Jurnal Keperawatan Padjadjaran

ISSN 2338-5324 (print)

ISSN 2442-7276 (online)
Online di http://jkp.fkep.unpad.ac.id
DOI : 10.24198/jkp

Correlation between Spiritual Well-Being and Level of Fatigue

among Patients Suffering from Breast Cancer

Maria Komariah1, Mohd Khairul Zul Hasymi Firdaus2, Kalpana Paudel3, Abdul Latif4
1
Faculty of Nursing, Universitas Padjadjaran, Bandung, Indonesia, 2Kuliyyah of Nursing, International
Islamic University Malaysia, Kuantan Pahang Darul Makmur, Malaysia,
3
Maharajgunj Nursing Campus, Institute of Medicine Tribhuvan University, Kathmandu, Nepal,
4
National Institute of Advanced Nursing Education and Research, Dhaka, Bangladesh
Corresponding Email: [email protected]

Received: 09-01-2021 Revised: 01-04-2021 Accepted: 05-04-2021

Abstract

Cancer-related fatigue has been shown to be a significant side effect that influences a person’s wellbeing, during
treatment, and after treatment. It is recorded that cancer patients have also been shown experiencing spiritual
distress. The study aims to determine the connection between spiritual well-being and cancer-related fatigue
among patients suffering from breast cancer during chemotherapy treatment. 112 patients who were undergoing
chemotherapy treatment were recruited in this study using a correlational design. The instruments used in
assessing spiritual well-being and fatigue are Functional Assessment of Chronic Illness Therapy - Spirituality
(FACIT-Sp) and FACIT-Fatigue Scales. Data were analyzed using the Spearman Correlation analysis. Mean
spiritual well-being score was 35.91 (SD = 6.89), and the mean fatigue score was 33.04 (SD = 9.58). There
were a moderate and significant correlation between fatigue scores and spiritual well-being (r = .364, p < 0.001).
Breast cancer patients who had higher spiritual well-being that means they would alleviate fatigue symptoms.
Therefore, nurses should consider that increasing spiritual well-being would reduce fatigue and vice versa.

Keywords: Breast cancer, chemotherapy, fatigue, spiritual well-being, treatment.

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 Maria Komariah: Correlation between Spiritual Well-Being and Level of Fatigue among Patients

Introduction fears about death. Thus, it results in patients

experiencing set-backs in a chemotherapy
Breast cancer patients with a complicated treatment schedule (Borneman, Irish, Sidhu,
stage suffer from the threat of death, Koczywas, & Cristea, 2014).
uncertainty, and various symptoms because Fatigue is a general term used to describe
of the disease and its treatment (fatigue, pain, the different feelings with a diversity of
weakness, dry mouth, constipation, decreased terminologies indicating alleviated either
energy, taste change, and depression) (Sari, physical, mental, emotional, or social
2019). All these symptoms are reported to capacity, and it is also indicate distress
impact on a cancer patient’s functional status (Lewis, Salins, Rao, & Kadam, 2014).
and wellbeing status (Dodd, Cho, Cooper, Fatigue is the paramount prevailing symptom
& Miaskowski, 2010). Spiritual distress can among cancer patients receiving radiation
occur due to suffering of being terminally ill therapy and cytotoxic chemotherapy. CRF
(Lestari, Nuraeni, & Setyorini, 2018; Loh, is an experience subjective to the individual
2004; Villagomeza, 2005). Patients with cancer patient, and it is affected by various
spiritual distress have stated that they see the determinants, such as physical, psychological,
meaning of their life, their illness, death and and spiritual factors. Physically, fatigue
suffering as a punishment. Such patients may can result from the direct effects of cancer,
well be unstable emotionally, sad, withdrawn, cancer-related symptoms, and therapy effects;
apathetic, and in denial (Komariah, Adriani, psychologically, fatigue can result from the
Indrayani, & Gartika, 2020; Loh, 2004). emotional distress stimulated by cancer and
Having a complicated breast cancer diagnosis, its effects; and spiritually, fatigue can result
or other life-threatening conditions, could from the spiritual dryness due to cancer. Not
change a person’s perception about life only a few cancer patients feel like religion
(Komariah, Adriani, et al., 2020; Manning- or spirituality becomes their comfort, which
Walsh, 2005), and put such an individual in several occasions, it is associated to
in danger for altered spiritual well-being positive psychological result and depletion
that changes within the person’s wellness, in distressful symptoms (Lewis et al., 2014).
symptoms of their disease and treatment. Spirituality is said to higher quality of life
Moreover, many studies have reported that because it provides social support, enhances
the impact of advanced breast cancer patients the connection with the spouse, and provides
enduring cancer-related-fatigue (CRF) is interpretation, and decreases self-focus
extensive (Hsieh et al., 2019; Kinkead et and anxiety (Garssen, Uwland-Sikkema, &
al., 2018; Zimmaro et al., 2019)). Most Visser, 2015). Studies also showed that, in
cancer patients reside with CRF because contrast to those who only involved less in
of their cancer treatment and diagnosis. A spiritual activities, patients with certain illness
number of advanced breast cancer patients but holding a great principle to spirituality
might have physical and psychological seem to have a finer adaptation, undergo
comorbidities that may augment fatigue the higher level of well-being and quality of
and complicate its management (Bower, life, and encounter lower degree of distress
2008; Loh, 2004). Fatigue symptoms are (Garssen et al., 2015). This study examines
also the common side effect of patients who spiritual well-being and fatigue in patients
are admitted to the chemotherapy unit in suffering from breast cancer who undergo
Indonesian hospitals (Nurhasanah, 2014). chemotherapy and determines presence of
According to the National Comprehensive interconnection between fatigue and spiritual
Cancer Network (2009), fatigue experienced well-being in breast cancer stage III.
by cancer patients is a state of persisting Concept of spiritual well-being is defined
weakness, where the sensations felt are very as an expression (Wilding, Muir‐Cochrane,
personal, as well as the type of fatigue that & May, 2006), a person’s mental spiritual
is not relieved by rest. Fatigue can affect measure, which is built by two domains,
patients in an immensely negative way. It namely religion and spirituality. Clay, Talley,
impacts on the spiritual well-being due to and Young (2010) defined spiritual well-
feelings of uncertainty, helplessness and being as the capability to foster expectation

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 Maria Komariah: Correlation between Spiritual Well-Being and Level of Fatigue among Patients

and take interpretation from life experiences figured that life-threatening diseases, for
and feel the life force in dealing with self, instance breast cancer, can be a spiritual
God, family, and life elements that help encounter and a deeply emotional experience
empower themselves. Spiritual well-being is as they cope and find the way toward healing.
instrumental in health and healing process. Therefore, it can be concluded that spiritual
According to Ellison (2006), the spiritual well-being in this study reflects the extent to
well-being is defined as the process of which patients live in harmony with regard
elaborating the nature of the dynamic bond to the meaning, purpose, and values of life
between the person and the Creator, whose amidst suffering from cancer (Komariah,
harmonious relationship is dependent on Hatthakit, et al., 2020) This component is
the deliberate self-development, usually on important in the treatment process of cancer to
the basis of the appropriateness between increase hopeful health results. In Indonesia,
experiencing a meaningful life, the goals and two studies tested about the level of spiritual
values of personal life. This self-development well-being among breast cancer patients, they
is also made as a personal challenge, done by stated that moderate level of spiritual well-
meditation or contemplation leading to an being among all cancer survivors (Suara,
inner state of happiness. Mardiyono, & Anggorowati, 2017) but poor
Gomez and Fisher (2003) explain spiritual level of spiritual well-being among breast
well-being as a concept describing the innate cancer patients undergoing chemotherapy
state, with an element of motivation or inner (Wahyuningsih, Sofro, & Dwidiyanti, 2019).
drive to find the purpose of life, which is Additionally, several studies have shown
naturally dynamic and subjective. Further, it that 80% to 90% of patients suffering from
is focused on something distinctive, which breast cancer experiencing fatigues during
then is believed to be the truth. Spiritual well- undergoing chemotherapy (Schmidt et al.,
being contains a real act of dealing with the 2015). Fatigue symptoms were consistently
essence of existence, certain inner experience documented for above 50% of various types
and belief. All of them provide a goal, meaning of cancer therapy (Naraphong, Lane, Schafer,
and values for a quality of life, e.g., by giving Whitmer, & Wilson, 2015). Research study
thanks to God, loving others, and learning regarding fatigue among breast cancer in
from previous life experiences (Gomez & Indonesia reported that majority of the breast
Fisher, 2003). Spiritual well-being has some cancer patients developed fatigue in moderate
components, such as, feelings of harmony, level (50%) and , severed level 61 (42.4%)
peace, the meaning and purpose of life, and whereas only few (7.6%) of them had mild
the power of faith (Bredle, Salsman, Debb, level of fatigue (Dahlia, Karim, & Damanik,
Arnold, & Cella, 2011). Faith is an important 2019).
aspect that contributes to the spiritual well- The chemotherapy regimen can cause
being of the person. Various studies have fatigue; for instant, breast cancer patients
pointed out that faith, especially faith in God, who received 5Fluoroacil, Doxorubicin
helps the cancer patient to live well amidst and Cyclophosphamide chemotherapy had
the pain and suffering from cancer. There muscle weakness caused by stimulation cell
are many ways in which the persons with oxidative reactions from peroxidation lipids
advanced breast cancer express their faith in and protein carbonyl. They are released
God and how belief in God helps them to cope from doxorubicin and delivered to C2C12
with cancer. Some of them express faith in myotubes which will activate caspases
God through prayers asking for strength and enzymes and proteolysis and which result
spiritual well-being (Komariah, Hatthakit, & in muscle cell apoptosis. It causes reduced
Boonyoung, 2020). muscle mass and contraction ability as
Regarding sense of spiritual well-being, in the originator of the complaint of fatigue
a Muslim country, Ahmad, binti Muhammad, (Gilliam & St. Clair, 2011). When cancer
and Abdullah (2011) used a qualitative study threatens the meaning of an individual life,
to explore religious practice and spirituality religion and spirituality are often important
and coping among three Malay Muslim coping strategies (Lewis et al., 2014). Fatigue
females with advanced breast cancer. They can impact all dimensions of a person’s life

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 Maria Komariah: Correlation between Spiritual Well-Being and Level of Fatigue among Patients

including physical, psychological, social of fatigue, whereas a lower outcome of

and spiritual well-being. This study assesses FACIT-F indicates a high level of fatigue.
the correlation between spiritual well-being The original instrument showed reliability
and level of fatigue among patients suffering of alpha Cronbach 0.95 and the validity test
from breast cancer undergoing chemotherapy 0.88 (Yellen, Cella, Webster, Blendowski, &
treatment. Kaplan, 1997) while the Indonesian version
reported 0.88 for reliability test and alpha
Cronbach .95 (Aisyah, 2017).
Method The Functional Assessment of Chronic
Illness Therapy (Spiritual) (FACIT-Sp).
This is a cross sectional study appraising The measurement of spiritual well-being
fatigue and spiritual well-being in breast was assessed by the FACIT–Sp which
cancer patients undergoing chemotherapy. was established by Cella et al. (1993).
A total of 112 breast cancer selected using The FACIT-Sp is a 12-item scale with 2
consecutive sampling who receiving subscales (meaning/peace and faith); 8 items
chemotherapy between January and June of meaning/peace (items 1, 2, 3, 4, 5, 6, 7,
2018 at Chemotherapy unit in a teaching 8), and 4 items of faith (items 9, 10, 11, 12).
hospital, if they satisfied the selection criteria Using Likert-type scales (absolutely not = 0,
and gave consent to participate. Inclusion a bit = 1, slightly = 2, quite a lot = 3, very
criteria consisted of aged more than 18 years much = 4). A higher score indicates a higher
old, have a diagnosis of stage III newly or stage of spiritual well-being. Reliability
recurrently, cognitively intact without mental was announced for the total FACIT-Sp and
illness. The participants who satisfying the subscales. The internal consistency varied
selection criteria and willingness to participate from 0.81 to 0.88. The possible scores of
in this study imparted the following self- the FACIT-Sp stretched from 0 – 48. The
report questionnaires to examine fatigue and instrument had a Cronbach’s alpha coefficient
spiritual well-being. Fatigue and spiritual of .87.
well being were assessed using the functional Data was registered in Microsoft excel
assessment of chronic illness therapy and evaluated using statistical package for
(FACIT) measurement system, which is a social science version 16 (IBM corporation).
collection of QOL questionnaires aimed to A Bivariate Spearman’s correlation analysis
the management of chronic illness such as was carried out between independent and
cancer. The tools are validated and permission dependent variables.
for use wasobtained following registration
(www.facit.org). It is a cross sectional study
where the patients were screened at a certain Results
point of time during their active cancer
chemotherapy medicaments. The researcher A total of 112 breast cancer patients
did the screening after obtaining patients undergoing chemotherapy were included
informed consent for the same. The study in the study. Average age of patients who
was authorized by Intuitional review board participated in the study was 47.2 ± 8.2
of the Faculty of Nursng, Prince of Songkla years. Among the patients studied 32.1%
University, Thailand, number 2017 NSt-Qn had stage IIIa, 60.7% had stage IIIb, and
054. 7.2% had stage IIIc illness (Table 1). Based
The Functional Assessment of Chronic on the demographic data crosstab analysis,
Illness Therapy (Fatigue) (FACIT-F) was the study resulted that only the education
utilized to estimate the level of fatigue. had a significant relationship with spiritual
The questionnaire consists of 13 items in well-being. While the occupation and family
the form of statements. The total score of income had significant relationship with
FACIT-F should be in the range of 0-52. If fatigue (Table 2).
the score was < 30, this indicates that the Bivariate relationships were chosen
patient is having severe fatigue. The higher between dependent and independent variables
score of FACIT-F demonstrates a low-stage using Spearman’s correlation analysis. There

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 Maria Komariah: Correlation between Spiritual Well-Being and Level of Fatigue among Patients

was a notable connection between fatigue (Table 3).

scores with spiritual well being (P < 0.001),
Table 1 General Data on the Breast Cancer Patients Undergoing Chemotherapy
General Data Categories Frequency Percentage (%)
Age (Year) Mean : 47.2 - -
SD : 8.2 - -
Range : 27 – 64 - -
Education Primary 63 56.3
High School 41 36.6
University 8 7.1
Marital Status Single 4 3.8
Married 89 79.2
Widow 19 17
Breast Cancer Staging IIIa 36 32.1
IIIb 68 60.7
IIIc 8 7.2
Chemotherapy treatment FAC 90 80.4
TAC 13 11.6
AC+paclitaxel 9 8.0
Chemotherapy/cycle 1 42 37.5
2 35 31.3
3 16 14.3
4 19 16.9

Tabel 2 Crosstab of Demografic Data, Spiritual Well-Being, and Fatigue

Demographic data Spiritual well-being Fatigue
Education 0.023* 0.087
Occupation 0.322 0.009*
Family income 0.335 0.014*
Chi Square, *p < 0.05

Table 3 Means, Standard Deviation and Correlations of Spiritual Well-Being and Fatigue
Variables N Mean Value SD Correlation p
Spiritual well-being 112 35.91 6.9 .

Fatigue 112 33.04 9.6 .364 0.000*

Discussion that by increasing spiritual well-being, it

would potentially reduce fatigue and vice
The study reported that there is a positive versa.
association between spiritual well-being and These associations could also mean that
fatigue; it means that higher spiritual well- spiritual well‑being would suggest more
being would alleviate the fatigue symptoms. connectedness in life that would aid them
In other words, the nurses should consider endear to positive health behaviors such as

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 Maria Komariah: Correlation between Spiritual Well-Being and Level of Fatigue among Patients

being physically and socially active, going multidimensional, multifaceted approach

for walks in nature etc., This could give is quintessential for successful treatment
them a purpose and meaning in life and outcomes. In cancer patients, the focal
reduce distressful symptoms. Indian study on point is usually aimed at treatment and
spiritual well‑being in advanced lung cancer treatment related matters, regulating physical
showed that there was statistically notable symptoms and comorbidities. Psychological,
association between spiritual well‑being and interpersonal and spiritual well‑being matters
depression, anxiety, five domains of QOL are seldom evaluated and addressed (Nuraeni,
(fatigue, distress and sadness, mood, work, Ibrahim, & Rizmadewi, 2013; Nuraeni et al.,
relationship with others) and enjoyment 2015). This study brings out the importance
of life (Kandasamy, Chaturvedi, & Desai, of spiritual well‑being in cancer patients and
2011). Spiritual wellbeing is a complex its impact and correlation on fatigue which
dynamic state which has a significant impact is one of the most distressing and difficult to
on clinical outcomes (Komariah & Ibrahim, treat symptom.
2019; Nuraeni, Nurhidayah, Hidayati, Sari, According to Bredle et al. (2011), spiritual
& Mirwanti, 2015). well-being has some components, such as,
Cancer related fatigue is an immense feelings of harmony, peace, the meaning and
perception of exhaustion physically, mentally, purpose of life, and the power of faith. Faith
emotionally which occurs secondary to the is an important aspect that contributes to the
disease or due to disease related treatment. spiritual well-being of the person. Various
It can persevere over time and interferes studies have pointed out that faith, especially
with daily routines and varies from the faith in God, helps the cancer patient to live
tiredness of everyday life, which is normally well amidst the pain and suffering from
nonpermanent and diminished by rest. Cancer cancer. There are many ways in which the
treatment‑related fatigue usually enhances persons with advanced breast cancer express
following therapy is done; nevertheless their faith in God and how belief in God
several levels of fatigue may continue for helps them to cope with cancer. Some of
months or years after the treatment. Research them express faith in God through prayers
specifies that for at least a subset of patients, asking for strength and spiritual well-being
fatigue may be a conspicuous matter long (Komariah, Hatthakit, et al., 2020).
into survivorship. A study done by Taylor in patients
According to Lewis et al. (2014), fatigue is with recurrent cancer with various clinical
a general term used to describe the different subtypes showed that the symptom distress
feelings with a diversity of terminologies was inversely related to spiritual well‑being
indicating alleviated either physical, mental, (Taylor, 1993). A similar kind of study done
emotional, or social capacity, and it is in breast cancer patients showed that lower
also indicate distress. Fatigue is the most amount of symptom burden and distress was
prevailing symptom among cancer patients associated with a better spiritual well‑being
receiving radiation therapy and cytotoxic (Manning-Walsh, 2005). Likewise,
chemotherapy. Fatigue symptoms were demoghraphic data, namely education was
consistently documented for more than 50% significantly related to spiritual well-being,
of various types of cancer therapy (Naraphong it was inconsistent with previous study
et al., 2015). indicated that education unrelated to spiritual
Health related QOL is the degree to which well-being (Suara et al., 2017). In the present
average or predicted physical, emotional study, occupation and family income were
and social wellbeing are influenced by significantly unrelated to spiritual well-being,
a medical condition or its treatment. Its however they have a significantly related to
evaluation demands for attention to several fatigue.
measurements, which include physical The findings of this present study support
concerns (e.g. symptoms), functional ability, that the nursing interventions to increase the
family well‑being, emotional well‑being, patients’ spiritual well-being can reduce their
spiritual well‑being, sexuality and social fatigue. So, this research can be used as an
functioning. Hence in cancer treatment evaluation and input to enhance the quality

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 Maria Komariah: Correlation between Spiritual Well-Being and Level of Fatigue among Patients

services, particularly the provision of holistic

nursing care among patients with breast Bredle, J. M., Salsman, J. M., Debb, S. M.,
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Dahlia, D., Karim, D., & Damanik, S. R. H.

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