma care. When stoma adjustment was added, it significantly predicted quality of life (R² change = 0.376; F [1.90] = 25.009; P = .000), and 50% of the variance in quality of life could be predicted. In the third step, when the spiritual well-being variable was added, the estimation increased by 2% (R² change = 0.024). The entire group of variables significantly predicted quality of life (F [1.89] = 21.756; P = .000; adjusted R² = 0.525). This is a large effect according to Cohen.³¹ The beta weights presented in Table 4 suggested stoma adjustment and spiritual well-being are most useful in predicting quality of life in ostomy patients.

Although stomas increase patient survival rates, the physical, psychological, and social problems patients experience can decrease their quality of life.^6,20,31,32 Specifically, a patient’s adjustment to a stoma and his/her spirituality are reported to be factors that can directly or indirectly affect quality of life.^6,17,33 The mean quality-of-life score in the present study is in line with previous research from individuals in the US and China.^6,20 Although the adjustment to a stoma score of participants in the present study is similar to previous studies conducted in China⁷ and Turkey,⁸ it is higher than the scores of individuals with stomas living in China6 and Nepal.²⁴ The mean spiritual well-being score in the present study agreed with results of studies conducted in Taiwan (patients with a colostomy and colorectal cancer) and Australia (patients with cancer)^4,14; however, it was lower than scores of individuals with lung and colorectal cancer.¹⁶ As Clay et al¹⁶ noted, the results may have been different because adjustment to a stoma and spirituality were influenced by cultural and regional factors. 

Spirituality is an important component in coping with cancer, in individual adaption to life after treatment, and in assessing quality of life in situations that lead to serious changes such as undergoing stoma creation.¹⁶ The present study revealed a moderate, positive, significant relationship between spiritual well-being and quality of life and showed that as spiritual well-being increased, quality of life increased as well. Within this context, the data obtained in this study are in line with data in the literature.^13,17,22 Because nurses are important members of the health care team and play an important role in increasing the quality of life of individuals with stomas,³ developing spiritual well-being via nursing practices can play a significant role in improving the quality of life of these patients. 

 Although a sense of comfort and confidence stemming from religious and spiritual beliefs can be important factors for emotional, physical, and social well-being, a sense of peace and perception of life have been found to be more important for quality of life.^13,17,22 A moderate positive relationship was reported between the subscales of the existential dimension of spiritual well-being (the meaning and peace subscales) and quality of life in the present study. However, no relationship was noted between the religious dimension (the faith subscale) and quality of life. Other researchers have reported that spiritual well-being had a stronger impact than religious belief on individuals with serious diseases (including those with cancer), and feelings of meaning and peace had a stronger relationship than religious belief with quality of life.^4,13,17,22 The existential dimension is not a stable factor because it has been shown in an exploratory study³⁴ and in a randomized controlled trial³⁵ to have the capacity for improvement through structural interventions such as psychological therapy programs or the use of meaning-making coping strategies in individuals with stomas. The data obtained in this study are important in this respect. On the other hand, some studies^18,19 assert that the religious dimension is an important component of quality of life and that a higher religious dimension is associated with a better quality of life; however, the high scores of the religious dimension obtained in those studies could have resulted from the fact that the participants were apparently at the end of their lives, they believed their life-threatening disease would not change, and they attributed this situation to the will of a higher power. A cross-sectional, descriptive study in Turkey by Akgül and Karadag¹² to determine the impact of colostomy and ileostomy on Muslim patients’ (N = 150) acts of worship found mandatory Islamic practices were performed less by individuals with stomas after their ostomy surgeries. The systematic review by Iqbal et al¹¹ asserted that Muslims with ostomies had lower quality of life and that psychological factors, social isolation, lack of information about complications, and sexual dysfunction, as well as a decrease in religious practices, were factors in this finding. 

This study also identified a moderate positive relationship between spiritual well-being and adjustment to the stoma and that the greater the spiritual well-being, the better the adjustment. These results parallel the findings of a study conducted among patients with colorectal cancer and colostomy.¹⁴ Although the meaning and peace subscales of spiritual well-being had a moderate positive relationship with adjustment to a stoma, no relationship was found with the faith subscale in the present study. The descriptive, cross-sectional study conducted by Li et al¹⁴ among Taiwanese patients with colorectal cancer and a colostomy (N = 45) found spirituality is related to psychosocial adjustment in patients with colorectal cancer stomas, but the religious dimension did not affect psychosocial adjustment. However, a cross-sectional qualitative study³⁶ conducted among colorectal cancer patients in New Zealand (N = 20) and Iran (N = 20) found the religious dimension can be related to psychosocial adjustment. Spirituality can be affected by cultural factors, explaining the difference in results. It can be argued, based on the current results and the literature, that spirituality facilitates adjustment to a stoma by increasing the meaning of life through deeper understanding and aim or desire to live, thus becoming influential in the healing of the disease. 

According to a descriptive study,⁴ increasing spiritual well-being and psychosocial adjustment also affects patient quality of life. The present study found a high positive and statistically important relationship between the mean adjustment to a stoma and quality-of-life scores and that quality of life increased along with adjustment. These results are supported in the literature.^6,32 In this context, adjustment to a stoma and quality of life are related concepts, and adjustment to a stoma can increase quality of life.⁶ 

In the present study, no relationship was noted among stoma duration, quality of life, adjustment to the stoma, and spiritual well-being; these findings are supported by the research.^7,14,17 Having a stoma can lead to anxiety, making some patients’ adaptation to their new lives more difficult and prolongs their adjustment period. Getting used to living with a stoma takes time, and it is also necessary for the person to adjust their interest, attitude, and feelings toward living with a stoma.⁷ 

Hierarchical regression analysis revealed that adjustment to a stoma and spirituality have an effect on quality of life in individuals with stomas and that these variables are important predictors of quality of life. These results are compatible with the literature^4,6,14,17,22 that shows age, gender, and obstacles preventing care are factors affecting quality of life, adjustment to a stoma, and spiritual well-being.^6-8,20,25,31 However, the present study revealed these factors have no influence on these outcomes. In addition, it is clearly stated in the literature that a stoma, regardless of the type or the reason for the ostomy, leads to great changes in the functions and life of an individual.^3,13,21,31 The fact that demographic characteristics and stoma information did not affect quality of life could be attributed to the anxiety and stress, decrease in self-efficacy and psychosocial adjustment, deterioration in personal relations, lack of social support, and spirituality experienced by individuals with a stoma.^5,23,25,37 In addition, these results could have been affected by the fact that the study was cross-sectional and that the sample was heterogeneous. 

Nurses play an important role in evaluating individuals’ spiritual needs, establishing therapeutic communication, helping patients fulfill religious obligations, and providing emotional and spiritual care.^20,38 Using the results obtained from this study in the nursing profession will be important in terms of increasing adjustment to a stoma and quality of life of the patient. However, spirituality, which is an integral part of holistic care in the medical setting, is a factor that is mostly overlooked. Therefore, strategies and programs that integrate spiritual well-being and adjustment into nursing care are needed.³⁹ 

The first limitation of the study is the cross-sectional, descriptive design that limited the study to a certain period of time. This limitation did not clearly reveal differences in time points and did not allow the authors to assess causal relations. 

The second limitation was that the study was conducted among the members of a modern city in western Turkey; cultural differences exist among regions, and religion might be a more important phenomenon in other parts of the country. Therefore, the results cannot be generalized to the entire country or beyond. 

A cross-sectional, descriptive study evaluated spiritual well-being, adjustment to stoma, and quality of life in a group of 95 Turkish individuals with stomas. The mean scores of spiritual well-being, adjustment to stoma, and quality of life of individuals with stomas showed a moderate level of adjustment. Moderate, positive, statistically significant relationships were noted among these parameters. Multivariate analysis found spiritual well-being and adjustment to a stoma were significantly related to quality of life. The findings provide valuable evidence of the importance of adjustment to a stoma and spirituality as components of quality of life and suggest that existential dimensions (meaning-peace) of spiritual well-being should be included in the clinical evaluations of these patients and that nurses should evaluate the patient’s spiritual dimension in nursing practice. Planning well-designed, randomized controlled studies that evaluate the impact of the spiritual dimension of nursing care-based spirituality on patient outcomes as well as that of spiritual well-being on adjustment to stoma is suggested. 

Ms. Ayik is a Research Assistant, Dokuz Eylul University; and a doctoral student, Dokuz Eylul University Graduate School of Health Sciences, Izmir, Turkey. Dr. Özden is an Associate Professor, Dokuz Eylul University. Ms. Cenan is an enterostomal therapy nurse, Dokuz Eylül University Research and Application Hospital, Izmir, Turkey. Please address correspondence to: Cahide Ayìk, Nursing Faculty, Dokuz Eylul University, Balcova, Izmir, Turkey; email: cahideayk@gmail.com.