Examination of Spiritual Well-Being, Psychological Resilience Levels, and Quality Of Life of Patients with Cancer Undergoing Outpatient Chemotherapy

GEVHER NESIBE JOURNAL OF MEDICAL & HEALTH SCIENCES | ISSN 2717-7394 Arrival Date: 17.04.2025|Published Date: 30.11.2025|Vol: 10, Issue: 2|pp: 186-198|Doi Number: http://doi.org/10.5281/zenodo.17838628 Research Article-Gevher Nesibe Journal of Medical & Health Sciences 2025; 10(2): 186-198 186 EXAMINATION OF SPIRITUAL WELL-BEING, PSYCHOLOGICAL RESILIENCE LEVELS, AND QUALITY OF LIFE OF PATIENTS WITH CANCER UNDERGOING OUTPATIENT CHEMOTHERAPY AYAKTAN KEMOTERAPİ UYGULANAN KANSERLİ HASTALARIN SPİRİTÜEL İYİLİK HALİ, PSİKOLOJİK DAYANIKLILIK DÜZEYİ VE YAŞAM KALİTESİNİN İNCELENMESİ Yasemin ALPAY 1, Zülfünaz ÖZER 2 1 Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Türkiye. 2 Istanbul Sabahattin Zaim University, Istanbul, Türkiye. ABSTRACT Purpose: The study was conducted to determine the spiritual well-being, psychological resilience levels, and quality of life of patients with cancer undergoing outpatient chemotherapy. Method: The study population consisted of 200 patients with cancer undergoing outpatient chemotherapy in two public hospitals in Istanbul between April 2023 and July 2023. Data were collected with face-to-face interviews and a Personal Data Form, the Spiritual Well-Being Scale (FACIT-SP-12), the Brief Psychological Resilience Scale (BPRS), and the EORTC QLQ-C30 Quality of Life Scale. Results: The mean total score of FACIT-SP-12 was 32.94±7.39, the average score of the Meaning subscale was 11.75±2.81, the average score of the Peace subscale was 10.05±3.85, and the average score of the Belief subscale was 11.14±3.21. The mean total score of the BPRS was 20.28±3.63. The average score of the Functional Scale, which is the sub-dimensions of the EORTC QLQ-C30 Quality of Life Scale, was 71.71±18, the average score of the Symptom Scale was 40.77±19.31, and the average score of the General Quality of Life was 66.29 ± 24.06. Spiritual well-being strengthens its positive impact on the General Quality of Life and Functional Scale. Spiritual well-being strengthens its negative impact on the Symptom Scale. Conclusion: Spiritual well-being, psychological resilience level and quality of life of the patients were found to be moderate. Psychological resilience increased as the spiritual well-being of the patients increased. Psychological resilience has a direct impact on quality of life and an indirect impact with the role of spiritual well-being. Keywords: Cancer, Spiritual Well-Being, Psychological Resilience, Quality Of Life ÖZET Amaç: Bu çalışma, ayaktan kemoterapi uygulanan kanserli hastaların spiritüel iyilik hali, psikolojik dayanıklılık düzeyi ve yaşam kalitesini belirlemek için yapılmıştır. Yöntem: Çalışma, Nisan 2023-Temmuz 2023 tarihleri arasında İstanbul ilinde bulunmakta olan kamuya ait iki hastanede ayaktan kemoterapi uygulanan 200 hastayla gerçekleştirilmiştir. Araştırma verileri, Kişisel Bilgi Formu, Spiritüel İyi Oluş Ölçeği (FACIT-SP-12), Kısa Psikolojik Sağlamlık Ölçeği (KPSÖ) ve EORTC QLQC30 Yaşam Kalitesi Ölçeği (EORTC QLQ-C30) ile yüz yüze görüşme yoluyla toplanmıştır. Bulgular: FACIT-SP-12 toplam puan ortalaması 32.94±7.39, alt boyut puan ortalamaları ise Anlam 11.75±2.81, Barış 10.05±3.85, İnanç 11.14±3.21 olarak bulunmuştur. KPSÖ toplam puan ortalaması 20.28±3.63’tür. EORTC QLQ-C30’nun alt boyutları olan Fonksiyonel Ölçek puan ortalaması 71.71±18.62 Semptom Ölçeği puan ortalaması 40.77±19.31, Genel Yaşam Kalitesi puan ortalaması 66.29 ± 24.06’dır. Spiritüel İyi Oluş, psikolojik sağlamlığın Fonksiyonel Ölçek ve Genel Yaşam Kalitesi üzerine olan pozitif etkisini güçlendirmektedir. Spiritüel iyi oluş, psikolojik sağlamlığın Semptom Ölçek üzerine olan negatif etkiyi güçlendirmektedir. Sonuç: Hastaların spiritüel iyilik hali, psikolojik dayanıklılık düzeyi ve yaşam kalitesi orta düzeyde bulunmuştur. Hastaların spiritüel iyilik hali artıkça psikolojik dayanıklılığı artmaktadır. Psikolojik dayanıklılığının yaşam kalitesi üzerinde doğrudan ve spiritüel iyilik halinin rolüyle birlikte dolaylı etkisi bulunmaktadır. Anahtar Kelimeler: Kanser, Spiritüel İyilik Hali, Psikolojik Dayanıklılık, Yaşam Kalitesi Sorumlu Yazar / Corresponding Author: Zülfünaz ÖZER, PhD, Assoc. Prof. Department of Nursing, Faculty of Health Sciences, Istanbul Sabahattin Zaim University, Istanbul, Türkiye E-mail: [email protected] Bu makaleye atıf yapmak için / Cite this article: Alpay, Y. & Ozer, Z. (2025). Examination of Spiritual Well-Being, Psychological Resilience Levels, and Quality of Life of Patients with Cancer Undergoing Outpatient Chemotherapy. Gevher Nesibe Journal of Medical & Health Sciences, 10(2), 186-198. http://doi.org/10.5281/zenodo.17838628 Alpay and Özer Examination of Spiritual Well-Being, Psychological Resilience Levels, and Quality of Life of Patients with Cancer Undergoing Outpatient Chemotherapy Gevher Nesibe Journal of Medical & Health Sciences 2025; 10(2): 186-198 187 INTRODUCTION As one of the important healthcare concerns in the world and our country, cancer is defined as a disease characterized by uncontrolled cell proliferation and abnormal spread, affecting human life at physiological, psychological, social, and economic levels (Hintistan et al., 2015). Cancer, which creates a great burden on families and societies, affects individuals from all walks of life negatively, regardless of gender, rich or poor, children, young or old. Cancer ranks second among the causes of mortality in our country and the world. Approximately one in every 6 deaths globally and one in every 5 deaths in our country occur because of cancer and it is responsible for approximately 22% of all deaths (IARC, 2020; Turkey Cancer Statistics 2017, 2021). Chemotherapy, one of the cancer treatments, is employed to kill cancer cells or control the proliferation of these cells. Although only cancer cells are destroyed during the treatment, normal cells are also damaged in the body, causing side effects. As well as the disease process, cancer patients also face side effects such as fatigue, nausea, vomiting, alopecia, constipation, diarrhea, pain, weight loss, and psychological problems because of chemotherapy (Hintistan et al., 2015). Cancer is a type of disease that includes feelings and thoughts such as fear, hopelessness, helplessness, guilt, abandonment, and death anxiety, and must be addressed in integrity with its spiritual and psychosocial aspects (Aşut, 2020; Hintistan et al., 2015). Cancer poses significant difficulties in combating both psychological and physical symptoms (Otuzoğlu, 2017). The quality of life of cancer patients is affected negatively by long-term treatment that affects their spiritual needs as well as their physiological, emotional, and psychosocial needs. Physiological needs are easier to measure than psychosocial and spiritual needs because they are a more understandable and concrete concept compared to spiritual and psychosocial ones. For this reason, physiological needs that can be easily measured in the treatment and care of patients are evaluated first, and abstract spiritual and psychosocial needs are often ignored because they are difficult to measure (Mingir, 2022). Spirituality is defined as the individual’s effort to discover and embrace their relationships with themselves and others, their place in the universe, and the meaning of life (Bulkley et al., 2013). Cancer patients also face a life-threatening, long-lasting, completely incurable, unpredictable, progressively worsening, and even fatal disease (Otuzoğlu, 2017). Spirituality has positive impacts on these problems experienced by patients. For this reason, spiritual well-being positively affects the psychological resilience of patients (Ölmez and Karadağ, 2022). Psychological resilience is the process of acquisition or adaptation and is considered the process of a person’s adaptation to major stressors such as traumas, threats, tragedies or difficulties in family and relationships, serious healthcare concerns, and work, and financial problems. In other words, it is the ability of a person to recover from difficult life experiences or the ability to successfully overcome changes or disasters (Basım and Çetin, 2011). Psychological resilience gives individuals the ability to heal from the pain they experience and take responsibility for their lives. People with life-threatening diseases such as cancer need to be psychologically healthy, increase their strength, overcome the symptoms they experience, understand the value of life, and try to find new meanings (Özçetin and Hiçdurmaz, 2017). In studies conducted to date to determine the quality of life of cancer patients, the most common problems experienced by patients (e.g., pain, fatigue, nausea, loss of appetite, hair loss, difficulty breathing, vomiting, diarrhea, insomnia, heartburn, digestive problems, vision loss, and headaches) make the lives of people diagnosed with cancer difficult and reduce their quality of life (Dur, 2017). The basis of nursing in modern healthcare is a holistic care approach that takes into account the physical, mental, economic, cultural, emotional, and spiritual aspects of the individual. Spiritual health, the fourth element of health, is defined as “not only the absence of disease and disability but also a state of complete physical, social and spiritual well-being” and the importance of spiritual health is emphasized (Kutlu et al., 2022). Spirituality might affect decisions, attitudes, and behaviors regarding the treatment and care of cancer patients (Bulkley et al., 2013). In our country, no study has been found in which the spiritual well-being, psychological resilience level, and quality of life of cancer patients are evaluated together. For this reason, our study will provide new data to the literature on this subject. The present study was conducted to determine the spiritual well-being, psychological resilience level, and quality of life of cancer patients who received outpatient chemotherapy. Alpay and Özer Examination of Spiritual Well-Being, Psychological Resilience Levels, and Quality of Life of Patients with Cancer Undergoing Outpatient Chemotherapy Gevher Nesibe Journal of Medical & Health Sciences 2025; 10(2): 186-198 188 MATERIAL AND METHOD Type of Study The study had a descriptive, cross-sectional, and correlational design. Study Questions 1. What are the levels of spiritual well-being of patients receiving outpatient chemotherapy? 2. What is the psychological resilience level of patients receiving outpatient chemotherapy? 3. What is the quality of life of patients receiving outpatient chemotherapy? 4. Does spiritual well-being affect the psychological resilience and quality of life of patients receiving outpatient chemotherapy? Place and Time The data of the study were collected in the Outpatient Chemotherapy Units of two hospitals in Istanbul between April 2023 and July 2023. Population and Sample The sample comprised 200 patients diagnosed with cancer and received outpatient chemotherapy in two public hospitals in Istanbul between April 2023 and July 2023 and who met the inclusion criteria. In the power analysis performed with the GPower 3.1 program for the current sample size (n=200), the impact size was found to be 0.25 at 95% power and the margin of error was found to be 0.025. Inclusion criteria  Participating in the study voluntarily  Being 18 years of age or older  Having been diagnosed with cancer  Having received one or more cycles of chemotherapy  Being competent to answer all questions Exclusion criteria  Not being able to speak Turkish  Having psychiatric problems Data Collection Tools Data were collected with the Personal Data Form, Spiritual Well-being Scale (FACIT-SP-12), Brief Psychological Resilience Scale (BPRS), and EORTC QLQ-C30. Personal Data Form The form was created by the researcher by reviewing the literature data. The form contained 18 questions to determine the sociodemographic, disease-related characteristics, well-being, and perceptions of patients along with age, gender, education, marital status, income level, stage, duration of diagnosis, presence of another chronic disease, presence of a caregiver (Erdoğan, 2019; Ölmez and Karadağ, 2022; Kaya, 2016). Spiritual Well-Being Scale (FACIT-SP-12) The validity-reliability of the Spiritual Well-Being Scale (FACIT-Sp-12), developed by Peterman et al. (2002) to measure the spiritual well-being of individuals in all chronic diseases including cancer, was conducted in our country by Aktürk et al. (2017). The scale, which has 3 sub-dimensions (Meaning, Peace, and Faith) allows the examination of all components of spiritual well-being. The scale is Likerttype and consists of 12 items. The items in the scale have a numbering system from “0” to “4” (“0”-Not at all, “4”-A lot). The total score of the “Meaning” sub-dimension (Items 2, 3, 5, 8) varies between “0” and “16” points, the total score of the “Peace” sub-dimension (Items 1, 4, 6, 7) varies between “0” and “16” points, and the total score for the “Faith” sub-dimension (Items 9, 10, 11, 12) varies between “0” and “16” points. The total scale score varies between “0” and “48”. Higher scale values indicate greater spiritual well-being. In the validity-reliability study by Aktürk (2017) in our country, Cronbach’s Alpha value was found to be 0.87. In this study, it was found to be 0.80. Brief Psychological Resilience Scale (BPRS) Developed by Smith (2008), the Turkish validity-reliability of it was conducted by Doğan (2015). BPRS is a 5-point Likert-style self-report tool consisting of 6 items. The answers are “Not at all appropriate (1), Not appropriate (2), Somewhat appropriate (3), Appropriate (4), Completely appropriate (5)”. Items 2, 4, and 6 of the scale are reverse-coded. The score obtained from BPRS varies between “1” and “30”. High scores obtained indicate high psychological resilience. The Cronbach alpha reliability value of the scale was found to be 0.83. In this study, Cronbach’s Alpha value was found to be 0.76. Alpay and Özer Examination of Spiritual Well-Being, Psychological Resilience Levels, and Quality of Life of Patients with Cancer Undergoing Outpatient Chemotherapy Gevher Nesibe Journal of Medical & Health Sciences 2025; 10(2): 186-198 189 EORTC QLQ-C30 Quality of Life Scale The EORTC QLQ-C30 Quality of Life Scale version 3.0 (EORTC QLQ-C30) was developed by the European Organization for Research and Treatment of Cancer and its Turkish validity-reliability study was conducted by Beşer and Öz in 2003. The EORTC-QLQ-C30 consists of 3 subscales (“Functional Scale, Symptom Scale, and General Quality of Life”) and 30 questions. The functional scale includes physical, role, cognitive, emotional, and social functions. The symptom scale evaluates fatigue, pain, nausea and vomiting and dyspnea, insomnia, anorexia, constipation, diarrhea, and financial difficulties are also evaluated with one question each. The first 28 of the 30 items of the scale are 4-point Likerttype and the items are scored as “Not at all: 1, A little: 2, A lot: 3, A lot: 4 points”. In the 29th question, patients are asked to rate their health status (1: very poor, 7: excellent), and in the 30th question, patients are asked to rate their general quality of life. Questions 29 and 30 constitute the General Quality of Life domain. A high score on the “Functional Scale and General Quality of Life” and a low score on the “Symptom Scale” indicate that the quality of life is high (Beşer, 2003; Çalışkan et al., 2015). The Cronbach alpha value of the scale was found to be 0.90 (Beşer, 2003). In this study, it was found to be 0.84. Evaluation of Data The SPSS (Statistical Package for the Social Sciences) 25 program and SPSS PROCESS macro 4 Model were employed in analyses. To evaluate the data, descriptive statistical methods (mean, standard deviation, median, frequency, ratio, minimum, maximum) were made use of to evaluate the data distribution along with the Shapiro-Wilk Test. The Spearman Correlation Analysis was employed to determine the relationships between quantitative data. Regression Analysis was employed to determine the factors that affected the dependent variable. Structural Equation Modeling was used to determine the mediator variable in the factors that affected the dependent variable. Significance levels were taken as p<0.01 and p<0.05. Ethical Dimensions of Study Since the protection of individual rights is required, the Helsinki Declaration of Human Rights was adhered to throughout the study. Before the study, permission was obtained from the Istanbul Sabahattin Zaim University Ethics Committee (39550, 10.12.2022) (Appendix 5), the Institutional Permit from the Istanbul Provincial Health Directorate (212349285, 29.03.2023) (Appendix 6) and the owners of the scales used in the study. Before applying the surveys, the purpose, plan, and benefits of the study were explained to the participants and those who agreed to participate in the study signed the Informed Consent Form (Appendix 7). RESULTS The mean age of the patients was 57.43±14.72 years, 52.5% were female, 82.5% were married, 92% had children, 46.5% were primary school graduates, 60.5% had less income than expenses, the disease caused economic difficulties for 44%, 44% received economic support, 11% were working, and 47% were retired. The mean time from the first diagnosis of the patients was 222.64 days, 41% were in Stage 4, 49% were living with their spouse and children, 49% could not provide care for themselves, 59.5% perceived their illness requiring long-term treatment, 45.5% had another chronic illness, and 50.5% had hypertension as an additional chronic illness (Table 1). Alpay and Özer Examination of Spiritual Well-Being, Psychological Resilience Levels, and Quality of Life of Patients with Cancer Undergoing Outpatient Chemotherapy Gevher Nesibe Journal of Medical & Health Sciences 2025; 10(2): 186-198 190 Table 1. Socio-Demographic Characteristics of Patients (n=200) Mean±SD Min-Max (Median) Age 57.43±14.72 19-84 (60) Diagnosis Time (Days) 222.64±390.94 10-2920 (90) n % Sex Female 105 52.5 Male 95 47.5 Marital status Married 165 82.5 Single 35 17.5 Having Children Yes 184 92.0 No 16 8.0 Number of Children (n=184) 1 Child 15 8.2 2 Children 70 38.0 3 Children 47 25.5 4 Children 20 10.9 5 Children and Above 32 17.4 Educational Status Not literate 19 9.5 Literate 10 5.0 Primary education 93 46.5 Secondary Education 13 6.5 High school 46 23.0 Higher Education and Above 19 9.5 Income Level Income is More Than Expenses 12 6.0 Income Equals Expenses 67 33.5 Income Less Than Expenses 121 60.5 Case of Disease Causing Economic Hardship Yes 88 44.0 No 112 56.0 Receiving Economic Support Status Yes 88 44.0 No 112 56.0 Working Status Yes 22 11.0 No 178 89.0 Professional Groups Housewife 56 28.0 Small business 37 18.5 Worker-Civil Servant 13 6.5 Retired 94 47.0 Disease Stage Stage 1 15 7.5 Stage 2 30 15.0 Stage 3 73 36.5 Stage 4 82 41.0 Person Living in the House Spouse and Children 98 49.0 Alone 10 5.0 With family 8 4.0 Spouse 52 26.0 Other* 32 16.0 Failure to Maintain Care Because of Illness Status Yes 98 49.0 No 102 51.0 Perception of Disease Easily Treatable Disease 52 26.0 Disease Requiring Long-Term Treatment 119 59.5 Incurable Disease 29 14.5 Different Chronic Disease Status Yes 91 45.5 No 109 54.5 Chronic Disease Diagnosis (n:91) Hypertension 46 50.5 Heart disease 19 20.9 Diabetes 15 16.5 COPD** 4 4.4 Kidney Failure-Neurological Diseases 7 7.7 Alpay and Özer Examination of Spiritual Well-Being, Psychological Resilience Levels, and Quality of Life of Patients with Cancer Undergoing Outpatient Chemotherapy Gevher Nesibe Journal of Medical & Health Sciences 2025; 10(2): 186-198 191 *Relative, Friend**COPD: Chronic Obstructive Pulmonary Disease The Spiritual Well-being Scale total average score was found to be 32.94±7.39, Meaning subdimension average score was 11.75±2.81, Peace sub-dimension average score was 10.05±3.85, Faith sub-dimension average score was 11.14±3.21. BPRS total average score was 20.28±3.63. In EORTC QLQ-C30 sub-dimensions; the Functional Scale average score was 71.71±18, the Symptom Scale average score was 40.77±19.31, the General Quality of Life average score was 66.29±24.06 (Table 2). Table 2. Means Scores in Spiritual Well-being Scale, Brief Psychological Resilience Scale, and EORTC QLQ-C30 Quality of Life Scale Measurement (n=200) Mean±SD Min-Max (Median) Spiritual Well-Being Scale SubDimensions Meaning 11.75±2.81 2-15 (12) Peace 10.05±3.85 0-16 (11) Faith 11.14±3.21 0-16 (11) Spiritual Well-being Scale 32.94±7.39 2-47 (34) Brief Psychological Resilience Scale 20.28±3.63 8-30 (21) EORTC QLQ-C30 Quality of Life Scale Sub-dimensions Functional Scale 71.71±18.62 11.11-100 (73.33) Symptom Scale 40.77±19.31 2.56-92.31 (41.03) General Quality of Life 66.29±24.06 0-100 (66.67) To show the impact of psychological resilience on the Functional Scale and the mediating function of spiritual well-being in this impact, the SPSS PROCESS macro 4 Model was employed. The details of the analysis results seen in Figure 1 are given in Table 3. As a result of the analysis, it was found that psychological resilience (β=0.432) and spiritual well-being (β=0.422) positively affected the Functional Scale. In another result, it was reported that spiritual well-being mediated the impact of psychological resilience on general quality of life (β=0.102) and strengthened the impact of psychological resilience on the Functional Scale (β=0.534). These two variables’ predictive impact for explaining the Functional Scale was 55.9% (Table 3, Figure 1). Table 3. Direct and Indirect Effects of Brief Psychological Resilience Scale, Spiritual Well-being Scale, and Functional Scale Variables Direct Effect Indirect Effect Total Effect LLC ULCI t p Brief Psychological Resilience Scale 0.432 0.102 0.534 1.225 0.589 2.395 0.001* Spiritual Well-being Scale 0.422 1.752 0.659 1.626 0.001* Figure 1. Study Model Alpay and Özer Examination of Spiritual Well-Being, Psychological Resilience Levels, and Quality of Life of Patients with Cancer Undergoing Outpatient Chemotherapy Gevher Nesibe Journal of Medical & Health Sciences 2025; 10(2): 186-198 192 To show the impact of psychological resilience on the Symptom Scale and the mediating function of spiritual well-being in this impact, the SPSS PROCESS macro 4 Model was used. The details of the analysis results seen in Figure 2 are given in Table 4. According to the analysis results, both psychological resilience (β=-0.373) and spiritual well-being (β=-0.305) negatively affected the Symptom Scale. According to another result, spiritual well-being played a mediating function in the impact of psychological resilience on the Symptom Scale (β =-0.108) and strengthened the negative impact of psychological resilience on the Symptom Scale (β=-0.481). The predictive impact of these variables for explaining the Symptom Scale was found to be 0.093% (Table 4, Figure 2). Table 4. Direct and Indirect Effects of Brief Psychological Resilience Scale, Spiritual Well-being Scale and Symptom Scale Variables Direct Effect Indirect Effect Total Effect LLC ULCI t p Brief Psychological Resilience Scale -0.373 -0.108 -0.480 -0.253 -0.675 1,715 0.001* Spiritual Well-being Scale -0.305 -0.167 -0.952 1,254 0.001* Figure 2. Study Model To show the effects of psychological resilience on general quality of life and the mediating function of spiritual well-being in these effects, the SPSS PROCESS Macro 4 model was used. The details of the analysis results shown in Figure 3 are shown in Table 5. The analysis results showed that psychological resilience (β = 0.607) and spiritual well-being (β = 0.492) had a positive impact on general quality of life. As a result of another result, spiritual well-being was found to mediate the impact of psychological resilience on General Quality of Life (β = 0.173) and strengthened the positive impact of psychological resilience on General Quality of Life (β = 0.607). The predictive impact of these two variables in explaining quality of life was found to be 53.4% (Table 5, Figure 3.). Table 5. Direct and Indirect Effects of Brief Psychological Resilience Scale, Spiritual Well-Being Scale, and General Quality of Life Variables Direct Effect Indirect Effect Total Effect LLC ULCI t p Brief Psychological Resilience Scale 0.434 0.173 0.607 1,721 0.765 2,095 0.001* Spiritual Well-being Scale 0.492 1,321 0.925 2,726 0.001* Alpay and Özer Examination of Spiritual Well-Being, Psychological Resilience Levels, and Quality of Life of Patients with Cancer Undergoing Outpatient Chemotherapy Gevher Nesibe Journal of Medical & Health Sciences 2025; 10(2): 186-198 193 Figure 3. Study Model DISCUSSION Life-threatening diseases cause feelings such as fear of death, stress, and loss of hope in patients, and experiencing these feelings prioritizes the patient’s spiritual needs. Spirituality is an important resource in health services because it encourages coping strategies and supports the patient’s recovery process (Büyükbayram et al., 2022). Psychological resilience is the ability of an individual to experience positive emotions, especially at an individual level, and is an individual characteristic that is usually associated with production. In psychological resilience, the “ability to endure continuous pain or suffering”, develops positive psychological effects over time in individuals exposed to potentially traumatic events. Psychological resilience is a dynamic and evolving psychosocial process that we experience. In particular, people with resilience are those who can experience positive emotions even in the face of difficult events (Çetin and Anuk, 2023). The main purpose of the treatment of terminal diseases is to increase the quality of life of individuals. Because the disease and its treatment negatively affect the patient’s physical, environmental, mental, and spiritual state (Öner, 2012). This study was conducted to determine the spiritual well-being, psychological resilience, and quality of life in patients diagnosed with cancer who received outpatient chemotherapy. It was found in the present study that the patients’ spiritual well-being (32.94 7.39) was at a moderate level and they received the highest score in the Meaning sub-dimension. In other studies, it was reported that patients’ general spiritual well-being scores were similar to our study (Ata, 2018; Cheng et al., 2019; İzgü and Gök Metin, 2020; Köktürk Dalcalı et al., 2021; Martins et al., 2020; Yüksel, 2019). Spirituality is conceptualized as a framework that can be divided into several components as meaning, peace, and faith. Meaning and Peace are mainly used to measure the cognitive and emotional dimensions of spirituality. Faith is used to measure the relationship of illness with a person’s faith and spiritual faith (Cheng et al., 2019). Spirituality is an important and fundamental dimension of health and has the ability to connect all dimensions of the person (Fisher, 2016). The approach to caring for cancer patients must be based on a bio-psycho-social-spiritual model (Martins et al., 2020). Today, spirituality is considered an important strategy by palliative care specialists in coping with life-threatening diseases (Rabitti et al., 2020). The socio-economic status of patients and effective coping skills affect their psychological well-being, and it can be argued that using these methods is effective in spiritual wellbeing. Within the scope of the study, the psychological resilience of cancer patients receiving chemotherapy was found to be at a moderate level (20.28 3.68). When the studies conducted previously were evaluated (Atay 2019; Güngör, 2019; Salman 2017), it was found that psychological resilience was reported to be at a moderate level in studies like ours. In the study conducted by Yalçın (2015) with breast cancer patients, the psychological resilience of the patients was found to be significantly low. Resilience is a factor associated with many sociodemographic, clinical, psychosocial, and physiological variables of cancer patients (Aizpurua-Perez, 2020). Psychological resilience is the ability of a person to resist negative effects despite difficult conditions. Individuals can protect their mental health with Alpay and Özer Examination of Spiritual Well-Being, Psychological Resilience Levels, and Quality of Life of Patients with Cancer Undergoing Outpatient Chemotherapy Gevher Nesibe Journal of Medical & Health Sciences 2025; 10(2): 186-198 194 their dynamic abilities when faced with difficult processes (Yalçın, 2015). Whether or not patients have an effective coping mechanism affects psychological resilience, and cancer patients under chronic stress experience many healthcare concerns that negatively affect their mental health. In the study, it was also found that the quality of life of cancer patients receiving chemotherapy was at a moderate level (66.29±24.06). In the literature, it is reported that the quality of life of cancer patients decreases significantly because of both the disease and the treatment process (Jacob et al., 2019; Smyth et al., 2016). When the studies conducted in Turkiye were examined, it was found that the quality of life of cancer patients receiving chemotherapy was at a moderate level, similar to these results (Benzer and Yılmaz, 2022; Düzen and Göktaş, 2021; Kızılırmak et al., 2021; Köksal and Nural, 2024). In the study of Ekinci and Düger (2018), it was determined that patients were hospitalized with certain symptoms and their quality of life decreased because of the inability to manage these symptoms. Symptoms experienced because of chemotherapy reduce the quality of life of patients by restricting their daily life activities. Also, cancer diagnosis and treatment processes can cause psychological problems in patients. Psychological problems can significantly affect patients’ quality of life and reduce treatment compliance. Economic difficulties might affect patients’ quality of life negatively by restricting their access to treatment and increasing their stress levels (Benzer and Yılmaz, 2022; Köksal and Nural, 2024). Previous studies reported that psychological resilience scores increase with increasing spiritual well-being scores (Koral and Cirak, 2021; Ölmez and Karadağ, 2022). In a systematic review, evidence showed that psychological resilience is associated with life quality of cancer patients (Lau et al., 2021). In our study, psychological resilience increased as spiritual well-being increased. While there a positive and significant relationship was detected between spiritual well-being and its sub-dimensions, meaning and peace, and the functional scale and general life quality, there is a negative significant relationship between the symptom scale. When the literature is examined, it supports our study (Köktürk Dalcalı et al., 2021). Spirituality is positively associated with quality of life. When spiritual needs are largely unmet, end-of-life patients have to struggle with the general burden of daily troubles and concerns that affect their emotional and spiritual well-being and decision-making processes regarding healthcare (Rabitti et al., 2020). Spirituality appears to be associated with physical and psychological health, especially of cancer patients (Sheppard et al., 2018). As an important component of general health, spirituality is considered a universal characteristic in which patients seek meaning in life and has been shown to be positively associated with quality of life (Li et al., 2022). It has been concluded that spiritual well-being is associated with the best indicators of physical, mental, and environmental health in people with chronic diseases and that spirituality significantly affects the individual’s general quality of life and increases the quality of life (Öner, 2012). Our study results are parallel to the literature data. Spiritual well-being can have a significant impact on basic health measures. In advanced cancer patients, spiritual well-being reduces hopelessness, depression, and the desire to die, while increasing quality of life (Schultz et al., 2017). Chaar et al. (2018) reported that patients with higher FACIT total scores and meaning, peace, and faith sub-scores had higher emotional and cognitive functions, and patients with better general health status and quality of life also had higher meaning, peace, and total FACIT scores (Chaar et al., 2018) . In the present study, both psychological resilience and spiritual well-being positively affect the overall quality of life. Spiritual well-being mediates the impact of psychological resilience on the overall quality of life and strengthens the positive impact of psychological resilience on the overall quality of life. Psychological resilience not only directly contributes to the quality of life in cancer patients, but also effectively improves the quality of life by increasing their spiritual well-being. In their study, Chen et al. (2023) reported that spirituality played a mediating function in the relationship between psychological resilience and quality of life. Interventions aimed at increasing psychological resilience and then increasing spirituality may be beneficial in improving the quality of life of cancer patients (Chen et al., 2023). Spiritual well-being facilitates adaptation to illness, reduces levels of psychological distress, and has a positive impact on general health. This has also been accepted as an important coping strategy. Previous studies have shown that patients with high spiritual well-being scores have a high quality of life, while patients with low quality of life are more likely to experience anxiety and depression (Bovero et al., 2016; Yılmaz, 2022). In a study conducted in 2021 to determine the impact of spirituality on the quality of life of Lebanese cancer patients and whether the impact on the quality of life mediates the reduction of depression, Rached et al. concluded that spirituality has no direct