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Rev. Latino-Am. Enfermagem vol.16 no.2 Ribeirão Preto Mar./Apr. 2008
Spirituality in selfcare for intensive care nursing professionals
Luciana Winterkorn DezorziI; Maria da Graça Oliveira CrossettiII
IM.Sc. in Nursing, RN, Intensive Treatment Center at the Hospital de Clínicas in Porto Alegre, Brazil, email: email@example.com
IIPhD in Nursing Philosophy, Faculty, Rio Grande do Sul Federal University, School of Nursing
This study aimed to understand how spirituality permeates the process of caring for oneself and for others in the intensive care scenario from nursing professionals' point of view. This study used the qualitative approach of Cabral's CreativeSensitive Method to guide information production and analysis in nine art and experience workshops. Nine nursing caregivers from the Intensive Care Unit (ICU) of a university hospital participated in the study. This article presents one of the topics that emerged during this process: spirituality in selfcare, which is evidenced in the daily practices that take place through prayers, close contact with nature, as well as in the sense of connection with a Higher Power that provides peace, welfare, and greater strength to ICU caregivers' life and work. Selfknowledge emerged as an essential practice in caring for oneself, in order to deliver better care to others.
Descriptors: spirituality; intensive care; intensive care units; caregivers; nursing care; consciousness; nursing
This study approaches the spirituality in caring for oneself from the perspective of nursing professionals who work in intensive care units, showing how this subject appears in this environment(1).
Intensive care was chosen based on the fact that it is the authors' field of research. Through a critical look at the intensive care context, the researchers perceived how this scenario is still rooted in practices that privilege knowledge about external, physical and measurable realities, rejecting internal knowledge, such as subjectivity and the human spiritual dimension(2).
Hence, spirituality still remained far from discussions, and was relegated to individual experiences that did not appear in the professionals' reports and records. Only the casualness of daily dialogues showed the presence of distinct comprehensions about spirituality in the lives of the nursing professionals. This meant they could permeate the caring for oneself process, at the same time as the professionals looked after other people. However, one question remained unanswered, about how care and spirituality were associated, leaving a veil of invisibility over this theme in the intensive care scenario.
The return to spirituality and the great interest it arouses are related to the holistic notion of care. This notion comprehends all human dimensions(3) and the great efforts to include new approaches that meet not only technological, but also ontological competences, which are essential for the maturity of nursing and its survival as a profession(4). Therefore, education, research and nursing practice emerge in this discussion, with a view to understanding how human spirituality permeates the care scenarios, as well as its implications for contemporary nursing.
Although there is no definition of spirituality that captures the entire essence of the concept, each definition is as if it were a sense of direction of our attention to understand it in the care process(5). One of the great challenges to integrate spirituality and spiritual care in nursing curricula and practice has been the evolutionary understanding of the spirituality concept, which starts to be understood as something broader than religion, without excluding the latter(6). In this research, spirituality is understood as an encounter of one's selfknowledge with the most loyal and beautiful dimension the spiritual that enables the connection to oneself and the cosmos, and in which unequalled resources that influence the human life and its relations to the whole are reached(1). It is the essence; the center of the being, that permeates all aspects of life in a unifying way(3).
A growing number of studies on spirituality have been carried out in different health areas, demonstrating a clear wish to seek new rejuvenating sources that increase its possibilities to solve human pain, as well as to explain a large part of the mysteries and complexities in the cosmos. This paradigm change movement is evident in nursing. Besides articles on spirituality, there is research on the philosophical meaning of the concept(35,7), methods to evaluate spiritual needs(8) and practical aspects of its implications in nursing care(911). This study was performed in this sense, and has the clear purpose to contribute to the universe of possibilities that the dialogue about spirituality in education, research and nursing care may provide, as well as to contribute with the construction of this profession of love and care. Therefore, this research aimed to understand how spirituality permeates the process of caring for oneself and for others in the intensive care scenario from nursing professionals' point of view.
In order to dare transform care scenarios, it is essential that the experiences and diversity of knowledge built until that moment be used as the lever for this process. Therefore, in the diversity of qualitative research, the Creative and Sensitive Method (CSM)(12) approach was chosen, because it values human creativity and sensitivity as essential elements in research production. Moreover, it foresees the active participation of everyone involved in the process.
The combinations between "science and art, spontaneity and introspection, creativity and sensitivity, reality and creative expression" unquestionably differentiate the CSM from other methods, which are already consolidated in research, mainly in terms of data collection. This method joins collective semistructured interview, group dialogue and participative observation in the space created during the creativity and sensitivity dynamics, which are based on the artistic productions. In this aspect, corporeality and emotiveness are also brought into the creation process, confirming its innovative capacity in qualitative research(12). In this study, the creativity and sensitivity dynamics were named art and experience workshops.
The starting point of the CSM is artistic production, which becomes the synthesis of the individuals' creativity and sensitivity, representing their cultural universe, beliefs, values and experiences. The harmonious combination between the artistic production and group dialogues is essential when dealing with certain research problems, particularly those aiming to bring up latent issues(12). Based on this idea, it can be guaranteed that the CSM was capable of immersing in the universe of nursing caregivers and disclose the way spirituality pervades the care process for oneself and for others in the intensive care scenario.
This study was developed at the Intensive Care Unit (ICU) of the University Hospital of Porto Alegre (HCPA). The ICU is located on the thirteenth floor and has 34 beds; it is considered a closed unit, attending adult patients who require intensive care. The beds are distributed in three areas: cardiac six surgical beds and three coronary beds; area I 12 General ICU beds; area II 12 General ICU beds and one bed for transplants.
Subjects were selected intentionally, through invitations, and with the criterion of having a minimal experience of one year at the ICUHCPA. The group consisted of two nurses and seven nursing technicians, although the initial idea of the study had been to join a group with 12 people. In the information production period, the proportion was one nurse for every four technicians, so that nursing technicians naturally participated more. In order to comply with the ethical guidelines of resolution 196/96(13), subjects' anonymity was assured through fictitious names. This study was developed after approval by the Institution's Research Ethics Committee.
Nine art and experience workshops were held to produce the information. The workshops happened once a week, and lasted an average of 2 hours. Each workshop was structured to respond to the research purpose, with four guiding topics.
Each topic was developed in two workshops. The first workshop aimed to announce and investigate the topic, using guiding questions that should be answered through the artistic production and group dialogue. This manuscript translates the results of the two workshops on caregiver spirituality, using the guiding question: what is spirituality for you and how does it influence your life? All workshops were recorded on cassette tape. At the end of each workshop, the tapes were transcribed and the information was returned for the group, The second workshop deepened the reflection on the subject, and also extended and promoted the alliance and negotiation space of knowledge
Hence, information production and analysis, as planned by the CSM, followed a number of stages: coding, which comprehended the elaboration of the artistic production as a moment of introspection and selfdialog, in order to recover past experiences and reflections about the study subject; decoding, which was put in practice through the expression of the artistic production meanings, a stage when group dialog was established, including critical and collective analysis of the artistic productions and ideas that emerged in this space. Therefore, this stage also comprised knowledge negotiation, considered as the act of sharing experiences and ideas in the collective space, exchanging knowledge, feelings, and emotions.
Substantial statements emerged from this dialogue, which showed the world lived by the participants. The following stage was recoding or knowledge alliance, which included the moments of approximation and convergence of ideas, as well as the acquisition of new knowledge, involving respect for different thoughts. After all data had been compiled and the researcher had elaborated an indepth analysis according to theoretical frameworks, the ninth workshop was held to validate the analysis of the information.
This methodology led to the emergence of meanings and constructs of three themes: meanings of spirituality, spirituality in care for oneself and spirituality in care delivery to others(1). This article is about the second research theme.
SPIRITUALITY IN CARE FOR ONESELF
A group of nine female nursing caregivers, with ages ranging between 25 and 48 years, represented all ICU work shifts in the art and experience workshops. Without explaining religious preferences, they expressed a diversity of thoughts and practices that included spirituality in care for oneself.
The history of nursing essentially converges to care delivery to other people, which justifies its existence. However, lately, a different idea has been discussed, stating that, in order to care for the other, one must be aware that, first, it is essential to take care of oneself.
Nursing professionals are now awakening, from times of selfabandonment, to this condition. In this movement, subjects expressed their daily practices that included spirituality in care for themselves, which became habits for a healthy life, as presented in the following statements:
I have the habit of planning the whole day in the morning, as soon as I wake up [...] drink that glass of water [...] as if it was cleaning everything and any disease or bitterness, and hope for a really good day, and for the sun to light me up... (Lotus).
... when I want to escape, I feel really good in the water. [...] far from a busy environment. The water, the tranquility. It seems you can feel better. You get closer to God [...] to nature [...] I feel really good (Chamomile).
The statements evidence that intimate contact with nature, which humans are also part of, represents a relation of care for oneself, by taking distance from busy environments and reflecting about life, in peace. This experience broadens the caregiver's awareness, increasing the understanding of how care for oneself can be improved. This practice provides the nursing caregivers with tranquility and welfare for, contemplating spiritual welfare, which comprehends the belief in a Higher Being, the need for meaningful relationships, interior harmony, a good support system, as well as the appreciation of nature, in a sense of connection with others and the universe(14).
In addition, the statements also show that water symbolizes a practice of cleaning and renovation, evidencing human beings' potential to cure their own bitterness and diseases. The Sun symbolizes something that lights up the caregiver's life, contemplating the reverence to life as an expression of spirituality in these practices.
In this sense, it could also be observed that the subjects linked up to a Higher Power, in their care practices for themselves, while they also delivered care to others, as the following dialogue denotes:
... There is some Higher Power guiding us. [...] It is a kind of power we have (Lotus).
... there is an inner force. Seeking the faith and belief inside us. Believing in what comes from inside. [...] and that you are here to evolve and learn... (Lavender).
The statements evidence a close and intimate relation with a Higher Power, which represents a wider conception of the external and distant God, also to understand an inner God, a divine power inside oneself. The Higher Power emerging here is revealed as a sacred dimension of the human being, as a power that motivates the nursing caregivers in their lives. Spirituality provides support and assurance and is represented in care for oneself(15).
Spirituality refers to the awareness of an inner self and the tendency to build meaning by being connected to dimensions that transcend the ego. These experiences can occur in an intrapersonal (connecting oneself), interpersonal (in the context of the other and the natural environment) and transpersonal level (in connection with what it not visible, God or a Higher Power)(16). Among the practices that involve religious beliefs, integrated in the comprehension of spirituality, the subjects confirmed prayers as the way they take care of themselves:
I always say thanks as if the day had already happened. So that it is good, I am healthy, and everything goes right at work, on the street. [...] By asking for good things, I always have a nice day. [...] I think it is quite positive. It influences us a lot (Verbena).
Most subjects turn to prayers in care for themselves. This way of relating to a Higher Power creates a care environment that provides welfare to the caregiver.
The dialogues also expressed the experience of other people's death and pain, as well as the caregivers' feelings and emotions. These experiences evidenced spirituality as the way to seek the strength they need to face the difficulties of work at the ICU, as shown in the dialogue below:
... we deal with death very closely [...]. And those moments when I felt very frustrated, very depressed, I started to think [...].This development gives you more strength and support to stand stable here (Rue).
.... I have never had any other kind of treatment for better support, therapy or something like that. I believe that if I didn't do this, I wouldn't be here today. It is hard to cope with it (Verbena).
There is also the care for us, colleagues. We reach a level of stress in which we end up unbalanced, don't we? There is a lot of stress and tension here at work. Of course, we also come with problems from outside. [...] We cannot divide ourselves. We are a single being... (Lavender).
During the discussion, it is observed that the ICU scenario may be a source of suffering for these nursing caregivers as well. The statements showed the importance of spirituality when dealing with death, in order to find meanings for the existential questions that pervade daily life in the intensive care area. In addition, it was recognized that the intensive care environment may be a source of tension, due to the characteristics of working with patients in critical conditions and their families, for the use of the technology and the relations between human beings, which sums up to daily extrahospital problems, generating imbalance and, possibly, sickening due to stress.
Emotional stress and tension due to intensive nursing care often contribute to the development of the Burnout syndrome(17). In fact, intensive care probably does not cause burnout, but the lack of care by the caregivers. This situation was also presented in another study at an ICU, as the nursing professionals focused on their emotions and feelings and stressed how much of the world is pervaded by suffering experiences, which they generally do not think about together(18). Sharing these situations with colleagues is a way to mitigate the suffering and find solutions, as the following statement mentions:
... you can tell your colleague: I am not feeling well today. [...] because we are taking care of fragile people. [...] And even your colleague will support you [...] he will observe you better. [...] This is not weakness. [...] I think this is the care of the caregiver. If we don't take care of the caregiver... (Lavender).
As they become more aware of themselves, they recognize the need to receive care from their colleagues. Mutual help is perceived as care. Thus, a support network is needed which favors and contemplates communication. This way, it is possible to think that nursing will only reach the objective of taking care of other persons in their wholeness when a network of supportive care is established(19) in which spirituality may be contemplated in the emergence of sensitivity, solidarity, empathy and cooperation among caregivers, who often evidence situations of suffering, stress, abandonment and lack of care for themselves and for others at the ICU.
Within the intensive care and emergency scenario, caregivers need to stop and think this context over, as well as its meaning in care for oneself, as the subjects below evidence:
... you just have to stop and think, even at this moment, that we are meeting in this group. All of us should do it sometime. Stop. What are we? What are we doing? (Lavender)
... actually, we should start by ourselves. We have to find harmony [...]. I think what we are doing now is a way to care for ourselves... ... you have to be careful not to neglect. [...] And if you do not care for yourself, you cannot search for spirituality... (Myrrh).
Selfobservation, while delivering care to the other, leads to selfknowledge, which shows that lack of care for oneself can also lead to lack of care for others. One needs selfawareness in order to search, in spirituality, balance in life, including work. Therefore, care for oneself is considered essential, to feel good in the work environment as well as to take better care of the other. The search for harmony with oneself may provide more tranquility to the caregiver. The need to know and discover oneself, as someone who needs care, coincides with the subjects' comprehension that spirituality is selfknowledge. The participants also recognized that the art and experience workshops were a favorable place for these experiences.
Spirituality produces an internal transformation in human beings. From the deep internal change, spirituality unchains transformations in the community, society and in their relationships with nature and the universe(20).
In this sense, relaxation, meditation and reflection practices during the workshops confirmed that, by thinking of the experiences and finding time for themselves, the participants associated spirituality in this process. These practices provided the caregivers with the opportunity to find themselves, turning toward their inner world, in a movement to learn about the complexity of the deep Self and search for resources that bring more awareness and welfare. The caregivers, when thinking about their practices, stressed the relevance of selfknowledge and the need to care for themselves. Therefore, it is likely that caregivers who develop a positive attitude towards their spirituality are sensitive to the spirituality of the patient/family(9), providing space for it to pervade intensive care.
Daily practices were evidenced in the synthesis of the alliance knowledge on the theme: spirituality in care for oneself. They happened through prayers, intimate contact with nature, as well as through the connection to a Higher Power, in an encounter that provided tranquility, welfare and strengthening for life and, therefore, for ICU work. The participants showed selfawareness as they acknowledged that, as ICU caregivers, they get fragile with the world they live in and also need care, which could be accomplished through mutual help among caregivers. Selfknowledge was found as an essential practice in care for oneself, constituting the starting point of the education process for a nursing practice that contemplates human beings in their fullness.
In the constructs and implications for nursing practice, this study suggests the inclusion of selfknowledge in the permanent education processes, as it was considered indispensable for spirituality to pervade care for oneself. Selfknowledge promotes the transformation of the caregivers, broadening their awareness and reintegrating them with themselves. Holistic care is only possible when caregivers are aware of themselves and when they are integrated and harmonious. In order to be capable of taking care of their patients' spirituality, nursing caregivers need to take care of themselves, through the continuous search for harmony and integrity(21).
Along the way, the invisibility veil on the subject of spirituality was left behind in a pure and simple opening movement of this issue, which seemed to be forgotten, replaced or even unknown.
Although spirituality in care for oneself, concerning nursing professionals in the intensive care scenario, remains a subject that is not discussed very often, the results of this study suggest new possibilities for spirituality to be comprehended in intensive care, based on the inspiration provided by the experiences the participants shared. The caregivers' perspective on their experiences showed the nuance of a yearning for life; in their practice, they wish to reunify scientific knowledge, the expression of human sensitivity and deep awareness of the being(1).
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Recebido em: 22.9.2006
Aprovado em: 17.12.2007