RESEARCH ARTICLES

Spirituality in iminent death: strategy utilized to humanize care in nursing

Fabiana Medeiros de Brito^I; Isabelle Cristinne Pinto Costa^II; Cristiani Garrido de Andrade^III; Kamyla Félix Oliveira de Lima^IV ; Solange Fátima Geraldo da Costa^V; Maria Emília Limeira Lopes^VI

^I Nurse. Member and Searcher of the Bioethics Studies and Researches Core of the Federal University of Paraíba. João Pessoa, Paraíba, Brazil. E-mail: fabianabrito_@hotmail.com
^II Nurse. Speech Therapist. Master in Nursing and Doctorate in Nursing by the Federal University of Paraíba. Professor at the Medical Science College of Paraíba. Member and Searcher of the Bioethics Studies and Researches Core of the Federal University of Paraíba. João Pessoa, Paraíba, Brazil. E-mail: belle_costa@hotmail.com
^III Nurse. Speech Therapist. Master in Nursing by the Federal University da Paraíba. Professor at the Medical Science College of Paraíba. Member and Searcher of the Bioethics Studies and Researches Core of the Federal University of Paraíba. João Pessoa, Paraíba, Brasil. E-mail: cristiani_garrido@hotmail.com
^IV Nurse. Master in Nursing by the Federal University of Paraíba. Professor at the Medical Science College of Paraíba. Member and Searcher of the Bioethics Studies and Researches Core. João Pessoa, Paraíba, Brazil. E-mail: kamylaoliveira@hotmail.com
^V Nurse. Doctorate in Nursing by the University of São Paulo. Coordinator of the Bioethics Studies and Researches Core of the Federal University of Paraíba. João Pessoa, Paraíba, Brazil. E-mail: solangefgc@gmail.com
^VI Nurse. Doctorate in Education by the Federal University of Rio Grande do Norte. Professor of the Graduation in Nursing Course of the Federal University of Paraíba. Vice-coordinator of the Bioethics Studies and Researches Core. João Pessoa, Paraíba, Brazil. E-mail: mlimeiralopes@hotmail.com

ABSTRACT

It is objectified to investigate the comprehension of nurses of concepts of spirituality and spiritual necessities of patients without therapeutics possibilities. Exploratory research with qualitative approach performed with seven nurses in the intensive care unit of a public hospital, in the city of João Pessoa, Paraíba. Data were collected in recorded interviews, between December 2011 and January 2012, and analyzed qualitatively by the technique of content analysis. The categories emerged from the empirical material were: spirituality in the view of nurses and spiritual necessities of patients without therapeutic possibilities: nurses' comprehension. These categories indicated that, from the comprehension, of the spiritual dimension, they start to give value to it in clinical practice, helping the patient to face in a better way the process of terminality. Thus, it is hoped that this research can support new investigation, because they are still incipient those ones which discuss spirituality in care for the terminally ill patient.

Keywords: Spirituality; nursing; terminally ill patient; humanization of care.

INTRODUCTION

Spirituality refers to intrinsic qualities to the human spirit, such as love, compassion, forgiveness, contentment, the responsibility, the pursuit of greater sense to exist, the relationship with the sacred and the transcendent, without limitation with beliefs or practices¹.

The literature has demonstrated increasing evidence that the spiritual/religious aspect is related to the physical and mental health, and consequently to a better quality of life². In is noted that the World Health Organization (WHO), in 1983, modified the classical concept of health, including the spiritual dimension, which reveal important contribution to the issue of spiritual paradigm³.

The spiritual dimension is part of the totality of the human being; however, it tends to mobilize it and express it more intensely, when experiencing crisis situations⁴. Among these situations, it can be highlighted those experienced by the terminal patient.

It is noted, therefore, that the spirituality is tied to the terminally, working as an instrument of the utmost relevance, since it assists in the process of confrontation, of hope and of being alone in the face of such events⁵.

Spirituality is considered an important instrument to provide a holistic and humanized assistance, this by understanding that the promotion of well-being is essential and also be the utmost importance to patients who are experiencing the end of life, which require nursing treatment and a special and humanized care⁶. This is because the nurse at the moment that holds knowledge of this subject will have, at the same time, resources to walk towards the humanization of health care.

In this way, the nurse, the professional who stays longer beside the terminal patient, should be put in the position of health promotion facilitator of the bio-psychology, social-spiritual and emotional welfare, leading to better ways to counter the process of terminally.

Against the above, the study aimed to investigate the nurses' understanding about concepts of spirituality and spiritual needs of the patient without therapeutic possibilities.

REVIEW OF THE LITERATURE

Caregiving is a humanistic attitude, which includes responsibility, attention, concern and involvement, which rise from the establishment of intersubjective relationship between the caregiver and the care, promoting the interest and willingness to serve others and, thereby, ensuring well-being ⁷.

Thus, the deal should have as guiding principle respect for human dignity, taking the premise to consider the patient in its uniqueness, distinguishing their individual differences and promoting targeted assistance to each human being holistically, as, for example, child, adolescent, adult, elderly and terminally patients⁸.

The care in hospitals, specifically, before the terminal patient, should cover all their needs in order to supply with the maximum of security and comfort. It is appropriate to emphasize that among these needs it is included the physical, psychosocial and spiritual.

In study developed with the goal of addressing the interconnections between health and spirituality, it was observed that the use of spirituality in patient care in terminal phase, can assist him in the promotion of peace and well-being in the disease, as well as provide with a fundamental support for confronting in the process of death and dying⁹.

Aspects such as forgiveness, daily spiritual experiences, religious support and self-perception of religiosity interfere significantly in the state of mental health of patients¹⁰. In this approach, another study emphasizes the importance of spirituality/religiosity as terminal patients approach strategies, which proved the advancement in the quality of their lives, by the integration of spirituality, faith and religiosity¹¹.

Spiritual care promotes the maximization of the potential of the patient without therapeutic possibilities, enhancing their capabilities, renewing the hopes and bringing an inner peace that allows dealing with their problems, healthier¹². However, to achieve these goals, it is important that the professional, nurse in particular, promotes an assistance based on respect, on humanization and reception.

It is important to point out that, to enhance the spirituality in care, the nurse becomes able to see the world and offer their fundamentals and essential connections to an act, whose priority is to use their professional skills to alleviate the suffering of the patient, in all its forms.

METHODOLOGY

This is an exploratory study with a qualitative approach. The scenario of research was the intensive care unit (ICU) of a public hospital, located in the city of João Pessoa, Paraíba. This institution is considered a reference in the State of Paraíba, for the attendance of individuals carrying infecto-contagious diseases.

For the selection of subjects, the following criteria were adopted: the nurses should accept to participate in the study in a free and clarified way; be in professional activity at the time of data collection; have at least one year of professional experience in that location. The participants totaled seven nurses working in the unit selected for the study.

The present study was carried out according to ethical principles in research in research and its resolution nº 196/96 of the National Health Council. The research project was approved by the Research Ethics Committee of the Medical Science College of Paraíba, under the Protocol 58/11.

The data were collected in the period December 2011 to January 2012, through a form containing questions related to the objectives of the study, using the technique of interview, with recording system. The interviews were transcribed in full, in conformity with the colloquial speech. To maintain the anonymity of the participants, the testimonials were referenced by the letter N (for nurses), followed by one to seven numbers (N1, N2. N7).

The empirical material from the interviews was coded and treated qualitatively by content analysis technique¹³, being operationalized in: 1st step, pre-analysis, where they gathered the testimonies and held the Constitution of corpus of analysis; the 2nd step consisted in the exploration of the material; and the 3rd step understood the treatment of results from the presence frequency and verification of the homogeneity of sense.

The data were grouped into two categories: spirituality in vision of nurses; spiritual needs of patients without therapeutic possibilities of healing: understanding of nurses.

RESULTS AND DISCUSSION

Category I – Spirituality according to nurses

To define spirituality is something quite complex involving meanings, purposes and human values, such as love, compassion, empathy, responsibility, care, wisdom, among others. Spirituality is connected with the reflection, with the personal search of the meaning of life and with the sacred or transcendent, and may or may not be linked to a religion. Religion is organized by beliefs, rituals, practices and symbols, all designed to assist in the proximity of the individual with the sacred or transcendent¹⁴.

Therefore, spirituality is not limited to dogmatic and doctrinal aspects governing a religion; however, these two constructs seem to present certain relationship among them. Perhaps this is due to the historical domain of religions on topics relating to the issues between heaven and Earth, with the existence of God and with themes related to transcendence. Another factor that can justify this hypothesis is based on the fact of religion mean a path to better access to patients' spirituality¹⁵.

This relationship can be understood by the fact that religion, in the middle ages, was responsible for the knowledge of topics such as heaven, hell and divinity¹⁶. Based on this understanding, it is evidenced the binding between spirituality and religion. Such a link can be found in excerpts of testimony of the participants of the study:

For me spirituality is directly connected to my religion. As much as I am sometimes absent, the duties of attending Church, anyway, but we have that affection, isn't it? (N1).

Spirituality is also of extreme importance, because nobody lives without a religion, and we have to be steadfast. [...] Tell him that Jesus forgave, that Jesus is with open arms, they will have a good passage, isn't it? [...]. (N2).

So, spirituality! That's a tough one! [pause]. Spirituality, I think that's what everybody is. So, the way we live our daily lives. The way we can believe in God or not. So, is that you get something of a human being, being God or holy, or any entity that the person thinks is correct, as long as they do good. (N5).

The place of testimonials imply, so emphatic, the difficulty of the interviewees to present conceptual aspects about the spiritual dimension, identifying the interconnection between spirituality and religion. Despite this linking, a study reveals that the professional should impose ethical limits on use of this sources, how to conduct for the construction of a therapeutic relationship with the patient and with the family¹⁷. Research conducted with the aim of promoting a revision of literature on spirituality, on the international basis, showed that is experiencing a dilemma today, regarding the establishment of differences between spirituality and religiosity¹⁸.

This fact can be proved in the excerpts of the depoiments. In these places, the job of para-linguistics elements, such as breaks and using emotive language sources, as it is not that demonstrates some professional insecurity in talking about it.

In the context of nursing, understanding of the spiritual dimension is strongly related to the concept of religiosity. Research conducted with nurses revealed the unpreparedness of these professionals in addressing the spiritual patients' needs/religious, on the understanding that, during such thematic's education has not been studied with due attention¹⁹.

The insertion of spirituality in care with the patient without possibility therapy promotes some benefits, such as: increased general well-being; lower prevalence of depression; better quality of life; greater coping (way to deal with the disease); lower mortality, shorter hospitalization; better immune function²⁰.

About this, a study has shown that the lack of satisfaction of spiritual needs can result in spiritual anguish affecting the patient's ability to fight the disease and, at certain times, intensifying physical and emotional symptoms²¹.

Thus, the spiritual aspect requires greater attention of health professionals, especially nurses, making necessary the qualification to better cope with such size, in order to promote a holistic and integral assistance to the terminal patient.

Category II - Spiritual needs of patients without therapeutic possibilities: understanding of nurses

Spirituality as a basic human need, therefore, essential to every human being, especially the person in front of diseases without therapeutic possibilities, should be valued by health professionals, in particular by the nurse, who must have sensitivity to endure the pain of the other, ensuring him, listen to him, support him in his struggle and ennoble the meaning of life and human dignity.

In the field of nursing, the need to enter the spiritual dimension was recognized by the International Council of Nurses, by the Commission of American Hospital Accreditation and by the Patients' Rights Commission. According to these organs, the nurses must stop skill, knowledge and expertise to promote and evaluate the fulfillment of spiritual needs of patients²².

Thereby, emerging spirituality as a basic human need, it is essential that nurses know to use appropriate means to identify such needs in patients without therapeutic possibilities in order to provide the best possible assistance.

Among these means, we highlight the communication, which is considered the fundamental basis for interpersonal relationships²³. The communication refers to a process with two dimensions: the verbal and non-verbal²⁴.

Verbal communication is characterized by the use of words in a clear and valid way, exercising the colloquial language, the appropriate tone of voice and attention. Based on this premise, it was observed that the professionals interviewed identified spiritual needs by verbal communication, as evidence the following reports:

Well, if the patient express themselves, it becomes easier for you to know what he's thinking. But, with the unconscious patients is very difficult. [...] Tries to talk, look, until the patient can express themselves somehow, but it's pretty difficult. (N1)

I think mostly the first thing, above all, is communication. Is the interaction between him and you. (N3)

These places of statements demonstrate the appreciation of verbal communication in identifying spiritual needs/religious, in patients without therapeutic possibilities. Thus, it was noted that the nurses, participants in the study, consider the verbal communication an instrument that can be used in identifying such needs.

It is worth pointing out that another way to identify spiritual needs is the use of verbal communication with the family, which represents a source of support to the dying patient, as noted in the following statement:

And talking about family, you end up realizing that there are some patients who frequented the Church. (N7)

Corroborating this assertion, a study involving relatives of individuals admitted to the intensive care unit, highlighted the family as a source of information about the spiritual and religious needs of patients²⁵.

The non-verbal communication also emerges in the process of identifying the spiritual needs of dying patients. It occurs when interfaces without the use of words, using the touch, facial expression and body attitude. This mode of communication is intended to supplement the verbal, especially by a cinesic, proxemics paralanguage, which covers the perception, understanding, expectations and values exchanges²⁴. It was also pointed out by some participants of the study, as evidence the following:

And they can see that we are passing this way, sometimes by tears down, brow furrowed and heart rate changed. (N2)

With communication between them, that spiritual interaction that you pass to them; and see, as for example, the simple act, despite him not being able to respond, sometimes, is in a coma, or pre-coma, but they will listen. [...] A tear that, suddenly, comes out of his eyes, it's a sign that he is in need of it. [...]. (N3)

Patients who really have spiritual needs that carry their Bible; We leave them with the Bible or with a rosary. There, comes with those ribbons [...] of Bahia and is tying [...]. We tie in the equipment, in the holders of serum. And stay there, the holy. We don't rule out, we Include the treatment. (N5)

These statements imply, so emphatic, some discursive details which confirm the presence of non-verbal signals in patient care in terminal phase, as the physical signs presented by patients. The religious symbols, such as Bible, rosary and ribbons of Saints, can be considered non-verbal sources that indicate possible religious/spiritual needs and should be valued by professionals.

That's how the spiritual dimension emerges as a basic human need and communication and family reveals itself as an essential means for their identification. Study of cancer patients found the presence of certain spiritual needs, such as: the loss of their roles and their identity and the fear of dying; connection of these needs to feelings, like anxiety, depression, insomnia, anxiety and despair before death²⁶.

Another research pointed out that spirituality can have a good impact on the emotional and physical wellbeing of the terminal patient, relieving pain, decreasing anxiety and hopelessness, promoting him feeling of serenity and facilitating the experience of dying process²⁷. Thus, once identified such needs, the nurse will have the means to intervene concisely, promoting the reduction of suffering and improving the quality of life of patients in terminal stage.

Regarding the importance of identifying spiritual needs, it is observed that the inclusion of spirituality in nursing process through the use of the approach of the spiritual needs, at the time of patient admission, as well as in daily need, would help in the evaluation, dissemination and practice spiritual care to the patient²⁸. The study clarifies that the nurse, regardless of their religious belief, must know the religions of their patients and reinforce those beliefs in every way. In addition, this study points out that the power of faith is unparalleled and the comfort and security that religion offers is a stimulus to life²⁹.

A recent study has shown that the professional nurse understands and respects the religiosity of the patients, which is of extreme relevance to professional practice, in a way that increases its powers of care, seeking the integrality of attention in health¹⁹.

Corroborating the last assertion, study participants consider it important to identify such needs, in order to attend the global needs of terminal patients, providing them with many benefits, as illustrating the following testimonials:

Yes, I consider important because it is what leads us to convey peace, the word, the spiritual comfort [...]. (N2)

I think because sometimes they are so, [pause], needy and so traumatized with everything, with the pathology, with their situation, calling for help, asking for spiritual support, the moment you identify it and stimulates this faith, you show them that you're missing the point. Seeing that he is in need of peace of mind; more than that: he is in need of forgiveness, needing a prayer there, next to him [...]. (N3)

I think it's important. [...] I think that soothes the heart of each patient, leaving him more comfortable dealing with his present situation. (N5)

I think it's very important because often these people have something to say to somebody: something, a family disagreement, any unresolved issue and, so, we have to identify the need to give greater comfort. (N7)

Based on the narratives, it was observed that professionals consider important the perception of spiritual needs, in order to convey peace, comfort, faith and hope to patients. Corroborating this assertive, a research conducted with nurses related to spirituality, revealed that the spiritual assistance is of extreme importance to patients who are experiencing the terminally ill. Thus, this assistance will contribute to minimize suffering, providing welfare, improving the quality of life of dying patients.

It is Noted that two participants of the study considered it important to identify the spiritual needs of terminal patients; however, they reported experiencing difficulty in the perception of such requirements, as is evidenced in the following reports:

It is important, [...]. Work on top of the need is easy, but the hard part is you identify the need, because sometimes it takes a patient who comes straight to ICU [...]. The problem is precisely the previous question, is able to identify, it is not always we can. (N1)

I think it is important, even when it couldn't identify most [pause], in the vast majority of the time [...]. (N6)

These places of statements are the difficulty of the nurses involved in the study to identify the spiritual needs of patients in terminal stage. Probably this is due to the lack of preparation of the professionals in dealing with these issues. In order to provide it in the spiritual dimension of the patient, several studies have recommended that the curricula of several courses of the health area, such as medicine and nursing, be reviewed as appropriate and will include in its programmatic content learning about the spiritual aspects³¹.

In this approach, the health professionals, especially nurses, to understand and appreciate the spiritual and religious practices, will be able to assist the client in the confrontation to the process of illness, mainly before dying.

It is worth mentioning that one of the limitations of the study was the small number of subjects which prevents the generalization of the findings.

CONCLUSION

Although spirituality and religion being distinct constructs, in fact there is an important relationship between the two. The present study confirmed this assertion, by the testimony of nurses participants. Religion emerged as a guiding principle for access to an individual's spiritual dimension in terminal phase, in order to provide the construction of the humanized care in nursing.

The spirituality category in view of nurses revealed, from the reports, insecurity and the lack of preparedness in sharing such themes, which leads to infer about the need to include in the curriculum for the training of health professionals, especially in nursing, issues related to spirituality.

The category spiritual needs of patients without therapeutic possibilities: understanding of nurses indicated that most of the nurses study participants use verbal and non-verbal communication to identify such needs, in order to provide the best possible assistance. It is important to remember that the spiritual aspect, to reveal as a basic human need and inherent in these patients, requires the nurse the ability to understand, identify and access these requirements, using means such as communication with the patient and family.

In the tangent to the non-verbal communication, the use of religious symbols as sources of this mode, highlighted the influence of religion in access of the spiritual dimension. Some of the participants surveyed reported difficulty in accessing the spiritual dimension of patients. It is understood that, in order to identify the spiritual needs of patients, the professional caregiver must have, in their training, a curriculum that focuses on themes related to the process of death and dying, passing to better understand the emotional and spiritual needs of the patient, providing the humanization of assistance to him and his family. It is therefore urgent the need for permanent education of these professionals, with regard to spirituality, especially to those who already give care in their daily lives, with the patient who experiences the final stage of life.

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