Spiritual well-being and hope in the preoperative period of cardiac surgery

Objective: To characterize relations between spiritual well-being and hope of patients in the preoperative period of cardiac surgery. Method: Exploratory cross-sectional study with quantitative approach, performed in the infi rmaries of a reference hospital in cardiology. We evaluated 69 patients hospitalized in preoperative period of myocardial revascularization, valve repair or replacement. Results: We verifi ed that patients hold relevant scores of hope and welfare in all areas, being the existential well-being signifi cantly lower than the religious one. The average of the spiritual well-being score was below the required to be considered high. There was no signifi cant correlation between welfare and hope. Conclusion: Nurses should develop a watchful eye to these issues, be trained in specifi c protocols of spiritual anamnese and use the real moments of care to strengthen the patients. Descriptors: Preoperative Period; Cardiac Surgery; Myocardial Revascularization; Spirituality; Psychological Adaptation. RESUMO Objetivo: Caracterizar as relações entre o bem-estar espiritual e a esperança dos pacientes em pré-operatório de cirurgia cardíaca. Método: Estudo transversal, exploratório, com abordagem quantitativa, realizado nas enfermarias de um hospital de referência em cardiologia. Foram avaliados 69 pacientes internados no período pré-operatório de cirurgia de revascularização miocárdica, troca ou plastia valvar. Resultados: Verifi cou-se que os pacientes mantinham relevantes escores de esperança e bem-estar em todos os domínios, sendo que o bem-estar existencial foi signifi cativamente menor que o bem-estar religioso. A média do escore de bem-estar espiritual fi cou abaixo do corte para ser considerada elevada. Não houve correlação signifi cativa entre bem-estar e esperança. Conclusão: Os enfermeiros devem desenvolver um olhar atento para essas questões, ser treinados em protocolos específi cos de anamnese espiritual e aproveitar os momentos reais de cuidado para fortalecer os pacientes. Descritores: Período Pré-Operatório; Cirurgia Cardíaca; Revascularização Miocárdica; Espiritualidade; Adaptação Psicológica. RESUMEN Objetivo: Caracterizar las relaciones entre el bienestar espiritual y la esperanza de los pacientes en el preoperatorio de cirugía cardíaca. Método: Estudio transversal, exploratorio, con abordaje cuantitativo, realizado en las enfermerías de un hospital de referencia en cardiología. Fueron evaluados a 69 pacientes internados en el período preoperatorio de cirugía de revascularización miocárdica, cambio o plastia de válvula. Resultados: Se certifi có que los pacientes mantenían relevantes puntajes de esperanza y bienestar en todos los dominios, siendo que el bienestar existencial fue signifi cativamente más pequeño que el bienestar religioso. El promedio del puntaje de bienestar espiritual quedó abajo del corte para ser considerado elevado. No hubo correlación signifi cativa entre el bienestar y la esperanza. Conclusión: Los enfermeros deben desarrollar una atenta mirada para esas cuestiones, ser entrenados en protocolos específi cos de anamnesis espiritual y aprovechar los momentos reales de cuidado para fortalecer a los pacientes. Descriptores: Período Preoperatorio; Cirugía Cardíaca; Revascularización Miocárdica; Espiritualidad; Adaptación Psicológica. Spiritual well-being and hope in the preoperative period of cardiac surgery Bem-estar espiritual e esperança no período pré-operatório de cirurgia cardíaca El bienestar espiritual y la esperanza en el período preoperatorio de cirugía cardíaca Eduardo Tavares Gomes E-mail: edutgs@hotmail.com CORRESPONDING AUTHOR


INTRODUCTION
Surgery is generally referred in literature as the major stressor, and the preoperative period represents not only the possibility of cure, but also of failure and nonsuccess (1) .Cardiac surgery has the peculiarity of involving the organ popularly recognized as the "noblest" and directly related to the maintenance of life.The unknown, along with the possibility of failure, causes anguish in individuals, translated, in most cases, into anxiety and depression (2) .
The theme of spirituality and religiosity has awakened interest in the academic milieu (3) .Spiritual needs can be understood as the satisfaction of a spiritual growth, which makes people more sociable, hopeful and at peace with their divinity or transcendence (4) .
An investigation conducted with preoperative patients of general surgery showed that patients with high religiosity levels had lower levels of anxiety (5) .This study, though presenting selection bias of the sample (Islamic, in total) and not using a validated instrument for evaluation of the studied religiosity, indicates the need to elaborate the subject in the academic and professional milieu.
Another research, aiming to evaluate the relations between believing in God and religiosity in the preoperative period of cardiac surgery, using qualitative methodology, presented that belief positively affected the encounter with a new sense to the surgical process.The interviews inferred that the disease was not directly related to old ideas of divine punishment, but the awareness of the relation of heart disease with lack of healthy habits proved to be associated with feelings of guilt (1) .
Therefore, it is necessary to understand the spirituality phenomenon and its role in maintaining patient's welfare when facing the sickness, surgical process and arising existential crisis as well as their relations with the encounter of a meaning to the moment of life and with the hope that patients lay on their future.
The incipient "theme approach" in the education of health professionals directly affects their professional practice.The patient does not suffer alone with that deficit, but also the team loses opportunities, since they do not understand subjective phenomena in the health-disease process.
Besides seeking to understand these gaps in therapeutic relationship between professional and patient, more research should be performed to provide evidence for the integral care.With the incorporation of new evidences, assistance protocols can be reformulated considering hitherto neglected dimensions in health care such as spirituality and religiosity.
This study aimed to characterize relations between spiritual well-being and hope of patients in the preoperative period of cardiac surgery.

Ethical aspects
The research was based on the precepts of the NCS Resolution no.466/2012 and evaluated by the Ethics Committee of Complexo Hospitalar (Hospital Complex) HOUC/PROCAPE of the University of Pernambuco and an integrant part of the approved project.

Design, study location and period
This is an exploratory cross-sectional study with quantitative approach, performed in the infirmaries of coronariopathies, myocardiopathies and valvulopathies of the Pronto-Socorro Cardiológico Universitário de Pernambuco (PROCAPE/UPE) (University Cardiological Emergency Room of Pernambuco -PROCAPE/UPE) between October 2015 and February 2016.

Population and sample
A total of 69 patients hospitalized in the collection period that already knew the date of the surgery of myocardial revascularization, valve repair or replacement, were evaluated considering the following inclusion and exclusion criteria: Inclusion criteria: admitted patients in preoperative period of cardiac surgery of myocardial revascularization, valve repair or replacement, aware of the surgery date for the following day; Exclusion criteria: lowered awareness level, impaired verbal communication or any clinical or psychological condition that harmed the interview or made it uncomfortable; surgical indication for aortic diseases and congenital diseases; previous use of antidepressant; previous medical diagnosis regarding mood or anxiety disorders, or any other psychiatric disorder; not have participated in any health education or anxiety reduction protocol; refusal at any step of the interview.

Study protocol
Patients were evaluated in the afternoon, before the visiting hour for relatives, whereas the visit routines of the nursing and medical teams were performed in the morning.Since the time for interviews was restrict, between lunch and visiting time, only one per day was usually performed.Preferably, it was asked the companion to leave the interview in such a way that the patients could have greater freedom to respond.The interviews, average time of 22.4 minutes, occurred on the surgery eve, and they were not conducted on the date scheduled for the operation.
Data were collected by researchers through their specific instrument, containing: a questionnaire elaborated for sociodemographic survey, which requested data such as sex, age, origin, income (in minimum wages, considering the current value in the period -R$ 788.00), education (in years of study), religious affiliation, type of surgery, hospitalization time etc.; Spiritual Well-Being Scale (SWB); and the Herth Hope Index (HHI).
The spiritual well-being is related to a way of understanding the health of the individual -the spiritual health.It can be evaluated in four main domains: relationship with the self (personal domain), others (communal domain), environment/nature (environmental domain) and other transcendent/divinity (transcendental domain) (6) .
Spiritual well-being and hope in the preoperative period of cardiac surgery Bezerra SMMS, Gomes ET, Galvão PCC, Souza KV.
Among the possible domains, only the personal and the transcendental domains were assessed, since they are closer and more related to the object of study and, to this end, it was used an already validated scale, the SWB Scale.This is an instrument divided in two subscales (of 10 items each), one of religious well-being (RWB) and another of existential well-being (EWB).The items regarding RWB contain a reference to God, and the ones of EWB refer to the feeling of encounter with purpose and commitment to something meaningful in life.
Half of the questions in the scale are written in positive direction and the other half in negative one.The scale has 20 questions that must be answered by a Likert scale of six options: totally agree (TA), agree more than disagree (Ad), partially agree (PA), partially disagree (PD), disagree more than agree (Da), and strongly disagree (SD).The questions with positive connotation (3, 4, 7, 8, 10, 11, 14, 15, 17, 19 and 20) have its score summed as follows: TA = 6; Ad = 5; PA = 4; PD = 3; Da = 2; and SD = 1.The other questions are negative and should be summed in an inverse way (TA = 1; Ad = 2; PA = 3 and so on).The total of the scale is the sum of the scores, which can range from 20 to 120 of these 20 questions (7)(8) .
The HHI was the chosen instrument, among other international hope measurers, since it is a self-report scale, of easy and fast application, multidimensional, which clearly reflects the dimension of hope in clinical populations, with few items and reduced complexity, being a tool more clinically helpful (9) .With suitable validity and reliability, it assists researchers in the assessment of states of hope among patients and the effectiveness of strategies to increase hope.The Index consists of a scale of 12 items affirmatively written, and the ranking of items occurs by Likert scale of four points.The total score ranges from 12 to 48, where the higher the score, the higher the level of hope.There are two items -the affirmation number 3 and number 6 -that present inverted scores (9) .

Analysis of results and statistics
The primary data storage was presented in software Microsoft Excel 2013 spreadsheets.Data were analyzed through resources of descriptive and inferential statistics, using Epi-info 7.0 and SPSS 20.0 softwares.We used the t-student test to verify the significance in the average comparisons of the continuous variables, considering the statistical significance as p < 0.05 (5%).The association between used scales and subscales and other variables was evaluated through the Pearson correlation coefficient and, finally, the internal consistency of the items of the scales was assessed by Cronbach's alpha (α).

RESULTS
The sample was predominantly composed of male patients (56.5%), aging more than 60 years (56.5%) and education of up to 5 years of study (79.7%) -considered to be low.The income was lower than 1 minimum wage for 72.5% of the patients.Most had more than 2 children (66.7%) and a partner (59.4%), both considered, in such cases, regardless of the relationship being formal or not.Regarding the origin, 55.1% resided outside the metropolitan region (Table 1).All the patients were adherents to a religion, being 52.2% Catholics and 47.8% Evangelicals (Table 1).The surgery they would undergo was, in most cases, a myocardial revascularization (68.1%), this being for most the first cardiac surgery (75.4%).A considerable part of the sample (24.6%) had passed, in the period of hospitalization, through cancellation of surgery, i.e., they experienced the preoperative preparation and received the news that the procedure would not be performed on the scheduled date.A time of hospitalization (admission to the interview) longer than 15 days was the reality of 62.3% of the interviewed (Table 2).During this period, the majority (71.0%) received religious visitation of voluntary groups related to churches, and Spiritual well-being and hope in the preoperative period of cardiac surgery Bezerra SMMS, Gomes ET, Galvão PCC, Souza KV.
only two patients (2.9%) requested the presence of a leader or a religious representative (Table 2).
There was no difference between sexes regarding the spiritual well-being, its dimensions, nor hope.When we dichotomized the sample between elders and non-elders, it was ascertained that elders reported better results in all welfare domains, mainly regarding the religious and total wellbeing, and presented spiritual well-being considered high, i.e., more than 100 points.In the assessment of hope, there was no difference between elders and non-elders (Table 3).
Among the groups, there were no differences of spiritual well-being and hope when assessed in the context of years of study, income, or presence of companions (Table 3).
Although the difference is not significant, probably due to the dimension of the sample, the Evangelicals presented higher well-being scores, and the Catholics, higher scores of hope.Only the domain of religious well-being had statistical significant difference, being highest among Evangelicals (Table 3).
The experiments of previous cardiac surgery, cancellation of surgery, presence of companions, long hospitalization time and religious visitation were not variables that significantly affected spiritual well-being and hope (Table 4).
In a correlation analysis, we found that spiritual well-being has weak and direct association with age (p = 0.045) and weak and inverse with the number of children (p = 0.04), while hope had weak and direct associations with the years of study (p = 0.013) and income (p = 0.007) and weak and inverse with number of children (p = 0.05).There was no significant correlation between well-being and hope (Table 5).Note: Avg ± sd -average ± standard deviation; SWBT -total spiritual well-being; RWB -religious well-being; EWB -existential well-being; MW -minimum wage in the period (R$ 788.00).
Spiritual well-being and hope in the preoperative period of cardiac surgery Bezerra SMMS, Gomes ET, Galvão PCC, Souza KV.

DISCUSSION
People perennially present spiritual needs related to transcendence and satisfaction of a growth, whose accomplishment promotes hope, well-being, sociability and encounter with peace and meanings for life (4)(5)(6) .
Regarding the studied sample, existential well-being, related to crises experienced during the period, the pursuit for meaning and to inner questioning about the whys of every situation, was significantly lower than the religious well-being.
The maintenance of religious well-being, considering the relationship with God through the individual's personal religiosity, helps giving sense to the difficult process that the patient is going through (1) .Although the process of how the experience of religiosity impacts physical health is still unclear, there are evidences of better results for those who use these resources (10) .An international cohort study on 162 patients, assessing physiological markers of stress (serum cortisol, Creactive protein and Interleukin-6), reported that those who used religious coping strategies and social support also had better results after cardiac surgery (10) .
The sample of the aforementioned study presented an average of age close to 60 years, i.e., higher than the one of our study.Studies demonstrate that older patients have more mood disorders in the preoperative period, despite not evaluating the relation of these disorders with spiritual well-being, disregarding the religiosity and the subjectivity in the experience of surgical procedure (11) .
A survey conducted in a national reference center, when comparing the manners of hosting in the preoperative period,  demonstrated, through the evaluation of lower levels of anxiety, that the presence of the family is more significant for the confrontation than the sole contact of a nurse (12) .In evaluations carried out in the sample of this study, the presence of companions was not determinant for better or worse results of spiritual well-being or hope.However, it was not evaluated the type of relationship with the companion nor the sphere in the relationship where the most intimate fears, anxieties and concerns would be approached or the religiosity expressed.
Another study of the preoperative period, when assessing the strategies of confrontation used by patients waiting for the cardiac surgery, reported that the modality of sustentative coping, which includes spirituality, was used in 50% of cases (13) .Other researches with qualitative approaches demonstrated the presence of positive feelings and the pursuit of faith and hope in religiosity when facing the event of cardiac surgery, with high values of spiritual resources in the confrontation with the operation (14)(15) .
One more cohort study observed 335 patients submitted to cardiac surgery, excluding the ones of emergency and heart transplant, for 30 months and concluded more than the religiosity implication in reducing preoperative anxiety and depression.They applied validated scales for evaluation of spirituality, religiosity, religious practices and beliefs, religious/spiritual coping, optimism and hope, to present results over time.The reports demonstrated that better rates on these aspects reflected in higher existential growth regarding the psycho-spiritual development of individuals that underwent a surgical experience (16) .
Another publication from the same authors, also in cohort to evaluate long-term anxiety and depression (30 months) regarding the spiritual and existential aspects in the preoperative showed prayer, optimism and hope as predictors of lower rates of depression and intrinsic religiosity and hope as predictors of lower anxiety (17) .Still in the same cohort, the authors named prayer as protection factor against fatigue during the followup, and preoperative anxiety, on the other hand, as increasing factor in evaluating the physical and mental fatigue (18) .Finally, there were few studies that investigated the issue of hope in the preoperative period of cardiac surgery and considered it as main or secondary outcome of the investigation.There was a study that determined a significant association between hope and religious-spiritual positive coping, but none that correlated it with spiritual well-being (19) .
In Brazil, research that considers hope of chronic patients and their relationship with the clinic are relatively recent, keeping in mind that the authors who translated and validated the scale stated that until 2005 there was no instrument available in Portuguese for such (9) .However, the hope construct has emerged in qualitative research to understand the meanings and factors that influence the process of going through cardiac revascularization surgery for patients, families and healthcare professionals (20)(21)(22)(23) .In these studies, spirituality is referred as important in the participation in the surgical experience, since patients can share their anguishes with God and have, in faith, the hope of achieving good results after surgery (20)(21)(22)(23) .Lastly, although the relation between hope, faith and religiosity and the expectation about the surgery is frequent, patients can refer to it without making such correlation, just by knowing that the prognosis without surgery would be worse, despite the arising risks (23) .

CONCLUSION
In the preoperative period of cardiac surgery, the patient assessment should consider the perspective of completeness, with metaphysical dimensions, often neglected, which can directly impact on reestablishment of the health of the body and, mainly, the psycho-emotional welfare before a particularly difficult and delicate process.
Regarding this perspective, the evidences in our study, in which patients generally did not reach high scores of spiritual well-being or hopes, should be a target for more reflection.Nurses should develop a watchful eye to these issues, be trained in specific protocols of spiritual anamnese and use the real moments of care to strengthen the patients.Referring the find that existential well-being fell short from the religious one, a suggested strategy to nurses who deal with preoperative period of cardiac surgery is using, in their interventions, the religiosity that the patients have to help them in the process of encountering sense and re-significances.
We suggest, finally, that these propositions should be tested in practice and assessed in research in the preoperative period of cardiac surgery, in order to contribute to the maintenance of spiritual well-being, alleviate possible crises, reduce anxiety and depression and increase hope in life, promoting health in full perspective.

Study limitations
The sample that composed the study was not enough in order to observe some relations through the employed statistical tests.We suggest that other studies with qualitative approach can deepen what was evidenced in this study.Whereas there was no difference between spiritual well-being and hope when assessed from the perspective of most of the tested variables, it is suggested to evaluate afterwards which factors can directly impact these outcomes.

Contributions of the study
This study reinforces the commitment that nursing must maintain a humanistic, as well as a metaphysics, proposal associated with values that refer to the recognition of the spiritual dimensions of life and inner strength mobilized at the period of care.
This study presents, empirically, a reality that diligent nurses, in the process of taking clinical care, must realize when dealing with this population of patients waiting for cardiac surgery.When seeking to expand ideas and values, the research in this field aims to recognize, in the nurse-patient relationship, that the real moments of care are deep and meaningful in the health-disease process, favoring its confrontation by patients.

Table 3 -
Scores of spiritual well-being and hope by socioeconomic dichotomized variables, Recife, Pernambuco, Brazil, 2016

Table 4 -
Scores of spiritual well-being and hope by variables related to the hospitalization and surgery, Recife, Pernambuco, Brazil, 2016 Note: Avg ± sd -average ± standard deviation; SWBT -total spiritual well-being; RWB -religious well-being; EWB -existential well-being.