Spirituality and practice of the euphemism in the workplace: perceptions of a nursing team.

OBJECTIVES
to understand the spirituality and the practice of euphemism experienced by nursing professionals in the hospital scenario.


METHODS
a descriptive, exploratory research with a qualitative approach, carried out with 18 nursing professionals from a hospital in southern Brazil. Data collection took place from September to October 2018, through recorded audio interviews. The reports were submitted to thematic content analysis and the discussion was based on the theory of transpersonal care.


RESULTS
four categories emerged from the speeches: Motivational reflection of spirituality in the work environment; Adherence to the practice of euphemism by nursing professionals; Satisfaction and frustration in the practice of euphemism by nursing professionals and; Spirituality as an increase in human faith.


FINAL CONSIDERATIONS
professionals understand spirituality and the practice of euphemism as a tool that helps in motivating the team to face difficulties at work and increase the faith of hospitalized patients.


INTRODUCTION
Spirituality in the organizational environment comprises three dimensions: self-immersion in work, interconnectivity and selffulfillment (1) . The first concerns the support offered by the organization for employees to experience aspects of their spirituality, aiming to increase their commitment, result and efficiency in the work environment; the second refers to the feeling of belonging to something much bigger than yourself in the organization and; finally, the third, self-fulfillment, which is associated with the level to which employees feel full or satisfied when going through experiences of mental and spiritual growth (1) .
Spirituality and religiosity are sometimes understood with the same semantics, but there is a difference between them because spirituality is related to one's existential dimension, by driving someone to the awareness of own moral context or not (2) , that is, spirituality consists in the personal search for answers about the meaning of life and the relationship with the Sacred and/or transcendent (3) . In this respect, spirituality may or may not be related to religious doctrine (2) .
Religiosity, in turn, presents itself as a quality of religion (3) . It is the connection between man and the divine, through an organized system of beliefs, practices and rituals performed by individuals who come together in search of the approach to the Sacred and/or transcendent (3) .
An important religious and spiritual experience is the search for God through euphemism: orate (supplication, invocation, communication, speech); petition (oral ritual, requests, pleas, instances) and; prayer (act of reciting or reading aloud) (4) . Despite the discreet dissemination in the scientific community, the term euphemism was used in this study because it encompasses the concepts of orate, petition and prayer, assumed as synonyms because they represent the search for God and divine intervention in petitions.
In the health field, the Spirituality/Religiosity (S/R) experienced in the work environment brings a sense of life and comfort amid human suffering that permeates the personal discovery of transcendence of the individual's health-disease state (2) . Spiritual/ theological reflections associated with spiritual practice at work favor the respectful relationship between professionals, better management of conflicts, humanized and satisfying care for patients (5) . This is because the interdisciplinary insertion of spiritual/theological issues in a clinical/therapeutic setting, empty of imposed religious traditions and dogmas, seems to strengthen the construction of professional "knowledge" that results in a rich performance in organizational work and in the whole dimension of the Human Being, consolidating the art of holistic health care.
In the 1990s, the World Health Organization (WHO) created an instrument that assesses people's quality of life (6) . Based on this, strategies were established to assist health promotion and quality of life (7) . Among the strategies, religious and spiritual experience, such as euphemism and meditations in health care, proved to be factors of longevity and physical, mental and spiritual well-being (7) .
In nursing, it appears that S/R contributes to the promotion of the emotional comfort and well-being of those who care and those who are cared for (8) . In this regard, the theory of transpersonal care, created by Jean Watson, in 1988, is a model of assistance, based on humanistic and metaphysical concepts, which has a central focus on holistic care, which includes the physical, biological and spiritual dimensions. This theory intends to promote harmony between spirit, mind and body and thus reestablish human subjectivity, both for the patient and the nurse involved in the care process (9) .
Concerning the spiritual care offered in hospitals, it is a useful strategy to strengthen the nurse's commitment to providing comprehensive care, with the further concern of serving and respecting the patient's religious beliefs (7) . The appreciation of spirituality by nursing managers is the primary step towards the development of awareness and sensitivity to spiritual/religious issues in the art of care (10) , to overcome the reductionist belief that limits the patient to the physiological dimension. On the other hand, the insertion of S/R is considered a challenge for the nursing team, because, since academic training, there is no preparation for this care practice (11) .
Still in the hospital scenario, the acknowledgment of the benefits of S/R is evident, but, paradoxically, institutional support for the spiritual dimension seems to be elementary, as it is observed that it is little applied as a strategy for self-immersion at work, interconnectivity and fulfillment of nursing professionals. Thus, understanding the S/R phenomenon in the work environment and in the care practice of the nursing team, where the workday is often hard and stressful, is justified because, according to the literature, the professional's spiritual experience, through euphemism, provides mechanisms, such as faith, in coping with hostile situations, in places with excessive pressure (12) .
Based on the above, this study has the following research question: In the organizational and care context for hospitalized patients, how are the spirituality and the euphemism perceived by nursing professionals, along the working day?

OBJECTIVES
To understand the spirituality and the practice of euphemism experienced by nursing professionals in the hospital scenario.

Ethical aspects
For the development of this study, the ethical and legal aspects regulated by Resolution 466/2012 of the National Health Council were followed, and the project was approved by the Ethics Committee in Research with Human Beings of the participant institution. All participants signed the Informed Consent Form, and to guarantee their anonymity, the extracts of their speeches are identified with the letter "I" for the interviewee, followed by an Arabic number referring to the order in which the interviews were conducted. It is worth mentioning that, in this process, the non-identification of the participants was guaranteed.

Theoretical-Methodological Framework
To systematize and analyze the data, the content analysis technique was used, in the thematic modality (13) . The theoretical framework was based on Jean Watson's Transpersonal Human Care (9) .

Study design
A descriptive study with a qualitative approach, based on the Theory of Transpersonal Human Care.

Methodological procedures
First, the hospital approved the research to be carried out with the professionals of the Nursing team. Afterward, the project was sent to the Research Ethics Committee Involving Human Beings for consideration and approval.
Data collection was carried out by the intentional choice of professionals, as practicing, or having practiced euphemism in the workplace was the eligibility criterion. For theparticipants' recruitment procedure, initial contact was established with the nursing supervisors from the clinical-surgical inpatient units of the hospital under study, to confirm whether the teams and the nursing professionals practiced the euphemism and who they were. After the identification of the sample of eligible individuals, a personal invitation was made, at first to professionals in the morning shift, and after to the workers from the afternoon.

Setting
The study scenario was a medium-sized hospital in a municipality in the southern region of Brazil. This hospital is a private, non-profit, philanthropic institution and benefiting from social and health assistance, which offers outpatient and inpatient service to private clients, insured by health plans and SUS. The beds are arranged in the varied hospitalization units: Unit A -serves female and male SUS patients; Unit B -intended for patients with a private health plan; Unit C -designated for private patients and other health insurance; Unit D -serves male SUS patients; Pediatrics unit; Pre-delivery unit; Maternity unit; Emergency Room; Neonatal and pediatric ICU and; Adult ICU.
In about 2015, the nursing manager, with institutional support, proposed to the inpatient units the practice of collective and voluntary euphemism by nursing/health professionals at the beginning of the shift. However, due to the turnover of supervisors, this collective practice has become unstable and even absent, over time, in most units.

Data source
The study participants were 18 nursing team professionals (Nurses, Technicians and Nursing Assistants), who belonged to the institution's effective staff, worked in the morning and afternoon shifts, and had practiced or still practiced euphemism, individually or collectively, before and/or along with the shift. Workers who were on vacation or any other type of leave during the investigated period were excluded.

Data collection and organization
Data collection took place in the clinical-surgical inpatient units, at a previously scheduled time, in September and October 2018, through a semi-structured questionnaire (age, sex, marital status, schooling, religion, spiritual/religious practices) and audio-recorded interview, based on the guiding questions: Tell me about spirituality at your work; Tell me about the practice of prayer by nursing professionals in your work environment.
The interviews lasted an average of 15 minutes and were carried out by two researchers who had no relationship with the researched institution, in a private room. The inclusion of participants continued until the data saturation and the achievement of the objective was reached in the 18 th interview.
The interviews were recorded with the participants' previous authorization for later transcription. It is noteworthy that all interviews were transcribed in full, categorized from the first participant, by the two interviewers and, afterward, validated by the other researchers of this study.

Data analysis
The data analysis of the interview was based on the content analysis technique, in the thematic modality, following the stages of pre-analysis, material exploration, data treatment and inference of the results (13) . Four categories emerged from this process, and its discussion will be based mainly on the conceptual theoretical framework of Transpersonal Care, by Jean Watson (9) .

RESULTS
The 18 nursing professionals who participated in the study (16 Nursing Technicians, one Nurse and one Nursing Assistant), had a mean age of 29 years (minimum 18 and maximum 61 years). Of these, 17 were female, 11 declared themselves single, four married and three divorced. Regarding education, 14 had completed high school, and four had completed higher education.
Regarding religion, 15 expressed being catholic (eight lapsed Catholics), three evangelicals (one lapsed). Regarding the frequency the respondents pray, seven reported doing it once a day, two reported it two or more times a day, three once a week, four two or more times a week, and two, sometimes in a year. All of them reported believing in God, feeling His presence when they pray, or read the Bible, and having practiced, at some point, team euphemism at the beginning of their shift. Eight declared that, for now, they did not pray at any time at work, ten said they did it individually and, of these, five said they practiced team euphemism, but occasionally.
Because the specific level of the professionals in this study characterizes a Christian profile, the arguments and results assume a status consistent with the "Christian perspective" and will be discussed in the light of the theory of transpersonal care.
From the speeches, the following categories emerged: "Motivational reflection of spirituality in the work environment"; "Adherence to the practice of euphemism by nursing professionals"; "Satisfaction and frustration in the practice of euphemism by nursing professionals" and; "Spirituality as an increase in human faith".
It is emphasized that the excerpts/extracts/fragments presented underwent minor corrections, without changing the meaning of the excerpts, and the slangs and repetition were suppressed. Finally, to facilitate the reader's understanding, words or terms were inserted in parentheses.

Motivational reflection of spirituality in the work environment
Spirituality, although intrinsic to the human being (9) , when practiced through euphemism, seems to work as a motivational trigger for the nursing worker to face the challenges of working in the hospital environment. [ The practice of prayer at the beginning of the shift, as a way of dealing with possible tribulations at work and providing personal well-being, was also reported. Euphemism also emerged as a support for professionals to deal with work overload, with the complexity of care and with deaths.

Satisfaction and frustration in the practice of euphemism by nursing professionals
The feeling of satisfaction and frustration is implicit in the excerpts, as some professionals emphasized that S/R is essential to the Human Being and its absence causes an emotional gap. The excerptsthat support this testimony reveal an intrinsic cause-effect link in the work environment, according to the interviewees' perception: [

Spirituality as an increase in human faith
The spiritual dimension evokes a condition inseparable from the physical and mental dimension of the human being, because, in the professionals' perception, spirituality produces benefits not only for the caregiver, but also for the patient. Among the expressed benefits of S/R in the management of negative feelings in hospitalized patients, the positive/optimistic response was the one that stood out the most.

DISCUSSION
In hospital institutions, there is constant stress, fear, and the risk of death. These factors result in an emotional burden on health professionals, patients, and family members, which must be managed and assisted (14) . However, if spirituality permeates the process of managing and assisting emotions, it can improve the levels of satisfaction of individuals who experience the nosocomial environment. This is because S/R provides harmony between body, mind, and soul, with a positive influence on the emotional balance of health professionals and patients (9) .
According to the excerpts presented, the practice of orating, petitioning, or saying prayers generates, in professionals and patients, well-being and support in the management of situations of suffering and pain that involve the health care process. Thus, reinforcing this opinion, some authors (8) affirm that spirituality is additional care that Nursing can use, without restriction.
In Brazil, a study carried out in a philanthropic hospital with patients undergoing chemotherapy treatment revealed that prayer provides a new perspective for nursing care, as it is a care option that offers benefits to conventional treatment, besides meeting the spiritual dimension of inpatients (12) . In the same study, the authors state that a prayer is a tool that helps to cope with anxiety and illness and, therefore, can be considered a care strategy by Nursing (12) .
Through religion, some advantages can be stimulated, for example, tolerance, the acceptance of different situations, the promotion/valuation of ethical and moral principles, and also the improvement in relationships among professionals (15) . The aforementioned questions or virtues converge to the participants' statements (I4, I13 and I17), who stated that, through the euphemism, there was an improvement in the interaction among the team members, corroborating what Watson exposes (9) when he affirms that the respectful interpersonal relationship causes the dimensions of sense of being and harmony in the work team.
The aforementioned excerpts and others presented in this study confirm the literature (9,12) , in the sense that belief and faith among nursing professionals lead them to a growing spiritual development throughout life, in addition to providing balanced environments and harmonious relationships between people of different faiths.
In the hospital scenario, the literature (16) points out that it is common for health professionals to feel physically and emotionally overwhelmed, due to complications in their work routine. This fact was also observed in the statement of I10. To minimize this condition, it is suggested to health managers to promote means for the development of S/R in the hospital environment, as it promotes personal satisfaction, mental health and the high sense of Being (9) .
The little experience and practices of moments of prayer performed in the workplace are sometimes defined as a lack of opportunity to experience spiritual moments in a team (17) . This situation was observed in the statements of I7 and I8, which showed the inconstancy of individual and collective euphemism in the workday. Thus, it is recommended to experience individual and collective S/R among health professionals, to encourage communication between the team and self-sufficiency in the work environment (1,9) , as long as individual, ethical-professional and institutional respect are ensured. The dualistic feeling between the satisfaction of the nursing team in the presence of euphemism, and frustration in its absence, during the workday, was found in the excerpts of I8, I13 and I15. These feelings can be better understood in the light of the framework (9) that guides this study and addresses that the harmony between mind, body and soul generates a feeling of consistency within the person and contributes to self-knowledge, self-respect, self-control, health and well-being. Disharmony and inconsistency lead to threat, anxiety, inner turbulence, existential despair, malaise, and fear (9) .
The spiritual dimension has been widely valued and recognized for its positive results in the workplace (1,9,12,(18)(19)(20) . Despite this, it is observed that it is still a little-explored element as a healthcare practice, especially in the hospital environment. As reported in the literature (9,20) , if this practice is applied by health professionals, it can provide benefits to patients such as strength, tranquility and faith to face the disease and the treatment process, even in cases of incurable pathologies.
Although the practice of euphemism in dealing with the patient has not been observed, the fragments express the benefits of care centered on spirituality. These results corroborate the literature (9,(18)(19)(20) that reports the benefits on the patient's health status: relief of tension, increased feeling of hope and, especially, reduced anxiety. Also in this perspective, Watson (9) highlights the importance of the nurse developing the patient's personal and spiritual potentialities, considering that this professional is an active participant in the care process and can promote benefits to that, such as the self-recovery of human integrity and harmony between who cares and who is cared for.
In the S/R scenario, seeking the applicability of holistic health care, it was proved, in a study (19) carried out in Brazil, with chronic renal patients in a hospital, that the practice of euphemism promotes relief of the patient's suffering undergoing hemodialysis, besides improving vital sign values. Likewise, another study carried out in Iran revealed that the implementation of programs based on religious beliefs improved the quality of life, as it promoted hope in patients with heart failure, also beneficial effects on the physical and mental health of their families (20) .
A study carried out with 404 (90.8%) North American nurses, estimates that the nurse's S/R has an impact on nursing care when this professional does a spiritual or religious discourse congruent with the patient. Also, the study corroborates that professionals should not hold in their beliefs while providing care, as long as the spiritual care offered is respectful and ethical (21) .
The care associated with S/R was observed in a study (10) developed with nurses from a hospital in Saudi Arabia, who recognized the importance of spiritual care for institutionalized patients, showing concern for the full well-being of the patient. With this, it is possible to observe that transpersonal care is filled in the act of understanding the comprehensiveness of the individual as mind, body and spirit, favoring the release of feelings that allow the patient to receive not only physical care, but the improvement in the condition of their Being (9) .
Caring involves getting to know oneself, getting to know the other, being compassionate, caring for people not only in life and death situations, but, above all, understanding the connections of the human being in their entirety, and all of this, surely, is related to transpersonal care that has the premise of intervening in a single Being, without dissociating the dimensions of its existence, whetherv physical, mental and/or spiritual (9) .
The health professionals' performance in comprehensive patient care can be influenced during their training, as many professionals do not feel prepared and qualified for the care practice that incorporates the spiritual dimension. In this regard, a study (22) carried out with undergraduate students from the health area found that they were in favor of including themes on S/R, during the comprehensive health care classes, as part of professional training.
Given the above, it is considered that there are still gaps in the process of managing comprehensive care, especially in the current national curriculum structure, which limits the development of S/R as a care strategy by nursing professionals in the face of unpreparedness for this practice since academic training, and this tends to weaken holistic care for hospitalized patients.
In this study, it is observed that nursing is based on one of the pillars of care: transpersonal care, which involves the binomial professional-patient, from the perspective of an ontological view with sensitivity for understanding the value of life that transcends the physical and mentalaspects, consolidating the praxis of taking care of oneself and the other, in professional practice.

Limitations of the Study
As a limitation of this study, the peculiar experience of the practice of euphemism stands out forbeing onlyone group of essentially Christian nursing professionals, from the day shift of a single hospital institution. Also, the study was not guided by the limits of the literature regarding ethics and patient-centered care, which the professional recognizes and ensures the patient's values and motivations for any spiritual practice. Thus, further studies that portray the problem of professional practice and the ethical dimension of how to deal with patients' spiritualityare suggested. It is suggested that other scenarios of the health care network be investigated, with different categories of workers and with methods that complement and deepen the knowledge about the phenomenon investigated, as is the case of the mixed research approach.

Contributions to the Nursing field, health, and public policies
This study proves to be relevant for nursing because the approach of care centered on spirituality/religiosity can arouse the need to implement health education strategies focused on this theme, as a feasible path for the commitment of the team, patients and family members based on a respectful and supportive organizational environment. The results obtained here also contribute to the value of strengthening teams, having euphemism and spirituality as mediators, because, according to the statement of the participants, the practice of euphemism is important for the teams'euthymia, to raise the condition of a particular mood, and also the clinical relationship.

FINAL CONSIDERATIONS
In this study, it was understood that nursing professionals perceive spirituality and the practice of euphemism as a motivational tool for the team, to face the difficulties experienced at work and to increase the faith of the hospitalized patient. Also, the inconsistency in the practice of euphemism in the daily work of the nursing team was mentioned as a reason that generates a feeling of satisfaction, in its presence, and of frustration, in its absence.