Spirituality in urgent and emergency services

There is a growing interest in the relationship between spirituality and the process of health and disease, due to the protection potential attributed to this dimension in difficult situations, such as during urgent and emergency care, which are identified as stress generators due to their characteristics. The aim of this study was therefore to evaluate how spirituality is addressed in urgency and emergency services. A review of literature from publications indexed in Medline and Scopus from 2000 to 2014 was performed and seven articles were selected. It was observed that spirituality is identified as a need for patients and families, particularly in relation to end of life situations. The understanding of this dimension in the context of emergency care remains a challenge, however, as it is not perceived as a priority during care due to the difficulties of working in health services.


Spirituality in urgent and emergency services
http://dx.doi.org/10.1590/1983-80422017253216 The emergency service takes place in an environment where patients who are critically ill and at risk of death receive more adequate care for reversion or stabilization of the clinical picture.The suffering perceived by professionals and users stems from the severity of the clinical picture and the obstacles encountered, such as insufficient structure of the emergency network and overcrowding of the premises, resulting in poor quality of care and irrational use of available resources 1 .
The high demand of the modality, coupled with the need for rapid and effective measures, and the consequent stress experienced by the professionals all contribute to perpetuate practices that compromise the humanized assistance 2 .These phenomena are reflections such as the hardening of interpersonal relations and the distancing of integral care to improve quality of life (QoL) and health 3 .
Humanization depends, among other factors, on the transformation of people in favor of values related to life and, because of their vulnerability, on solidarity and social support 3 .Spirituality, in its existentialist dimension, can be a way of giving meaning to life by the interactions with the self, the other and the environment in which it is inserted 4 , stimulating the emergence of solidarity attitudes.In addition, its intrinsic character relates it to the humanization of work in the organizational context, reorienting values and practices 5 .
The understanding of spirituality goes beyond religiosity, being associated to the adaptation to life and the meanings attributed to one's very existence 6 .Religious practice is cited as the most widespread way of bringing people closer to the spiritual dimension 7 .
In 1998, the World Health Organization (WHO) reformulated the concept of health in its constitution, including the spiritual aspect, in addition to the physical, mental and social ones 8 .Since then, spirituality has been identified in the health area as an important adaptation factor in difficult or stressful situations due to inability to develop human skills in the maintenance and care of life 9 .International studies associate spirituality with health, considering its potential to assist in the recovery of diseases 10 .In this sense, this study aims to verify how spirituality is approached in the emergency and emergency services, based on the current literature.

Methods
This study consists in a systematized review fo the literature in Medline databases, through the search in the Virtual Health Library (VHL) and Scopus.In the former, the following Descriptors in Health Sciences ("Descritores em Ciências da Saúde" -DeCS) were used in Portuguese, English and Spanish: "emergency hospitals"; "Emergency treatment"; "Emergency hospital service"; "Emergency relief"; "Emergency medical services", relating them to the descriptor "spirituality", through the Boolean operator "and".In Scopus, correlated terms were searched in English using the Medical Subject Headings (MeSH).
The inclusion criteria defined were: publications in article format between 2000 and 2014 -a period after the WHO's new definition of health was published -in Portuguese, English or Spanish, made available in full text, as it would be difficult to analyze results from summaries only.Thesis, dissertation and monograph documents, duplicates, and those that did not fit within the time interval mentioned or that eluded the topic after reading the abstract, were excluded.
The search in the Virtual Health Library, using the descriptors "emergency medical services" and "spirituality", resulted in two studies, and one of them was excluded because its full text was not available.The terms "emergency hospital service" and "spirituality" led to eight publications, four having been discarded for the same reason.Finally, with the search for "emergency treatment" and "spirituality", four articles were obtained and dismissed: two because they did not appear in full, one for having diverted from the theme and one for being redundant.
In Scopus, the search with the terms "emergency medical services" and "spirituality" resulted in two studies, also eliminated according to the exclusion criteria.The terms "emergency service", "hospital" and "spirituality" resulted in nine publications, two being discarded for not fitting into the "scientific article" category, two due to complete unavailability and three for being duplicates.Four studies were found in the search with the terms "emergency treatment" and "spirituality", which were excluded because they did not meet the inclusion criteria.
In both databases, no documents were found, after research, related to the terms "emergency hospitals" and "emergency relief" with "spirituality".Therefore, only seven articles met the objectives and inclusion criteria in this review.From the data collection, information was constantly categorized into thematic units and examined according to the technique of content analysis proposed by Bardin 11 .

Results
Selected studies are original research articles.Of these, six were published in English, one in Portuguese and none in Spanish; five of them were indexed in the Medline database and two in Scopus.
Regarding the year of publication, two articles are from 2010 and the rest are one from each of the following years : 2004, 2008, 2009, 2011 and 2012.This finding reveals that, despite the current discussion on the subject, there are few studies that address spirituality in urgent and emergency health services.
Table 1 presents some items of the studies selected for review: author (s), title, journal, year of publication, indexing platform and main points discussed.The article addresses the prevalence and consumption patterns of complementary and alternative medicine for patients in the emergency department of a Catholic hospital; it presents spirituality as a form of care to be stimulated.Prayer/spirituality was one of the most widespread and complementary therapies among patients.Inferences were made about the sociodemographic characteristics to explain the adoption of prayer as a lower cost practice.
(Medline) 13 The article describes experiences of families of patients seen in the emergency room, including feelings and the support network; it points to two categories, one of feelings and difficulties, such as fear of death, and the other discomforts caused by insecurity and unpredictability; and other family support resources, such as spirituality, family unity and the care provided by health professionals.Spirituality is conceived as a coping mechanism in which families seek to deal with frailties arising from difficult situations, manifesting themselves through prayer and the belief in God.
Ziel R, Kautz DD.The highest priority in the emergency department may be a patient's spiritual needs.J Emerg Nurs.2009;35(1):50-1.(Medline) 14 The article portrays the difficulty of valuing the spiritual dimension of patients and their families due to the work process of the emergency service; it signals the importance of considering spiritual extension through the experience of being a nurse.Spirituality is perceived as a necessity for family members and patients, even in situations of risk of death.
Grudzen The article identifies and compares the profile of spiritual care among palliative care nurses and acute aggravation of clinical illnesses; it reflects on differences of perspective and spiritual attention among these professionals who work in different careers, concluding that consideration of these aspects and of palliative care were more frequent in nurses.The older age group, time working in the field and in the studied sector were associated.The greatest difficulties pointed out by the two groups in providing spiritual care were insufficient time and patient privacy.

Discussion
From the results, central themes about spirituality in emergency services were identified, which were categorized into: the patient's need for spiritual care; spirituality in a professional context; and guidelines for this type of care.

The need for spiritual care
In emergency services situations are experienced that invoke existential issues, such as birth and death 17 .Therefore, in these spaces it is important to approach spirituality in health care.Considering that, since 1998, the WHO has included this aspect in the areas that should be taken into account in the assessment to promote health 8 and that the disease can alter patients' biological, psychological, social and spiritual conditions 7treatment actions aiming at both cure and quality of life should consider these complementary factors.
One study shows that patients at imminent health risks report the importance of health professionals addressing their spiritual needs and points out the procedure, based on ethical principles, as a preponderant factor of significant benefits for treatment 19 .Another study corroborates the relevance of spiritual attention, since some people benefit when they understand faith and prayer as ways to face adversities and alleviate suffering 13,[20][21][22] .
Older individuals, who are seriously ill and who demand indispensable palliative care, comprise a patient profile whose numbers of urgently needed care are increasing substantially.This fact is associated with an increase in population survival and in chronic diseases 15,23 .In these cases, traditional emergency medicine, in which care is guided by the disease, does not reach the goals of treatment, since the needs encompass both intervention in physical symptoms and psychosocial and spiritual perspectives 15 , contributing to the integrality of health care.
With the increase of chronic diseases, worse scores in the quality of life domains of these patients were observed, compared to those with diseases that do not present chronicity, except for religiosity/spirituality and personal beliefs.These aspects are manifested positively and are more important among groups of patients who are ill 24 .The interaction of spiritual aspects and health parameters demonstrates the influence they exert on quality of life and consequently on health care 19 .
One study indicates that aspects related to healthy behaviors, emotional and psychological factors and family experiences associate issues related to the spiritual dimension with more tranquility and well-being in cases of chronic diseases and better prevention and recovery of patients 25 .
A survey on the treatment process of diseases 12 found that among complementary therapies, prayer was the most common type used by patients, associated with the belief that the practice was more effective for a faster cure, confirming the need to address spirituality, aiming at the holistic care of the patient.The operationalization of health practices for quality care and integral care induces qualified listening attitudes and directs care considering humanized care 26 .
In addition to the patients assisted, several people are involved in emergency and urgent care.Family members are often not present in the initial care and are called about the situation of their relative and end up projecting severe or fatal events.Faced with this situation, many of them, due to fear, rely on spirituality to face difficult times 15,23 .
In a study on the quality of life of family caregivers during the patient's stay in urgent and emergency units, spirituality/religiosity was a coping resource for those who suffer from the vulnerability of their quality of life 24 , including mothers who experience the death of their children, since spirituality rescues the senses of life and death, attenuating the pain of loss 27 .

Spirituality in the professional context
The work process in the emergency is characterized by the assistance to patients with both risk of death and non-urgent demands, which overwhelm health professionals and hamper the adequate care of all needs 28,29 .The fact contributes to the "denial" of spiritual assistance, in a timely manner, to the patients who desire it, disrespecting their autonomy.
The current crisis, which threatens the human dimension 3.5 , has affected professionals in health institutions, impairing their social involvement in the work context, is often related to a lack of belief in spiritual matters 7 .
Spiritual care practices may differ, considering the environment in which health care is provided 18 .This care is not perceived as a priority in emergency care due to the very essence of the service, which aims to revert or stabilize the clinical picture of the patient.patient However, this is an important factor for family members and patients who profess a religion or who accept religion, especially in the process of death 14 .The priority of traditional emergency care is related to technical and scientific actions aimed at intervening in the health problem, which would lead to the risk of death and prolong life 27 .Therefore, in order to complement and improve care, appropriate measures should be encouraged when identifying the spiritual needs of patients and their families.
On the other hand, the contribution of spirituality/religiosity as a factor of disease prevention and reduction of health impacts to health is remarkable 30,31 .Thus, the relationship between health and spirituality is the subject of research and inclusion of the theme in professional health education 6 , showing that beliefs related to the spiritual aspect of the patient should be respected by physicians, even when they do not recognize them 5 , basing their actions on the bioethical principles, mainly autonomy and beneficence.
It is noteworthy that nurses are more cited than other professionals in studies that discuss spirituality in coping with diseases 14,17,18 .It is also observed that Leininger's cross-cultural nursing theory is approached 16 as a useful tool to be developed by other professionals in the field, considering cultural diversity and including spiritual aspects in the health and disease process when desired by the patient or family member.Spirituality in the area of health should be understood as a medium of social, professional and interpersonal relationships 26 , and it is a space for interaction among the actors involved in the care process.The configuration of these spaces, therefore, contributes to the patient's well-being, to safeguard privacy and respect.This situation helps to promote more resolute attention with more humane characteristics 25 .
These characteristics, which are sometimes difficult to implement 25 , corroborate and strengthen the real sense of assistance, which treats humans being in their subjectivity and with values that are intrinsic to the spiritual being 3 .Therefore, spirituality in our context is shown as way to raise awareness and promote professional achievement, from the development of a conscience in favor of well-being and the orientation of values that will be translated into the practices of the worker 5 .

Guidelines for spiritual care
Seeking to strengthen care in emergency services, recommendations 17 were proposed for family and professionals to deal with the situation of death including spiritual care.The recommendations were divided into four themes: dealing with sudden death in the emergency room; resuscitation in the presence of the family; cultural and spiritual considerations; and institutional changes.
The presence of a family member during resuscitation guarantees beneficial factors 32 , such as enabling the bereaved family to regard death as a reality, which contributes to the mental health of the family member who witnessed the resuscitation efforts.In this sense, some care should be instituted, such as team awareness and effective training for cardiopulmonary resuscitation (CPR), since many studies show that safer persons feel more comfortable in the presence of their relatives 33 .establish a relationship of respect and collaboration between family and professionals.Despite these benefits and the importance attributed to the presence of the family in the CPR, some negative points were pointed out 34 , since in some situations this presence may interfere in the progress of the intervention, and in this cases, it is not possible for the family member to stay.
Throughout the care provided, religious/ spiritual and cultural issues must be respected in making decisions about the treatment, since, even if high quality scientific and technical knowledge is used, these must be in accordance with the culture of the people served, and must not generate discomfort to those involved or be perceived as acts of aggression to their values 16 .

Spirituality in urgent and emergency services
http://dx.doi.org/10.1590/1983-80422017253216 In agreement with the integrality of care, the observance of religiosity and spirituality may be fundamental for a better acceptance of health care 16 , because, when valuing the patient's beliefs, the individual tends to accept treatment more easily, without feeling coerced facing cultural differences 35 .
As cultural and spiritual issues are diverse, it is impossible to fully apprehend their particularities.Nurses and other emergency service professionals must be open to the cultural and spiritual needs of family members and patients 17 .
In this way, health professionals must adopt an impartial and respectful attitude towards the individual, and thus establish a relationship of trust in the care of patients of different cultures or religions.In this sense, Leininger's cross-cultural nursing theory is portrayed as an alternative for other health professionals 16 .Used in the field of nursing in order to understand and respect the cultural diversity of the assisted population, the theory favors the planning of actions to reach the desired results 35 .

Final considerations
Spirituality is conceived as a personal need of patients and families and helps them to face difficulties, related mainly to extreme situations, such as the end of life.Despite growing interest in the topic and its relation to health, research on spirituality in urgent and emergency services is incipient.
Working with the spiritual dimension is still a challenge, as it is not a priority in emergency care, besides requiring professional training.When there are tasks related to the organization of work in health, with overload of activities and shortage of human resources, the difficulties of considering the spiritual dimension in the care plan become even more evident.
The spirituality of patients and their families was the most discussed topic in the studies.Thus, research that demonstrates the relationship between care and spirituality is necessary to better get to know the subject -especially how spirituality can help professionals in the daily life of emergency services -and foster the spiritual need of the patients assisted .It should be emphasized that care should also be given to patients who do not want spiritual support, which refers to the bioethical principle of autonomy.
There are few articles on the subject, but the selected corpus has proven sufficient to point out the real need to assimilate spirituality in urgency and emergency health services, especially in relation to family and patients.The need to modify the architecture of emergencies, including places reserved for reception and contact with relatives, was evidenced in order to make the spiritual approach effective.Therefore, it is suggested that new studies be carried out, especially in the Brazilian context, since the publications found were scarce, which reflects the need to broaden the debate on the subject, as the country presents particularities such as its cultural diversity and the current health system.

Table 1 .
Articles from 2000 to 2014 on spirituality in the emergency sector The article discusses spirituality as an important dimension of integral care and the preparation of professionals involved in rescues or situations of catastrophe, relating cultural, religious and ethical aspects.One of the difficulties in these cases is to live with spiritual and cultural differences.It signals to Leininger's cross-cultural nursing theory as a tool for health professionals.
CR, Richardson LD, Morrison M, Cho E, Morrison RS.Palliative care needs of seriously ill, older adults presenting to the emergency department.Acad Emerg Med.2010;17(11):1253-7.(Scopus) 15The article identifies the usefulness of palliative care in emergency units, especially in the elderly with serious illnesses; it also exposes factors considered essential for emergency care.The most frequent needs refer to financial issues, access to general and personal care, assistance in daily activities or physical and mental health.Spirituality was pointed out as a necessity associated with other care types.considerations, and institutional changes.Spirituality is discussed in relation to cultural issues, being considered necessary by family and patients.It also emphasizes that nurses must provide assistance and respect cultural diversity.(Continues...) Spirituality in urgent and emergency services http://dx.doi.org/10.1590/1983-80422017253216