Holistic Care Philosophy for Patient‐Centered Approaches and Spirituality Holistic Care Philosophy for Patient ‐ Centered Approaches and Spirituality

Holistic care philosophy, acknowledging the existence of a very close relationship between body, mind and soul (spirit) and focusing on individualism, emphasize that every dimension of human is distinctive and unique as well as they are also connected to each other. While integrity value is defined as an important concept for personal development and health; providing treatment and healing by holistic approach extends to Hippocrates, the founder of medicine. It is emphasized in this philosophy that holistic approach is important for individuals and as well as physical ailments, spiritual effects of illness need to be investigated. Spirituality, one of the components of the holistic approach, takes “belonging to the community” into account. Spirituality is concerned with “growth,” and it is the essence of existence and congenital according to this approach. It is an instinctive (genetous) awareness for helping someone else. Individu‐ al's perception of his own spirituality increases his inner peace and personal satisfaction. Health‐care professionals should have environment and proximity, capable of offering holistic medical care services, for understanding patient's sociocultural and psycholog‐ ical situation as well as being closely acquainted with patient's family and life environment. Because this concept is individualistic, and an aspect of human arising from his multidimensional experiences. Undoubtedly, during these applications, it is also important to show the respect for autonomy of thought and belief basically in the context of principle of “not harming.” If it is acted responsibly in fulfillment of this approach, a good level of medical discipline, spirituality and science integration will be reached. The studies to be performed in this field will offer new opportunities for understanding the great mysteries of life and medicine better and for development of medical care services.


Introduction
Patient-centered approach, the level of increasing competition, technology, education, logistics and communication opportunities of our age made it necessary to focus on the expectations and desires of the patients in health care. With the humanistic approaches in the health care, the necessity has increased even more. And with the patient-centered approach, it became the contemporary approach, which is regarded as the presentation of the health care.
The patient-centered approach is an approach, which guarantees the patient values in clinical decisions at a certain extent and is respectful of the individual preferences, needs and values of the patient. The approach does not only guarantee the patient in informing them of diagnosis, treatment and healthy behaviors. Also, it does not mean that the patients must be provided with whatever they desire. What is expected in patient-centered approach is the guidance from health professionals. The patient should be provided with information about the alternatives, benefits and risks thoroughly and unbiased accompanied by guidance. This signifies that the patient's cultural tendencies and traditions, individual preferences and values, family conditions, social environment and lifestyle are taken into account. The fundamental basis of the patient-centered approach is the holistic approach. When the etymological origin of the holistic approach is analyzed, it can be seen that the word derives from "holism." Holism, eng: holism, fr: holisme, ger: holismus. Holism is the common term for the philosophical approaches emphasizing that the whole is greater than the sum of its parts. According to the approach, the whole cannot be understood by analyzing its component parts. The components that help us to see and to hear the reality constitute the whole. When viewed from this aspect, the holistic approach also applies to the field of medicine. While the concept of holism was first defined in the 1890's; in 1926, in the medical field, J. Smut in his work titled "Holism and Evolution" stated that "the world has been managed by a holistic process, in which the forms of substance increase continuously and new wholes are being formed" [1] and explained by noting that medical holism has individualistic, societal and environmental aspects. Human is considered to be part of the universe, nature, and supernature, in which they exist. In this perception, the spirit and body are designed with disease and health. The value of integrity is a significant concept for self-improvement and health. Therapy and cure with the holistic approach date back to 5000 years ago. Hippocrates (460 BCE-370 BCE), known as the founder of the medical science, emphasized that the holistic approach is significant and the spiritual effects of the disease must be considered. He emphasized this by saying "It is more important to know what sort of person has a disease than to know what sort of disease a person has" [2].
Hippocrates said, "The natural healing power inside us is the most important source for recovery." The duty of the doctor is to stimulate the healing power before giving a therapeutic substance [3]. As Galileo said: "You cannot teach a man anything, you can only help him find it within himself." A holistic approach is regarded in a variety of different respects of the holistic care. However, what is fundamental in the holistic approach is that the health professionals should be able to evaluate and view the patient as an entire "individual," not just as an individual with a disease. Humans are valuable; above all, they are just humans. The human is an entity with the most developed intelligence among the living beings and who can think, reason, communicate and plan for the future. So, the human is honorable. Human is an entity different in many other respects (intelligence, apprehension, memory, imagination, expression, opinions, speech, morals, modesty, curiosity, anxiety, happiness, regret) and has superior qualities and skills thanks to these respects in general. People, possessing integrity, are born, grow, age and die after living on earth for some time. People should be evaluated and treated with holistic approach due to their nature when required. In order for a quality service to be provided in the field of health, a health professional is expected to be a good listener, a good speaker, a fine thinker, understanding and feeling of the emotions of the others with good recommendations. When the modern medicine, developing technology, insufficiency of the health-care systems, rise in the diseases, changes in the climatic conditions, the fact that the health-care professionals work intensively and under stress are taken into account, it has become a complex system, in which the physicians are unable to spare sufficient time for the patients [4,5].
In the philosophy of holistic care, focusing on the individualism, which acknowledges that there is a strong relationship between body, mind and spirit, it is emphasized that every aspect of the human dimension is uniquely single as well as interconnected with each other. While the integrity, value is defined to be a significant concept for the self-improvement and health, it emphasizes that the spiritual effects of the illnesses along with the physical disorders must also be examined. In the philosophy of holistic care, the holistic treatment and care approaches along with the holistic diagnosis must be evaluated together.
In the concept of holism within the philosophy of holistic care, the physical and spiritual needs should be prioritized without ignoring the medical treatment applications. It can be stated that meeting the psychosocial needs effectively among these needs has a positive contribution in decreasing the physical needs and as well as increasing the effectiveness of the medical treatment. According to the World Health Organization, the health is a state of complete physical, mental and social well-being. Health is the harmony between the body, mind and spirit. Therefore, the holistic health of the individual is possible with the implementation of all the treatment types including spirituality [6].
Spirituality is an effort to understand and acknowledge the individual's relationships between themselves and other humans, their function in life and the meaning of life. At the same time, it is the result of knowledge gained throughout life and involves elements meaningful to an individual, which makes the purpose of life [6][7][8]. A variety of different definitions are used regarding spirituality ( Table 1). When providing nursing services, knowing these concepts will be guiding for professionals [9].
Spirituality is one of the elements of holistic approach takes the principle "belonging to the society" into account. In this approach, "growth" relates to spirituality and the essence of existence and is inherited. Being bound with unconditional love (Ellison 1983, Clark et al. 1991, Ross 1997 Loyalty to him/herself (Reed 1992) and loyalty to others (Sherwood 2000) Relationship between the mystery, great power, God, universe or life (Reed 1992) Beliefs of the individual regarding the world (Soeken and Carson 1987) It is an (inherited) innate awareness to help others. Individual's comprehension of their own spirituality, increases internal peace and individual's own pleasure. Spirituality is the learning and changing process as a result of supreme power and individual relationship. A person first understands and apprehends his/her own inner ego, then with the help of this knowledge, decides and implements their expectations and desires. A person, who can successfully execute this as it is supposed to be, that is, a person, who can comprehend their ego, may understand their environment, the incidents and people better [8,10]. When evaluated from this perspective, it can be seen that the majority of the holistic medicine applications tend to promote this belief and ego. According to another definition, "Spirituality is the learning and changing process as a result of an individual relationship." In the twelfth century, spirituality was defined so as to determine the psychological aspect of the human life in contrast to its physical aspect, to demonstrate the religious human in the fifteenth and sixteenth centuries, in the seventeenth century with its contemporary meaning for the first time in France, and in the twentieth century with its religious and nonreligious meanings. Nowadays, it is considered to be a broad concept rather than being bound to a traditional religion for many people. Since the spiritual dimension has a strong effect on factors relating to health, attitudes and behaviors, it is accepted to be the "fundamental element" of the philosophy of holistic care [10,11].
If spirituality is defined in contextual conditions, spirituality means a human's search for a relationship with a spirit and it is his/her expression of this. Spiritualism expresses a metaphysical notion, according to which the universe is based on a spiritual basis, and the substance is independent of the spirit. Spiritualism can be defined as "unifying power" affected by the body and spirit and affects the body and spirit at the same time.
Spiritual care/approach is the inclusion of the beliefs, which are helpful in coping with the physical and spiritual difficulties and particularly the emotional needs of the individual; selfeducation and self-actualization approaches to the treatment process. While in the World Medical Association Declaration of Lisbon (1981) [12], it is stated that "The patient has the right to receive or to decline spiritual and moral comfort, including the help of a minister of his/her chosen religion"; in the World Medical Association Declaration of Amsterdam (1994) [13], it is stated that "Everyone has the right to have his or her moral and cultural values and religious and philosophical convictions respected." Moreover, in the same declaration the statement "Patients have the right to enjoy support from family, relatives and friends during the course of care and treatment and to receive spiritual support and guidance at all times" and in the European Charter of Patients' Rights Basis Document (2002) [14] the statement "Article 12-Right to Personalized Treatment: Each individual has the right to diagnostic or therapeutic programs tailored as much as possible to his or her personal needs" emphasizes the spiritual care right.
It is important that the nurses take the concept of spirituality into account within the nursing plans, for which they are responsible for performing when delivering health care [15].
Spirituality is confused with many concepts. When the similarities and differences between concepts are specified, it will be possible to explain spirituality better. When spirituality and similar concepts are explained: The lexical meaning of the word belief is being bound to an idea, believing in a religion, belief in a thing, notion or discipline. In addition to these, it also means a fixed notion since it has been accepted widely and an established general opinion [6,8,[16][17][18]. James W. Fowler defines the word belief as a component of the main motivations of the individuals oriented towards life in its most general sense. When evaluating the belief development process, Fowler does not only emphasize the relational nature but also the imaginary nature. Fowler states that there is a significant relationship between the comprehension and evaluation forms of the human, and surrendering to the belief and imagination methods. Fowler believes that the belief is universal, unique to the human being's nature and correlated with human's interpretation process [19].
Spirituality is the sum of everything that the individual is associated with beyond the material and the intrinsic sources regarding their central meanings. Spirituality can also be defined as making an effort for the meaning of life, its purpose and the inner peace without any God belief beyond a religious dependence. Spirituality is also defined as a high level of belief, becoming divine or the infinite power of energy [11,20]. Not all the concepts of spirituality are associated with a religion. In an evaluation relating to spirituality, it is seen that the majority of the modern conceptions are in line with one of the three categories. (1) God-centered spirituality, regarded as the motivation for the notion and practice in theologies and envisioned to be wide or narrow; (2) earth-centered spirituality emphasizing the correlation between an individual and ecology or nature and (3) humanistic (human-centered) spirituality emphasizing the success or potential of the human. Thereby, spirituality is seen to be a multidimensional structure [21].
The dimensions of the spirituality is a matter, which focuses on making an effort to be in harmony with the universe, striving to find the answers about infinity, and individual's focus on emotional distress, physical disease or death [11,20].
Religion derived from the Latin stem religio, meaning the relationship between the human and a greater power than human. The researchers specified at least three historical definitions of this term: (1) supernatural power, in which individuals are motivated or tied, (2) an emotion emerging in an individual who apprehends such power and (3) the ritualistic behaviors that are done for this power. In the study conducted by Wilfred Cantwell Smith , it is put forth that the religion has been gradually materialized, in other words, religion, which is mostly an abstract process, is turned into a concrete matter through a certain system (for example, religious groups, theological traditions, major world religions, etc.). According to Heschel, religious thinking "is an intellectual effort beyond the depths of reasoning. Religious thinking is a mental source for grasping the inside story of the final problems regarding the human existence [21]. It is a societal institution, which systematizes believing in God, supernatural powers, diverse divine beings; a piety, and an organization, which provides and consolidates in the form of beliefs, rules, institutions, ethics and symbols. Religion is also defined as a system, which anticipates a lifestyle for believers and involves the sacred and metaphysical values or the concept of God within the belief system.

What is the level of religiosity in Turkey?
In a survey conducted with 21,600 participants across 12 regions of Turkey, while 99.2% have been found to define themselves as Muslim, 4‰ as non-Muslim. 5‰ did not answer the question. 98.7% have been found to have no suspicion of the existence of God. About 96.5% of the participants agreed with the statement that the verses of Quran are true and valid in all times 96.5% agreed with the statement that humans will be resurrected and questioned after death, whereas 1% disagreed. About 42.5% of the participants across Turkey state that they pray five times a day; while 16.9 never pray. About 83.4% across Turkey express that they fast if they are in a good state of health. 2.5% never fast. 7.3% do not fast due to health status. While 11.7% of the participants melt lead and pour it into cold water to not be touched by an evil eye, 79.3% do not believe that it is beneficial. It was found that 64.9% shape their lives according to the rules of the religion. About 50.7% of the participants indicate that the most significant criteria of religiosity are to have faith in god, worship in complete and lead a life in line with the Islamic ethics. About 37% report that believing in God and being pure in heart is enough for religiosity, whereas 7.9% define religiosity as worshipping and praying on sacred days [22].

What is the level of religiosity in the United States?
Even though the religious beliefs and rituals are commonly practiced in the United States, it is seen that their implementation and evaluation are less common in the medical applications. In a Gallup Poll conducted in 2008 in the United States, it was found that 78% stated that they believed in God and 15% in a higher spirit. In a study conducted in 2010, it was found that 77% of the Americans identified themselves as Christian, 5% with a non-Christian tradition, 43% reportedly attended religious services at least once a week and 18% did not have an explicit religious identity.

What is the level of religiosity in the Europe?
In a survey conducted across the country in 2013, 26% of the respondents claim that religion is important in their own lives and 22% claim it is fairly important [23]. According to a Gallup poll conducted in 2011, 53.48% of the British claim that they are Christian and 7.22% said that they belonged to other faiths, whereas 39% said they had no religion. In 2015, the poll was repeated and 49% of the participants said they were Christian, whereas 42% said they had no religion. In 2011, a poll was conducted in Scotland and 56% of the respondents said they were not religious and only 35% said they were religious. According to the 2014 survey conducted in nine European countries, a majority of the population believes that did not think that a belief in God was a necessary part of being moral. This figure was as high as 85% in France and 80% in Spain [24].

Spiritual approach and spiritual care
Spirituality can be considered as the first component of the religion; however, it is a very broad term, which cannot be limited only to religious beliefs and applications. Spiritual beliefs or values may or may not be correlated with an organized religion. Besides, people without strong religious beliefs have spiritual dimensions as well. Spiritual values and beliefs are concepts beyond a belief in the power and consist of beliefs subjects such as health, death, sin, life after death and responsibility for others. It is a traditional, ritual and specific doctrine different than that of religion spirituality. Spiritualism is a lot more comprehensive than the religious applications, however, may include religious applications as well [7,8,20].
Spiritual needs are needs that promote the spiritual power of an individual or reduce the spiritual deprivation. Humans can meet these needs by means of relations with humans or God. Spiritual needs can be defined as trust, hope, love, truth, need for finding out the meaning and purpose of life, relationships, forgivingness, creativity, experiencing, need for emotional feelings (tranquility, comfortableness), need for speaking, consolation, rituals, praying and worshipping [6,20].
Spiritual needs and applications are very important concepts for many patients; however, they are ambiguous terms for the health professionals. Throughout history, the doctors have been trained to diagnose and treat disease and received little or no education regarding the spiritual dimension of the patient. In addition to this, it has been alleged that the professional ethical approach permits the doctor to implement their professional practice but not to question the patient's beliefs, and the deficiency in the concept is tried to be explained as such. When the deficiency is combined with the differences in societal beliefs, religious rituals and spiritual applications, a wide range of belief systems emerge. As a matter of fact, no doctor is expected to comprehend the individual applications of different belief systems. What is expected is necessary sensitivity since individual needs may show variations.
When conditions that may arise as a result of spirituality is addressed, it is understood that while the spiritual values help individuals feel themselves better, the spiritual distress occurs in a group of individuals, who are having trouble with their belief and value system, which gives meaning to life and brings hope and power, or in a group of individuals who are at risk. Spiritual distress occurs when the individual's values and beliefs are under threat in the environment they live in or the individual is in an existential crisis. Spiritual distress emerges at times when the individual is in a despair condition or unable to find a reason to live. The individual feels a moral gap. Besides, as a result of spirituality, conditions such as spiritual pain, spiritual alienation, spiritual anxiety, spiritual guilt, spiritual anger, spiritual loss, spiritual despair, disappointment, displeasure, gap, regret, guiltiness, grief may emerge [25].
Health is the harmony between body, intelligence and spirit. Therefore, in order to help the individual to protect and sustain the integrity of their existence, a care system (medical and nursing care), which will ensure the care of individual's existence, should be implemented. The fundamental care functions are to protect and enhance health, prevent diseases and relief pain. Thanks to this point of view, providing care for the spiritual dimension of an individual must be part of the fundamental functions of the health professionals. Individual's needs such as hope, finding the meaning and purpose of life, love and belonging to somewhere are their spiritual needs and in this case, it is a therapeutic application for health professionals to listen to the individual's concerns, empathize with the individual and respond these needs. It is important to evaluate all the humans with this perspective and plan approaches, which will enhance the health of the individual holistically.
There are many effective factors for the spiritual approach to be included within the care services. The opinion system, spiritual needs and comprehending the physical care, hope for health, willingness and sensitivity, which are particularly at the center of the care service among the factors, has been effective. However, the conducted studies show that the patient's spirituality has been ignored and the spiritual care is insufficient (Wong and Lee 2008; [27]). The researchers state that the most important reason for the lack of spiritual care is the time constraint and educational deficiencies. According to a study conducted on nurses, the nurses both consider the issue about spirituality and spiritual care important and meet the work requirements (only 15.5% of the nurses and midwives have obtained information on spiritual care and 33.3% claimed that they have never heard the term spiritual care) [26,27].
There are significant principles, which must be taken into account, regarding spiritual care.
These are as follows: 1. It must be aimed to explain the power of individual regarding the spiritual needs as much as the existing and potential problems.

2.
The primary purpose of the health professionals in spiritual care must be to evoke the spiritual sources of an individual.

3.
Spiritual care must be planned to respond to the spiritual needs of an individual, not to alter their beliefs or change their perspective.

4.
Spiritual diagnosis and care must be built upon a reliable and sensitive relationship between the patient and physician. The care must be planned so that it would involve the culture, social and spiritual sources of the individual as well as their idea and religious applications.

5.
When sharing information about the patients among team members, they must be aware of the personal limitations.

6.
The importance of mentioning the spiritual care in health applications in written must be taken into consideration and the necessary regulations must be established [11].
The studies suggest that the religious beliefs and spiritual applications of the patients are important factors when deciding to cope with diseases and even in termination of life and in the resolution of ethical dilemmas regarding treatment options. It has been found that determining the spiritual beliefs of the patients during the healing process (with correct questions and independent of our own belief systems within the communication process) is very helpful and easier when giving explanatory information regarding the treatment process and its results [23,28]. Research shows that religion and spirituality are associated positively with better health and psychological well-being [28][29][30]. Recent research also shows that patients involved in "religious struggle" have a higher risk of mortality [31]. Thus, physicians need to inquire about the patient's spirituality and to learn how religious and spiritual factors may help the patient cope with the current illness, and conversely when religious struggle indicates the need for referral to the chaplain.
The idea that there is a correlation between the tendency towards spiritual needs and religiosity is a popular belief around the world. However, it can be stated that this is not directly correlated with delivering the health care and religiosity.

It is important to include spirituality into the health applications
Religion and spiritual beliefs play an important role for many patients. When illness threatens the health, and possibly the life of an individual, that person is likely to come to the physician with both physical symptoms and spiritual issues in mind. Humans grapple with common issues of infirmity, suffering, loneliness, despair and death while searching for hope, meaning and personal value in the crisis of illness [32].
Religion is generally understood as a set of beliefs, rituals and practices, usually embodied within an institution or an organization. Spirituality, on the other hand, is commonly thought of as a search for what is sacred in life, one's deepest values, along with a relationship with God, or a higher power, that transcends the self. Persons may hold powerful spiritual beliefs and may or may not be active in any institutional religion. Spirituality can be defined as "a belief system, focusing on intangible elements that impart vitality and meaning to life's events." Many physicians and nurses have intuitive and anecdotal impressions that the beliefs and religious practices of patients have a profound effect upon their existential experiences with illness and the threat of dying. Recent research supports this notion.
It has been found that when patients face a terminal illness, religious and spiritual factors often figure into their coping strategies and influence important decisions such as the employment of advance directives, the living will and the Durable Power of Attorney for Health Care [23,33,34]. In such cases, it is very important to determine the necessary comforting factors for the patient to trust the higher power and cope with the existing crisis.
In another survey, whereas 77% of patients like to have their spiritual issues discussed as a part of their medical care, <20% of physicians currently discuss such issues with patients. Around 50 medical schools now offer "spirituality and medical approach" elective course. The evidence in the medical literature that suggests a strong relationship between spirituality and medicine is increasing [35]. In a conducted study, it was found that religion and spirituality had positive effects on physical health and the nurses had a tendency to believe spirituality as a religious need.
According to a study conducted with 1800 patients by Dr. Herbert Benson from Mind/Body Medical Institute, the conclusion that there is a direct correlation between prayer and healing the illnesses. According to the studies conducted in the United States and the UK, it was discovered that praying reduces the symptoms and accelerate the healing process. According to the study conducted by Michigan University, the depression and stress are less likely to be experienced by religious people, whereas according to the study conducted by Rush University of Chicago, the premature death rate is found to be 25% less when compared with those who are not affiliated with a religion. In another study conducted on 750 patients, who had angiography, by Duke University, "the healing power of prayer" was scientifically proven. It was revealed that the cardiac patients that pray have 30% less mortality rate few years after the surgery. The chaplains prayed for 466 cardiac patients, receiving treatment at St. Luke's Hospital, and as a result the patients who were prayed for healed 11% faster and their disease symptoms reduced. According to the study conducted by Columbia University, people with reproductive problems were regularly prayed for. The fertilization success rate in these people rose to 16% from 8%. The growth rate of the healthy embryo rose to 50% from 25%. In another study conducted on 393 cardiac patients by the Hospital of San Francisco, 150 patients were regularly prayed for and it was revealed that the patients, prayed for by strangers, responded to the pharmacotherapy faster [36,37].
It has been shown in many studies that the spiritual dimension has a clear effect on health, wellness and quality of life [27,38,39]. In the study conducted by Strang et al. [40] in Sweden, it was found that 98% of the nurses considered the spiritual care as necessary and 48% provided spiritual care. In the study made by Narayanasamy (2001), it was discovered that the nurses were not enough aware of the spiritual needs of the patients and emphasized that there was a lack of background information on creating the nursing care scheme about the spiritual care [40].
According to the survey conducted to determine the spiritual values by Wong et al. [27], it was found that the spirituality sub-dimension level was high; however, it was also noted that spirituality should not only be affiliated/evaluated with a religion.
In some studies, the effects of the spiritual well-being, hope and mood are focused upon. Fehring et al. (1997) defined the correlation between spiritual well-being, religiosity, hope and depression and determined the positive mood of the elderly individuals, whose religiosity and spiritual well-being is at a high level, were at a high level. Post-White et al. (1996) discovered that the spiritual and religious hope were influential in 32 cancer patients, who defined hope on the whole [40]. It has been revealed in a study that more than 40% of the 248 cancer patients stated that they got rid of their fears, found the meaning of life, refreshed their hopes and felt vigorous when their seven spiritual needs were met [15]. The researchers carefully examined spirituality and chronic diseases and determined that spirituality was a strong source in order to overcome problems regarding health. It has been discovered in a study on 35 hemodialysis patients that hope, worship and trust in God have an important role in defense mechanism. In a study conducted on patients with arthritis, it was found that they stated that belief in God is an important factor in their well-being. In another study, worship and faith were found to be a very significant source for the cancer patient [9]. In a study conducted on colorectal cancer patients, it was shown that high level of spiritual well-being is effective in the treatment of the major physical symptoms. It has been stated that patients' experiences with cancer increase their spiritual awareness, which is part of themselves [15,41].
Spirituality has a critical importance in patient-centered care when coping with the disease during the diagnosis and the treatment period, survival, relapse and death processes of the cancer patients. Spiritual needs, spiritual distress and spiritual well-being affect the quality of life [42,43]. The spiritual needs of patients with advanced cancer are found to be 72%, and it was stated that the spiritual needs are not supported enough in health care [43]. Being with family was the most frequently cited need (80.2%), and 50% cited prayer as frequently or always a need. Around 26% of the patients cited at least one unmet spiritual need [44]. Hsiao et al. stated that the four most cited spiritual needs during the semi-structured interview by the patients was, hope to survive and have a tranquil state of mind (88%), make life livable and protect dignity (88%), experience mutual human affection (100%), get help for a peaceful death (85%) [45]. In the compilation, in which the psycho-spiritual well-beings of the advanced cancer patients and patients who faced a terminal illness was examined by Lin and Bauer-Wu, they have specified particularly six main themes: self-awareness, effective coping with stress, engagement with others, sense of belief, sense of trust and the meaning of life/hope [46].
On the other hand, there are studies that emphasize adopting religious rituals and approaches or thinking intensively about religion may have negative effects on some patients and results [31]. There could be times that the disease will result in death or approach the terminal period, struggling with religion may play an important role. Patients who feel alienated from God, unloved by God, or punished by God, or attribute their illness to the work of the devil were associated with a 19-28% increased risk of dying. A study of religious coping in patients undergoing allogeneic stem cell transplants also suggests that religious struggle may contribute to adverse changes in health outcomes for transplant patients. In such cases, professional support will positively affect the clinical results [31,47]. In this regard, it is emphasized that the spiritual care units founded in a health unit, provided significant results for the patients since they worked in cooperation with the doctor [48].
It has been emphasized in a study conducted on nurses and midwives that it is significant for the nurses, who have knowledge of spirituality and spiritual care concepts, to provide their patients with spiritual care for the knowledge to be implemented. It was found in the study that the concepts of spirituality and spiritual care are new concepts in the field of nursing, the nurses and midwives did not receive sufficient information regarding spirituality and spiritual care during their training and did not provide spiritual care. It was revealed that the nurses and midwives were affected by receiving information and providing the patient with spiritual care as a result of their scores on the spirituality and spiritual care evaluation scale. Therefore, it is recommended to include spirituality and spiritual care concepts within the nursing and midwifery training curriculums and regulate on-the-job training programs, intended for developing the awareness, knowledge, and applications of the nurses and midwives on holistic care's spiritual dimension [6].
In another study conducted in Turkey, it was found that the nurses lacked knowledge regarding the concept of spirituality and had a tendency to consider the spirituality as part of religious needs. Thus, the importance of providing enough knowledge to the members of the healthcare team on spiritual and religious needs of the patients was emphasized during their training [49]. In the study conducted by Yılmaz and Okyay [50], it was discovered that 34.8% of the nurses obtained information regarding spirituality and spiritual care. While 70.3% defined the concept of spirituality correctly, 93.4% defined the concept of spiritual care correctly. In the study, 33.3% of the nurses and midwives claimed that they have never heard the concept of spiritual care [50].
In the study conducted by Çelik et al. [51], it was found that the nurses' comprehension of spiritual care affects the spiritual care service as well. There are new studies concerning spiritual care other than the field of nursing in Turkey. First of all, "1st National Psychology of Religion and Spiritual Care Workshop" was organized. "Cooperation Protocol Intended for Providing Spiritual Support in Hospitals" signed between the Presidency of Religious Affairs and the Ministry of Health on 01/07/2015. During the signing of the protocol, it was stated that the Ministry of Health has been cooperating with the Presidency of Religious Affairs since 2012, and case studies from Europe and the United States have been examined. After the chaplains are trained with the required knowledge, the spiritual support service will be provided to the patients and patient's relatives for the first time through the pilot scheme in some cities [52].

What should be done when determining the spiritual needs of the patients?
It has been emphasized in many studies around the world that there is a necessity for identifying the needs for spiritual care and evaluating spiritual/moral distress. Even though there are many scales in the literature regarding the matter, they need to have a conformability and validation between cultures when identifying the spiritual needs.
HOPE questions, which were developed to help to initiate the spiritual evaluation process during the meeting/medical anamnesis for doctors, are significant in qualitative aspect for the statements to be evaluated. They are confirmed by a survey by the researchers who developed it. This specific approach enables the general spiritual sources and concerns of the individual to be expressed with open-ended statements [35].
HOPE Questions are officially used for spiritual evaluation by doctors. First clue: H is related to the basic fundamental spiritual sources of the patient without directly focusing on spiritu-ality or religion. Sources of hope, meaning, comfort, strength, peace, love and connection. This approach enables the patient to communicate on a variety of significant matters. Here, spirituality involves significant contacts, which are excluded from the limits of traditional religion, or covers people who have somehow drifted apart the religion. It allows some to express the concepts of prayer or god explicitly and voluntarily. There are many ways to ask questions in this regard and identify it. The second and third letters are O and P. It shows the area of assessment made to determine the importance of religion in patients' lives and the most beneficial applications for individual spirituality. If the answer to this question is "Yes," the inquisition should continue with questions concerning religion and individual spirituality. If the answer to this question is "No" and the patient seems to be comfortable, the physician either could conclude the inquisition or try to elaborate on the matter by asking "Isn't it important for you at all?" If the answer to this question is "Yes;" the physician may ask so now "What has changed?" in order to discuss the spiritual anxieties, which may have an impact on the medical care of the patients. The last reminding letter is "E." The matters concerning the medical care and termination of life are about the spiritual effects and beliefs of the patient. These questions might be especially helpful in the clinical care service level to an extent that they could be used in clinical management. They could also be beneficial for the patients, who are in the oncological treatment process, or patients with chronic diseases [35].
In the approach recommended to be used in the care processes of the nurses: Listening to the patients statements concerning their spiritual tendencies;

2.
Evaluation of the observable signs on the patient and their room regarding the spiritual tendencies; spiritual books (Bible, Quran, etc.) and symbols (cross, etc.).

3.
Evaluation of the anxiety (concern) symptoms; discouragement, worry, weakness/ insufficiency in participation the daily spiritual applications, patient's statements regarding their concerns about god or higher power.

4.
Evaluation of the spiritual distress symptoms: A communication process must be sustained taking into account the statements as follows: crying, sign of guiltiness, sleep disturbances, lack of spiritual trust, feeling of alienation from god or higher power, anger against health professionals/family/god or higher power, refusal of the belief and value systems, losing the meaning and purpose in life [15].
Individuals with spiritual perspective must be respected in health care; the health professionals must protect the fundamental principle autonomy and ensure the benefit-damage balance when determining the treatment and care plan, prepared for the patients. The implementation of the treatment and care scheme must be paid attention as part of the individual's respect principle. All the medical rehabilitative services delivered to the individuals must be implemented within the fundamental ethical principles. Even though the individual's respect principle is based on a secular foundation, it cannot be isolated both from the perception of the value of the health professionals and the patients, especially from the disease conditions.
There is always a person, who needs the value system, identified as the god or higher power. Accepting this as a fact or not ignoring it means the completion of the patient's physical, emotional, social and spiritual care. Thus the value judgments, which the patient has for their spiritual well-being, are their integral part. The protection of the existence of this integral part is the most fundamental way to respect.

Hospitals should work with the spiritual care specialists
The doctor needs a teamwork formed by well-educated chaplains/spiritual care specialists, who are trained to help the patient in a hospital. It is encouraging for a doctor to let their patients know that they are not alone concerning their spiritual needs; however, doctors may also be unauthorized in terms of spiritual needs.
Humans are indisputable beings due to their existence. The value of human beings does not decrease when they are diseased or it is hard to be granted for them or cannot be ignored. The high-speed change and differentiating needs have been more on the front lines when eliminating the illnesses. The coping methods should be included in the spiritual needs as part of the holistic health applications. Spiritual needs are considered to be an unavoidable part of the global health system as an evaluation scope. Both the doctors and patients have some difficulties in understanding the concept of spiritualism from this aspect within the societal organization. The studies and discussion, which will be made regarding this matter, will be a significant step for creating awareness. Since the beginning of history, the existence of spirituality within the holistic approach is as important as the other components since its sensitivity to the diseased individual and the support it provides during the healing process. It was scientifically proven that alienation from the patient-centered approach in medical applications for a certain period of time had negative effects on the patients. It has been intensively discussed again to include the holistic approach and its components in the medical applications.
In the recent history, there was a legal gap on delivering the spiritual services oriented towards either inmate or outpatient. In 2016, the cooperation protocol was formed, which was intended for delivering "spiritual care and religious consultancy services in hospitals." Within the limits of this protocol, six pilot cities including Ankara were identified and spiritual care units were formed and chaplains began to provide service. In the spiritual care unit, the patients and patients' relatives are provided with spiritual values such as patience, meditation, prayer/ implementation of some rituals related to beliefs and spiritual approaches with religious themes like destiny/sense and belief of existence. The implementation is a significant step for our country. It is insufficient and unilateral. It is necessary to scientifically emphasize the importance of this approach, in which the medical services are included, can be carried out by the health professionals, who has a qualification to talk with the patients and their relatives, and it even must be performed [52].
In this aspect, implementing the spiritual care applications effectively and efficiently, receiving wide acceptance and correct planning of the studies plays a crucial role. First of all, it is necessary that the health professionals, who are going to deliver this service, must believe the significance of this concept and form the correct approach methods for the patients. Therefore, primarily it is necessary for the health professionals to; (a) Possess the psychological counseling skills, (b) Possess the fundamental health knowledge, (c) Grasp the illness psychology, (d) Use the effective communication skills and (e) Be dominant over the religious literature, grasp the religious and cultural values of the community they live in. When delivering the health care, a sincere approach, and environment, which can deliver the holistic medical care services oriented towards understanding the sociocultural and psychological state of the patient along with understanding the family of the patient and the environment they live in, must be developed. In the course of these applications, it is very important to maintain the respect for the autonomy of thought and belief as part of the fundamental principle "no-harm." Whether the health professionals are a member of a religion or not, their beliefs and value judgments may affect the physician-patient relationship. In this bilateral condition, the physician should never ignore the individual respect principle for the patient. The fundamental purpose of the health professionals is to listen and talk to the patient.
The health professionals are as free as the patients on practicing their own belief and value judgments. The majority of the times the problem is not being able to put limits on the patients when determining the patients' needs and discussing their condition and patients' responses with instructions or obstructions. The health professionals refraining from these, mostly prefer to ignore patients' these needs.
If this approach is executed with responsibility, it will be a significant improvement in the medical discipline, spirituality and science integration. The studies, which will be conducted, will offer new opportunities to both develop the medical care services and to understand the great mystery behind life and medicals.

Obstructions which emerge when discussing the spiritual matters
Some doctors may find some reasons to prevent the controversies on the spiritual beliefs, needs and benefits of the patients. The reasons why the doctors do not discuss these matters are an improper environment, lack of knowledge on spiritual issues, or the variety of religious statements due to different cultures. Since the doctors do not possess any training on how to manage the meetings with their patients regarding this matter remains as one of the biggest obstacles. Occasionally, the doctors may have to approach the patients tolerably in order not to violate the ethical and professional limits or impose their own ideas on the patients.
In 2004, JAMA's curricular survey showed that: "in 1994, only 17 of the 126 accredited US medical schools offered courses on spirituality in medicine. By 1998, this number had increased to 39, and by 2004, to 84 schools" [53].
In 1998, Association of American Medical Colleges (AAMC) developed medical school objectives related to spirituality and cultural issues. Regarding this matter, the prospective physicians are expected to improve themselves with the help of spiritual and cultural program.
Beyond the 4 years of medical school, residency programs, particularly, those with a primary care focus and a palliative care focus, are incorporating education in spirituality training residents. In addition, Continuing Medical Education (CME) events are now offered to practicing physicians through a series of annual conferences on "Spirituality in Medicine," the first of which was hosted by Harvard Medical School with Herbert Benson, MD, as a facilitator.
Since 2008, Dr. Puchalski has directed an annual Spirituality and Health Care Summer Institute sponsored by the George Washington Institute for Spirituality and Health (GWISH) in Washington D.C. [23].

Conclusion
The patient benefits from a physician, they trust in and get support from. In the medical applications from past to present, the necessity of three fundamental combinations has been emphasized, the modern, classical medicine, biomedical medicine, holistic consciousnessbased medicine. Holistic medicine, focusing on the spirit and self-ego, reveals the sense of life and the world and particularly the hidden and secret sources and power inside the patient. All three approaches form a combined whole. The holistic approach is unavoidable and necessary, particularly in diseases whose process is long and painful. In studies conducted in this aspect, it is seen that some approaches, implemented taking into account the spiritual past of the person, can be carefully examined. There are some issues, which must absolutely be discussed: Are patients' beliefs are important? Do they have a set of rituals related to their beliefs? Do these require limitations? The spiritual emotions patients are feeling must be evaluated. In this respect, when supporting the patient, aid must absolutely be received from the spiritual care specialists and sometimes from the chaplains. How the spiritual problems of the patient should be taken into consideration must be evaluated with the patient. There are some issues which need to be clarified: How can the spiritual care applications be influential/ efficient and receive general consent? How to correctly plan the studies in this aspect? Who can primarily provide this service and what kind of training they need to have? The spiritual care studies should be conducted interdisciplinary and under a single roof. Psychology, Psychological Counseling and Guidance, Psychiatry, Social Services, Psychology of Religion and Health Sciences must be a strong liaison with each other.