Nursing is a profession based on human needs and the only task that has not changed throughout history is care, which is the basis of nursing practices [1]. While providing care, nurses have to make the right decision in order not to harm human health and dignity. Nurses' conscience is a prerequisite for them to make the most ethically correct decision and provide care [2]. Conscience is a feeling that leads a person to be in favor of doing good, to reject evil and to be uneasy with evil, and is an emotion that constantly judges. It is also the ability to morally judge one's conscious actions and the level of understanding of what is right or wrong [3]. For nurses to provide effective care and protect their own health, intelligence, which is the ability to solve problems, is important as well as the ability of conscience to make the right decision [2]. Intelligence is all human abilities of thinking, reasoning, perceiving objective facts, judging and drawing conclusions, comprehension, intelligence and heredity [4, 5]. In the information age, a different dimension was brought to the concept of intelligence, and the concept of 'conscientious intelligence' emerged by using conscience and intelligence together [3, 6].

Conscientious intelligence, also known as spiritual intelligence, is listening to one's inner voice and being aware of one's internal and external responsibilities [7]. Listening to the inner voice, being aware of internal and external responsibilities, responsibility towards the creator, accountability, having ethical values, reasoning, being humble, having principles, wisdom and honesty constitute the values of conscientious intelligence [7]. Tarhan (2012) defines conscientious intelligence as the ability to act in awareness of one's responsibilities and at an internal level of consciousness [7]. Conscientious intelligence forms a whole with dimensions such as inner voice listening, corresponding to internal and external responsibility, accountability, and acting according to moral values, which include one's responsibility towards oneself and others [3, 7]. Conscientious intelligence is based on conscientious values [7]. It is anticipated that in organizations where individuals act according to conscientious values, activities will be conducted for the benefit of all stakeholders [8]. It is inevitable that nurses, who constitute an important component of health care systems, acting according to conscientious values will provide significant benefits to the health system [9, 10]. Conscientious values help nurses to provide quality and honourable care, to be understanding and careful in care delivery, reduce errors, encourage the protection of patient rights, and play an important role in decision-making, informing and guiding professional practices [1, 11]. In studies conducted in Turkey, it has been determined that conscientious intelligence is also effective in increasing nurses' work motivation and managing patient expectations [2, 4]. For these reasons, conscientious intelligence, which originates from conscientious values, has a very important place in nurses [12]. It has been stated that the high level of conscientious intelligence of nurses will enable them to solve their problems conscientiously, improve themselves by adopting a conscientious approach, and achieve prosperity and happiness [13]. In addition to nurses' own happiness, it has also been determined that the development of conscientious intelligence can help nurses to improve their creativity, productivity, versatility and communication skills for the benefit of patients [14]. In addition to the conscientious intelligence of nurses, their level of empathy is also very important in fully meeting patient needs, increasing satisfaction and maintaining healthy communication. Patients from different cultures have different health conditions such as nutrition, pain, tendency to alternative treatment methods, health-disease perceptions, and body language use. Conscience enables us to understand and respect these differences and the different values of patients [4]. The nurse should demonstrate an empathic approach to detect differences. Empathy in nursing is defined as the ability to fully understand and share the patient's feelings and thoughts by establishing healthy communication with evidence-based constructive approaches. Shared understanding based on empathic communication complements useful data for planning individualized care that encourages patients to actively regulate their health [15]. Empathy, caring, compassion and personal characteristics of the nurse are indicators of a value that is fundamental to the professional identity and ideology of nursing [16]. In order for the nurse to assist the patient they are caring for, it is essential for them to first reach out to the patient, show respect, try to understand them, engage with them, be aware of their needs, and maintain a relationship based on trust. A nurse can only reach the patient through communication knowledge and skills. At this point, while the nurse forms the foundation of care with an empathetic understanding, they also take the patient's culture into account when addressing individual needs effectively. The nurse reflects the importance of cultural values, beliefs, practices, and attitudes in the foundation of care and demonstrates a holistic and humanistic approach to care by using the ability to empathize [17, 18]. Holistic nursing care is a special nursing practice that argues that body, mind, spirit, emotions, environment, relationships and social and cultural aspects of life are interconnected and should be handled as a whole [19]. Holistic nurses should be able to use their intuition in addition to knowledge, theory, expertise and experience in order to provide care to the patient as a whole in the healing process of the patient [20]. In addition, they should maintain holistic communication, respect cultural diversity and show an empathic approach by accepting differences. Thus, a real holistic nursing care can be mentioned [21].

When we look at the definitions of the concepts of conscience and empathy, which emphasize the spiritual aspect of human beings, it is seen that they are intertwined concepts [22]. In addition, a nurse's ability to exhibit empathic behaviors depends on her/his spirituality [23]. According to the holistic approach, the individual is a whole with physical, emotional, mental, social, cultural and spiritual aspects. To protect and maintain the integrity of a person, spiritual needs must be met in addition to all their needs [24]. Spirituality is the life force in the individual, the search for the meaning and purpose of life, being in a relationship with the creator, healing through prayer, faith and meditation, and a sense of well-being through inner peace [25]. Spirituality can be defined as a broader and more universal construct than religiosity; spirituality is framed as a subjective experience that can exist both inside and outside a religious framework [24]. Spirituality plays a holistic and unifying role in medical and social services and plays an important role in helping people to regain their health, or if this is not possible, to face the current situation and maintain their connections with life [24]. Ethical and effective nursing care should respect the patient's spirituality and religiosity. Given this imperative, nurses are increasingly expected to provide spiritual care that assesses and addresses the spiritual distress and challenges of patients and families [26]. Spirituality-oriented nursing care includes diagnosing the spiritual needs of the individual, planning interventions for these needs, implementing interventions, as well as supporting the individual and evaluating the care [25]. Active listening and empathic approach, recognizing the spiritual, physical and emotional needs of the patient, supporting the patient's beliefs, the meaning attributed to the disease, spiritual history and religious practices are the practices that constitute spiritual nursing care [27]. However, nurses face some obstacles in providing spiritual care, such as insufficient time, lack of training, and the belief that spirituality is a private subject and that nurses should not enter this subject. Due to these obstacles, the frequency of nurses providing spiritual care decreases [24].

Conscientious intelligence has emerged as a result of the integration of intelligence with spirituality. The spiritual nature of man constitutes a motivation, the direction of which depends on human knowledge and reason. While recognising the similarity and integration between religion and spirituality, there is also a consensus on the differences and distinctions between them; religion focuses on the sacred, while spirituality points to meaning, sublimity and perfection [28]. In general terms, it is a known reality that the common goal of all religions is to bring peace and happiness to humanity on an individual and social basis and that they preach many universal human values and principles to achieve this goal. In this context, it is possible to state that the components of conscientious intelligence such as empathy, moral judgement, sense of justice, responsibility, respect, honesty and benevolence are also recognised and attributed importance as universal human values in religions. In this respect, it is possible to say that there are common denominators between spirituality and conscientious intelligence [29]. In the literature, it has been observed that some studies have been conducted on how to establish a relationship between conscientious intelligence and spirituality. For example, in the research conducted by Karakaş, it was determined that there was a positive relationship between spiritual intelligence and religiosity and flexibility of forgiveness [30]. Asıcı also found a positive relationship between emotional intelligence and forgiveness [31]. Özcan et al., also determined that there was a positive relationship between nurses' conscientious intelligence levels and care behaviours [1]. In these studies, it is seen that there are significant relationships between religion and spirituality and relationship intelligences and conscientious values. Based on this context, it was inevitable to address the relationship between nurses' conscientious intelligence and their perceptions of spiritual care.

In the literature, it has been observed that there is a significant relationship between conscientious intelligence and empathy level, and there is a strong link between conscientious intelligence and spirituality in the context of values. However, in the literature search, it was observed that the studies evaluating the effect of nurses' conscientious intelligence levels on patient care outcomes were very limited. It is essential to investigate the positive results of conscience, which has an important place in nursing care, and to integrate it into nursing education. Based on this scope, this study was conducted to evaluate the relationship between nurses' conscientious intelligence levels and their perceptions of empathy and spiritual care.

The hypotheses for the research were formed as follows;

H₁: There is a relationship between nurses' conscientious intelligence levels and empathy levels.

H₂: There is a relationship between nurses' empathy levels and their perceptions of spirituality and spiritual care.

H₃: There is a relationship between nurses' levels of conscientious intelligence and their perceptions of spirituality and spiritual care.

H₄: Empathy level mediates the relationship between nurses' levels of conscientious intelligence and their perceptions of spirituality and spiritual care.

The research model and hypothesis were formed as follows;

This study was conducted between January and April 2024. The population of the study consisted of nurses working in a training and research hospital located in the Eastern Anatolia Region of Turkey. All nurses working in the relevant hospital constituted the population of the study (N: 1040). The sample consisted of 314 nurses determined by using G Power 3.1.9.7 programme (0.20 effect size and 0.05 margin of error and 95% confidence interval). Nurses were selected from the population using simple random sampling method. The nurses were informed about the study and asked to fill out the data collection forms completely. A total of 315 nurses who volunteered to participate in the study and completed the data collection forms completely were included in the study.

The nurses working in the operating theatre were excluded from the sample because the patient-nurse relationship is very limited and the interaction with patients is very limited compared to nurses working in other units. As a result, including them in the sample could have diluted the study's focus on the patient-nurserelationship and patient outcomes. However, excluding operating theatre nurses may also impact the generalizability of the study's findings. By not including a broader range of nursing roles that interact with patients in different contexts, the sample may not fully represent the diversity of nursing experiences across healthcare settings. This exclusion limits the ability to apply the study’s results universally to all nursing contexts, particularly in areas where nurses play a pivotal role in patient care throughout the entire treatment process, including during surgery.

The impact on generalizability also extends to the potential differences in how patient care is delivered in the operating room versus other settings. Operating theatre nurses have unique skills and responsibilities that could influence patient outcomes in ways that are not captured by the study. Therefore, while the study design benefits from a more focused sample, the exclusion of operating theatre nurses reduces the representativeness of the findings in a broader nursing context.

The 'Personal Information Form,' consisting of questions related to age, gender, years of work experience, etc., which were determined based on the literature to identify the socio-demographic characteristics of nurses, as well as the The Conscientious Intelligence Scale (CIS)' Empathy Quotient Scale (EQS),' and Spirituality and Spiritual Care Rating Scale (SSCRS)' were used to collect data

It is a data collection tool consisting of eight questions (age, gender, educational status, years of employment, marital status, having children, satisfaction with the nursing profession) developed by the researchers.

It was developed by Aktı et al., (2017) to determine the level of conscientious intelligence of nurses. In the 5-point Likert-type scale, conscientious intelligence consists of a 7-factor structure including “ethical values”, “moral sensitivity”, “responsibility towards the creator”, “compassion”, “conscious awareness”, “social sensitivity” and “wisdom”. CIS consists of 32 items. These items are scored as “strongly disagree” (1 point), “disagree” (2 points), “undecided” (3 points), “agree” (4 points), “strongly agree” (5 points). The lowest score that can be obtained from this scale is 32, while the highest score is 160. Questions 1, 2, 3, 4 and 5 are reverse coded. In the development study of the scale, Cronbach's alpha coefficient for the total score of the CIS was determined as 0.85 [3]. In this study Chronbach’s alpha value was 0.85.

In order to determine nurses' perception of spirituality and spiritual care, Ergül and Bayık Temel [2007] adapted the scale into Turkish and conducted a validity and reliability study. The scale includes a total of 17 questions and consists of “spirituality and spiritual care” (item 6,7,8,9,11,12,14), “religiosity” (item 4,5,13,16) and “individual care” (item 1,2,10,15) sub-dimensions. The items are scored from 1, which means “strongly disagree”, to 5, which means “strongly agree”. The first 13 items are scored straight and the last four items are scored in reverse. As the average total score increases, the level of perception of the concepts of spirituality and spiritual care increases positively. Accordingly, the highest score that can be obtained from the spirituality and spiritual care sub-dimension is 31, and 16 from the religiosity and individual care sub-dimensions. The highest score that can be obtained from the total scale is 69. Cronbach's alpha coefficient for the total score of the SSCRS was determined as 0.76 [33]. In this study Chronbach’s alpha value was 0.73.

The sociodemographic data of the participants in the study are given in Table 1. As seen in Table 1, the majority of the nurses who participated in the study were female nurses. In addition, the highest number of participants were between the ages of 18–24, bachelor's degree, 1–5 years in the profession, married and satisfied with their profession (Table 1).

In this study, the relationship between conscientious intelligence levels, empathy and spiritual care perceptions of 315 nurses was investigated. In this study, we determined that the conscientious intelligence levels of nurses had a positive and significant effect on their empathy levels. People try to search for the meaning and significance of their behaviour and the questions they cannot answer. In fact, this search is a situation that people can learn through their own skills and even through the ways they will remember by evaluating them in the form of conscientiousness and empathy [22]. In addition to seeking answers to the questions they are looking for with their conscience and using empathy, people have also tried to come to a conclusion with the criticism of others by evaluating whether it is appropriate in terms of moral values [44]. Nurses who aim to provide holistic care to patients are expected to have developed levels of conscientious intelligence and high levels of empathy in order to respond to the problems and needs of patients. In the literature, there is no research on the relationship between conscientious intelligence and empathy level in nurses. However, in a study conducted on athlete students, it was found that there was a strong and positive relationship between students' conscientious intelligence levels and empathy levels [22]. It is seen to support our research result. It is thought that if the conscientious intelligence levels of nurses increase, their empathy levels will also be high and they will understand the patients better and this may be reflected more positively on their care behaviours.

It was concluded that empathy levels of nurses had a positive and significant effect on their perceptions of spirituality and spiritual care. In the literature, it is emphasized that spirituality is an all-encompassing concept other than having or not having a religious belief. It is reported that spirituality includes beliefs about health, illness, death, sin, afterlife and responsibility towards others [27], commitment, compassion, empathy, faith, hope, existence, purpose, goal, kinship [45]. The spiritual needs of patients and/or their relatives increase in sudden illness and crisis situations, risk of death or death situations. Spiritual needs; communication, trust, desire to give meaning and purpose to life, hope, forgiveness or forgiveness, love, consolation, coping with the reality of death, hope, prayer and other rituals, people, are defined as spiritually supportive needs. In order to meet these needs, it is very important for nurses to empathise by taking into account culture-specific differences [46]. In addition, it is stated that empathy, active listening, being sensitive to the physical, emotional and spiritual needs and expectations of the patient, knowing the individual's spiritual history, beliefs and the meaning he/she attributes to the disease, and supporting him/her to realize spiritual practices are practices for spiritual care [27]. In a study, it was found that empathy and spirituality are intertwined concepts and that nurses' empathic behaviors stem from their commitment to their spirituality [33]. In a study conducted in Turkey, it was determined that nurses' empathy levels positively affected their spiritual care competencies [47]. Again, in a study conducted by Karagöz on nursing and theology faculty students, it was determined that there was a significant positive relationship between religiosity and empathic tendency and intercultural sensitivity. It was emphasised that the healthcare team should have the ability to have empathy as one of the basic elements in understanding the spiritual world of the patient and realising this on the axis of that person's culture [46]. In this study, it is thought that nurses‘ understanding of their own spiritual world and their perceptions of spirituality and spiritual care are effective in finding a significant relationship between nurses’ empathy level and their perceptions of spirituality and spiritual care.

As a result of the findings of our study, it was seen that nurses' conscientious intelligence levels had a positive and significant effect on their perceptions of spirituality and spiritual care. As far as we know, there is no research in the literature that conscientious intelligence affects the perception of spirituality and spiritual care. In a descriptive study, it was determined that nurses used their conscience as a reference while providing care and defined conscience as an expression of social and spiritual values [48]. Conscience is one of the prerequisites for providing basic nursing care. Conscience, which has an important role in providing correct and safe nursing care, is also a prerequisite for ethical behavior. Conscientious intelligence is a power that enables the individual to listen to his/her inner voice and to realize his/her internal and external responsibilities [2]. Therefore, no matter what type of care a nurse provides, her conscience is a tool that will help her provide the best care.

According to the results of the analysis testing the mediation effect, empathy level mediates the relationship between conscientious intelligence and perception of spirituality and spiritual care and it is significant. The culture, beliefs, meaning attributed to the disease, diet and preference, reaction to pain, reaction to treatment methods, etc., of each patient that nurses are obliged to care for are different from each other. The conscience of nurses enables them to identify and understand these differences. Empathic approach plays an important role in determining these differences. In the care provided with an empathic approach, the needs of the individual in all dimensions are determined and holistic, ethical and effective nursing care is provided. The provision of spiritual care needs among these dimensions depends on the conscientious intelligence and empathy skills of a nurse. Spiritual care is often ignored for various reasons. There is a common perception among nurses that spiritual needs include only religious beliefs. However, spirituality is a universal construct and a subjective experience. Accordingly, nurses should adhere to ethical principles and moral values to support their conscientious intelligence. They should develop empathy skills and have knowledge and skills in spiritual care. When the international literature was examined, there was no study that determined that empathy mediates the perception of conscientious intelligence and spirituality and spiritual care. In this respect, this research result constitutes the original aspect of the subject.