Neurosurgery Nursing and Spiritual Dimension of Nursing Care

As healthcare started to be given in holistic approach, spiritual dimension has gained value by getting as much importance as other dimensions (physical, emotional and psycho-social) and this approach has removed the idea of the sipiritual deminsion being only for religious focus. Holistic nursing care is composed of a multidimensional structure including medical, moral, spiritual and religious aspects. In a study by McEwen however, it is stated that although some theoreticians define and accept spiritual necessities in holistic care concept, many others neglect that term [3]. In a study by Yılmaz and Okyay [4] on 621 nurses, it is noted that the neglection of the concept by many theoreticians should be one of the reasons that spiriutal needs are insufficiently considered in nursing education [5].


Introduction
Holistic view means focusing on the whole rather than the pieces. To analyze pieces apart from the whole would cause to disregard some elements of reality [1]. Holistic care comprises the idea of considering the individual as a whole on physical, mental, social, emotional and spiritual scales.
There is no era in nursing history that describes it as a profession of giving physical care only. Although ¨holistic care¨ concept was introduced to the nursing literature in back1980 by theoretician nurses such as Rogers, Parse and Newman, holistic approach has been used traditionally in care giving by nurses throughout the history [2].
As healthcare started to be given in holistic approach, spiritual dimension has gained value by getting as much importance as other dimensions (physical, emotional and psycho-social) and this approach has removed the idea of the sipiritual deminsion being only for religious focus. Holistic nursing care is composed of a multidimensional structure including medical, moral, spiritual and religious aspects. In a study by McEwen however, it is stated that although some theoreticians define and accept spiritual necessities in holistic care concept, many others neglect that term [3]. In a study by Yılmaz and Okyay [4] on 621 nurses, it is noted that the neglection of the concept by many theoreticians should be one of the reasons that spiriutal needs are insufficiently considered in nursing education [5].
Holistic care stands on a significant point for surgical nursing [6]. Surgical intervention is a situation breaking up the body integrity. Patients going into surgery may confront with various situations such as autonomy loss, worry and uncertainty since they would have anaesthesia and sedation. Particularly in that case, surgical nurses take the great responsibility of informing the patient and providing holistic care [7].
Holistic nursing care plays an important role in the success of surgical operations for nervous system. Spirituality, known as a concept for the introduction of holistic nursing care, has a significant role in the individual's healthcare acquisition process. American Holistic Nurses Assocciation has indicated that the individual's integral health would be possible only if all kinds of care including spirituality are provided [8].

Neurosurgery Nursıng and Spırıtual Care
Neurosurgery nursing requires advanced nursing knowledge and practice to meet the care needs of patients who have experienced cranial and/or spinal surgical interventions. Neurosurgery nurses often meet patients with traumas. Trauma is seen as the primary cause of death at 0-44 age range in many countries. The most frequent factors causing traumas are traffic accidents, to fall down from high metres, firearms or contact/edged weapon wounds, Multiple body wounds have increased by the progress in industry and technology. Cranial traumas and spinal traumas usually accompany with multiple wounds in patients. Cranial and spinal traumas appear as health problems which mostly require some lifestyle changes and which have individual and social significance. As a result of wounding, the individual has problems with physical image and self-confidence as well as loss of feeling, mobility and reflex. In these case; the spiritual dimension, which creates emotional stress, challenges his/her values and beliefs on physical illness and death, which causes the patient to begin a course of questioning life and eternity, which makes him/her insufficient to find the meaning of life, the sources of hope, power and dependence, becomes more important [3,5,9,10]. In this context, neurosurgery nurses should certainly include the diagnoses of ¨spiritual distress¨, ¨spiritual distress risk¨ and ¨readiness for improving the state of spiritual wellness¨, which are mentioned in nursing definitions by North American Nursing Diagnosis Associations (NANDA), within their care plans.
Spiritual care, which is important for all fields of health and individuals of all ages, also deserves importance in neurosurgery nursing. Nurses should have enough knowledge on the dimensions of spirituality and should be aware of his/her own spiritual values and beliefs so as to provide spiritual care regarding holistic care approach. It causes to underestimate the importance of issue and makes holistic care insufficient for its purpose to ignore the significance of nurses' spiritual care, to let the lack of its involvement in care, to confuse religion with spirituality, to have no expectation of spiritual care provided by nurses or to consider it as a non-scientific approach [3].

Spırıtual Dımensıon
The fact that materialistic values do not provide happiness, modern medicine is inadequate to personal meaning of loss on conditions of death, suffer as well as the seek for a peaceful and meaningful life and such relations have raised interest for spiritual dimension during post-war period and particularly in 1960s [5,11]. Since the spiritual dimension is an incomprehensible, abstract, oblique concept influenced by various internal and external factors, there is no consensus on the definiton of spiritual dimension despite the rising interest [5,[12][13][14][15][16].

Defınıtıon of Spırıtual Dımensıon
Spiritual dimension is considered by different definitions in the literature review. Some of them are a divine power, being affiliated to the God, loyalty or tranformation making someone feel mightier, existence free of material world, recovery through non-physical means (such as prayers, meditation, religious beliefs) and the feeling of wellness [17]. It is also defined as everything related to the individual far from the material and the whole of internal sources regarding their essential meanings as well as the efforts for the meaning and purpose of life and self-peace out of religious faith and divine confidence [16]. Spiritual dimension includes elements which comprise the purpose of life and are meaningful to the individual and it is related to what we do more than what we are. Ross has defined spiritual dimension in three area as meaning and objective, vitality (hope), trust for him(her) self / others and trust for the Gods. Ross has also emphasized that the relationship between meaning, objective and power increases with the help of religion [18]. Bash has tried to explain the concept under three approaches as theism, non-theism and a medium between theist and non-theist approaches. Bash states that non-theist approach implies the innate awareness an individual possesses, in order to help others. It refers to individual's prioritization of others' happiness as a result of considering him (her) self as a component of the society. Theist approach however is described as the learning and transformation process of the individual in his/her living environment, which results from his/her connection or relationship with a superior power existing in the universe. This approach is considered to be complicated since the use of a medium though comprises a superior power in itself, yet it denies that superior power in order to respond the questions. With this approach, spiritual dimension is considered a secular concept, yet its linguistic and thinking styles are utilized to reach the supreme power [5,11].
Studies display that ideas expressed by patients during the state of illness are related to ¨prayers and the God¨. Despite the great progress in clinical patient care, there is a dilemma confronted in nursing care during the state of illness, the formation of will to live or death process. Both patients and their relatives get worried due to the fear for unknown, thus nurses are not able to serve a multi-dimensional care for them. In line with recent technological advances, the consideration of spiritual dimension in nursing care becomes effective on the blossoming of patients' vitality hopes. The importance of hope for life should be counted not only as a cause of death in absence, but also as an accelerator of recovery when it becomes greater. Therefore positive effect of hope on patients should not be ignored.

Spırıtualıty and its Impact on the Recovery of Patıents
Spiritual needs are among the ingividual's essential needs. There is an internalized requirement lifelong going with the mutual effect of his/her physical and spiritual dimensions. Holistic nırsing care comes forth with the purpose of meeting these needs. It is known that there is an influence of spirituality on questioning illness and well-being cases, on orientation to changes, on gaining skills to overcome problems and on the way to regain the strength for recovery.
The following factors take a significant role in spiritual care provided by nurses: Working environment and conditions of nurses, their communication with other employees providing patient care, the patient's availability to communicate (coma, hear loss, dementia, etc.), nurse's personal thinking system (her awareness of spirituality and her spiritual power in her own life, her curiosity, interest in and seek for the meaning of life), spiritual needs and the care perception, nurse's own hope for life, willingness and sensitivity to the issue, and her level of spiritual care knowledge regarding the training and education [16][17][18]39]. The studies exhibit that the higher the nurses' educational levels Human's spitiual dimension is as critical as the physical, emotioanal and social dimensions and even closely related to them [16]. Studies have determined that patients with high spirituality are healthier in terms of physical, emotional and social aspects as well as having increased levels of hope, stress overcome and life quality while displaying lower inclination to depression and self-isolation on the contrary [19][20][21][22]. In a study by Vollurupoli et al. [23] it has been concluded that by meeting their psychological needs, the individuals become more capable of coping with stress resulted from their illnesses and that leads to decrease of fatigue, depression and anxiety symptoms by including spritiuality in care as well as an increase in general welfare and in life quality are seen. The same study has also revealed that the effective way implemented by most patients (93%) to cope with their diseases was to rely on their own religious/spiritual faith [23]. Spiritual care, which is over physical and psycho-social dimensions and beyond existence, affects the recovery process of patients. In several studies, spiritual dimension and patients' recovery processes have been compared and the former has been found to be effective on the latter [24,25]. Similarly, Messine et al. [26] study has shown that incurable metastatic solid tumor patients' life span might be lengthened by psychological treatment approach. Furthermore, positive impact of spiritual overcome coronary heart disease, hypertension, HIV, cerebralvascular diseases, high cholesterol, immunological deficiencies and most cancer types [22,[27][28][29][30][31][32]. In addition to all, Seybold and Hill's study has expressed some more effects of spirituality on physical health such as decrease in rates of cirrhosis, emphysema, myocardium infarct, renal failure and cardiac operation mortality; decrease in stress concerning surgery and chronic pain as well as increase in positive health habits [33]. In another study, individuals with spiritual practices have displayed lower rates of suicide and substance addiction [34]. Researches have commented that those mentioned positive effects should depend on their power to relieve patients' pain and anxiety, to comfort them physiolocially, psychologically and mentally and to enhance communication [4,[33][34][35][36][37][38]. Regarding the studies, spiritual care has been included in the Professional Nursing Practice Standards of Care Tanzania, Canada and the United States. Those standards have also mentioned the requirement for the involvement of both patients and their families in nursing care while determining and meeting patients' spiritual neeeds [8]. American Nursing Association and International Council of Nurses also emphasizes that the spiritual dimension is ought to be included in nursing care. International Council of Nurses (ICN) declares that it is the nurses' part to establish an environment respectful to human rights, human values, habits and spiritual faith [4,10].
are, the more open their spiritual care perceptions will be [35][36][37][38]40]. According to a study by Stang et al. [41] in Switzeland, though the most of nurses (98%) consider spiritual care as necessary, only half of them (48%) provide spiritual care. Baldacchico's study has revealed that nurses tend to recognize spiritual care as religiıus necessity [10] .

Conclusıon
The spiritual dimension has begun to get as much attention as physical, emotional, psychological and social dimensions after healthcare started to be provided through a holistic (integral) approach. It is anunavoidable fact that spiritual dimension influence health, well-being and life quality. Regarding to neurosurgery nursing, it is also crucial to emphasize that the awareness of spiritual care and providing holistic nursing care focused on spiritual dimension would have a positive effect on the patient's joy of life. Furthermore, it is considered to be practical for providing qualified nursing care to incorporate spiritual dimension into holistic approach while planning the in-service training programs for nursing graduates.